Use the tool to identify
the eligible patients. Then break that down as best as possible to each doctor’s patients. Provide a doctor with a short list rather than a very long list. And then sit down with them, with one of the team members,
particularly the nurses, who usually know these patients as well. To then, sift through that and identify patients who
could potentially benefit. Then you can actually develop techniques of either waiting for them to come in, or being much more
proactive in sending them introductory letters to the program, or introductory SMSs, or getting one of your staff who know them to call them, to invite them in. You can invite them,
provide them information, consent them, or enrol
them, all in one visit, or you could actually
just use the first visit to educate them about the program, answer any questions they have, and then bring them back
for the more detailed enrollment visit, which would include an assessment of a care plan, and that’s usually best done with other members of the team. In our practice, we have doctors, we have registered nurse, we have podiatrist, dietician. For new patients that
come in, I will tell them ‘If you join the Health Care Home program, you will be involved in
producing a shared care plan that will help to
achieve your health goals by, you know, that team care approach”. Dr. Ong is the one who’s
talking to patients first and if they agree to
enrol to Health Care Home, I’m the one who’s
responsible for the paperwork and for the consent, so explaining more about the Health Care Homes. If the patient doesn’t
understand anything, they can ask me. After that, I am the one who’s going to do the shared care plan. So, we’re going to book the patient again to do a mini case conference, and from there, I need the
help of my receptionist and the medical practice
assistant for booking them to different specialists
if they need to see them. Some of the concerns raised include, whether or not they’re still able to access me as their doctor, and the answer to that is very simple, and that is that I’m always here for them. We try and allay those
fears as best we can. Every practice system will be different. What’s worked for us is actually having a list of the Health Care
Home enrolled patients, and just one word on each sort of segment in that spreadsheet, to highlight to me, or to remind me of when
the next touchpoint is with us and so we then share that spreadsheet amongst the staff, myself, and the nurse, and the receptionist. And each person has delegated
roles and responsibilities on that spreadsheet, and so that ability to sort of get a bird’s-eye view of the cohort of patients
enrolled is really important. One of the things we’ve had
to do as a practice here is actually have really
clear goals and guidelines for who does what role. We’re sitting around in smaller teams, and we’re working out, you
know, what’s the correct policy. We actually work together
because we want to co-create health together. Again, it comes back to the team. It’s not one person’s responsibility; if the member of the team is
capable of doing that task or providing that skill, they’re the ones that do it. It doesn’t just come back to the GP. For me as a GP, and certainly as the
principal of the practice, having the team share the work and becoming the patient’s
team is absolutely liberating and absolutely joyful.