The Primary Care Team will consist of GPs, practice nurses, and allied health providers where patients can expect to receive preventive and holistic care, ongoing chronic and acute care management and referral and ready access to community, specialist, and acute services when needed. Services to be provided by the Primary Health Care Team include patient self-management support, health coaching, care planning, care navigation, multidisciplinary team care planning and case management as their chronic disease progresses and care becomes more complex. Patients will be managed and monitored by their GP supported with the assistance of community based Care Facilitators and specialist teams.
The primary care goals will be to maintain good health, prevent acute or chronic deterioration of the patient's condition, identify any deterioration promptly, provide immediate intervention, and determine when specialist services are required. The patients' health status and care plans will be regularly reviewed by the Primary Care Team. The Patient Centred Medical Home (PCMH) concept advocates enhanced access to comprehensive, coordinated, evidence-based, interdisciplinary care. The GP model of care to be provided to patients eligible for Integrated Care is based on the Patient Centred Medical Home Model (PCMH), which sees a focus on the provision of whole person, accessible and comprehensive care. This means a focus on the patient rather than their presenting problem.
For Integrated Care patients, this means a commitment to monitor and manage the patients and their health record over time, to maintain a dynamic shared care plan for the patient, and to work with the patients Care Facilitator to integrate the patients' care with other relevant health care providers.