A Home Doesn’t Need to Have a Single Roof – Because it Might Need to be a Neighbourhood

The “buzz words” floating around the newly discovered world of primary health care are “Patient-Centred Homes”, a concept where a focus is generated on a patient through a triage process where patients are provided an efficient sequential introduction to the health resource most required by those patients under the one roof.
Results to date in the US model have been “patchy” at best with pharmacists finding themselves financially disadvantaged by not being classified as “providers”.

Primary health care in both the US and Australia has been substantially provided through community pharmacies in the past, with community pharmacists personally speaking to patients, prescribing economical medicines or referring them to other resources according to the complexity of their condition.
Quite commonly this referral would be to a GP on an informal basis, or if it was, say a lower back pain, a pharmacist might have selected a chiropractor, osteopath or a physiotherapist as the more appropriate referral.
Up to 1960 more than seventy percent of primary health care in Australia was serviced in this manner, with pharmacy being the prime mover, because of training and accessibility.

When the National Health Service system was established in Australia early in 1950 there began a migratory change in patient behaviour because under this new scheme there was no charge from a doctor and no charge for written prescriptions.
So instead of a pharmacist being the first port of call with a referral on for the more complex patients, the first point of contact became the G.P who in turn, referred patients to medical specialists as a preference, rather than to pharmacists, allied health or complementary healthcare practitioners.

So reflect on that process and you will realise that this was actually a first attempt at creating a patient primary healthcare “home”.
Over time the “home” became more expensive as government policies and budgetary needs changed (governments are really totally inefficient when trying to partner private enterprise) and we are seeing similar situations arising over all facets of medicine and pharmacy as I write.

Part of the contributing reason for cost increases in the system is that the GP has evolved to become a full-time “traffic director” and generates ever-increasing referrals to an ever-increasing range of specialists, without trying to provide a level of treatment to their patient “on the spot”.
No longer does the GP lance boils, take out your appendix or tonsils or even apply liquid nitrogen to the odd skin cancer.
The GP of 50 years ago would have done all of this work themselves and at a much lower cost to the system than that which applies today, and with a lower rate of hospitalisation and added dramas from say, cross-infections.

Under the new proposal for a “Patient-Centred Home” what is it that the community will expect to see?
Well, it will see exactly what has been in place since 1950 with elements of the health community working in collaboration with GP’s, but supposedly with more streamlined processes and under contract, which will need to be thoroughly scrutinised before it becomes a reality in Australia.
Who will be the lead body for this type of negotiation?

And it will be led by GP’s, with the GP hosting as many support personnel (nurses, physician assistants and pharmacists) all under one roof, as can be economically sustained.
Also a lower out-of-pocket expense capitation rate for the patient, (and correspondingly lower costs for the government payers).

Whilst I applaud any collaboration and improvement in patient communications and I can see the potential for a more efficient patient service, I can also see it will need oversight on a continuous basis – but not doctor oversight.
If the model concentrates into the GP physical environment it will eventually become too costly down the track, following a similar pattern that has evolved between 1950 and now – and because of cost, it will be incomplete in terms of participating health disciplines and that will create competition for available health dollars between the GP and the other disciplines.
One other major obstacle is that a GP-led scheme under current processes would start with a higher proportionate cost base than a scheme which followed pre-1950 processes (with some minor modification).

Perhaps a better name for the concept is the one currently being adopted in the US – The Medical Neighbourhood.
The name implies a more inclusive range of health activities all operating independently, but in active collaboration with each other and GP’s.
And this concept recently gained momentum through an infusion of pharmacy “muscle”.

The chain pharmacy group CVS – a major pharmacy company in the US that features a range of walk-in clinics within its operation, has agreed to pilot such a model and stated that in a Medical Neighbourhood, all parts of the health care system are represented:
GP’s, pharmacy, retail clinics, acute and post-acute care, diagnostic services, public health, and community and social services are all considered.
All play an important role in keeping patients healthy, but rather than following a sometimes fragmented path from one provider to another, a patient’s care is led by a primary care or family physician.
This focus on primary care has many benefits, including decreased costs, improved health outcomes and even increased longevity.

To strengthen the Medical Neighborhood, CVS Health is collaborating with Health Is Primary, a campaign sponsored by the nation’s eight leading family medicine organizations.

These include the American Academy of Family Physicians, the American College of Osteopathic Family Physicians and the North American Primary Care Research Group.

The joint initiative is aimed at increasing coordination of care between different parts of the health care system, specifically primary care providers and CVS/pharmacy and MinuteClinic locations.
Initially, Health is Primary was focused on a Medical Home, but is now actively considering the Medical Neighbourhood approach.
Through the collaboration, CVS Health will support the campaign’s efforts to help patients understand when, where and how to access the services they need within the Medical Neighbourhood.

Interestingly CVS see their retail clinics as providing an important complementary role to primary care in the Medical Neighbourhood, by developing an integrative and collaborative system with primary care physicians and other health systems to coordinate patients within an identified Medical Neighbourhood.

With more than 1,050 locations across 33 states and the District of Columbia, MinuteClinic retail clinics are well positioned to play a key role in patient health by extending the hours of the Medical Neighborhood to evenings and weekends. MinuteClinic makes it easier to access care when it’s needed, focusing on acute care, preventive care and supporting management of chronic conditions, while also ensuring connection and communication with the patient’s GP or a referred alternative.

CVS Health and MinuteClinic are also affiliated with more than 60 of the nation’s leading health systems, building strong connections with institutions like the Cleveland Clinic, Henry Ford Health System and Emory Healthcare.

These clinical affiliations foster collaboration between MinuteClinic and health system physicians, facilitate joint programs for treatment of chronic disease and enable communication between electronic medical records.

As a result, MinuteClinic providers can send a care summary to a patient’s primary care physician following the visit.
Patients who do not have a primary care physician are encouraged to obtain one, and are even given a referral list of local physicians who are accepting new patients, to help them get started.

The strong infrastructure of CVS is how they are able to leverage the Medical Neighbourhood system and support it appropriately.
An Australian system founded on the same principles would be an ideal and would provide a liaison point for health professionals based in a GP practice.
Australian Community Pharmacies, as they are currently oriented, ought to be able to put in place a clinic system to their current offering.
This would distinguish them from Retail Pharmacies that are more intent on discounting PBS prescriptions than investing in collaboration.

Establishing a Medical Neighbourhood community pharmacy model would make an interesting project for both the Pharmacy Guild of Australia (PGA) with a 5000+ community pharmacy network already in place and the Pharmaceutical Society of Australia (PSA) who could actively arrange to provide an educative support system for walk-in clinics.
Given that PSA has already taken a role in establishing practice pharmacists based in a GP location and has a working relationship with the RACGP, the job to link the practice pharmacist back to a pharmacy-based clinic and the clinical pharmacists attached to that clinic should not prove too onerous.

If the coordination function also included public health elements that are integral to a Medical Neighbourhood there could also be cost savings for government as well through the pharmacy infrastructure.

And because Community Pharmacy infrastructure  is already in place through location rules, I can at least see a purpose in having Location Rules surrounding pharmacies with clinic structures coordinating Medical Neighbourhoods, including public health components.
In fact, if all parties such as pharmacy leadership organisations, government and doctor organisations, opened their eyes to the prospect of the Medical Neighbourhood, modified Location Rules may need to stay in place for these pharmacies.
This is a point that could be put forward to the committee set up to examine the Location Rules, provided it had wide support.
And why not?
Is it time to create new policies to deal with the differences between Community Pharmacies and Retail Pharmacies?
Medical Home Neighborhood, PCMH, Infographic

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