Better, sooner, more convenient health care in Midlands

The Integrated Family Health CentreA local focus on taking control of the day4• Community Pharmacists• Midwifery ServiceWhy they exist:This team becomes an individual’s health care team and takes on the responsibility of deliveringhealth care to their enrolled population. They provide coordinated, managed patient centred careto acute, chronic and well patients alike. Their focus is on the whole team providing the patients carewith each team member providing a key component of that circle of care.What they do:Self-managing (support available)Self-managing (support required)Not self-managing(support required)Well patient groupFocus on keeping the patient wellActive managementAchieve health milestones inside timeframesActively manage imms milestonesMonitor patient journey through thehealthright wheelReview information provided by thepatientReview changes in patient situation forpossible health risksRecommend wellness programmesHealth EducationRefer for secondary careTreat acute needsRecommend wellness programmesHealth Education and PromotionManage interventionsPatient centred management plansReview and plan with patient selfmanagementplansOversee Duty of Care model withcommunity management plansRefer for secondary careTreat acute needsRecommend wellness programmesHealth EducationManage interventionsPatient centred management plansReview and plan with patient selfmanagementplansOversee Duty of Care model withcommunity management plansDiscuss management optionscase conference for solutions withteamInter disciplinary team managementManagement Continuum42