Better, sooner, more convenient health care in Midlands

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4The Integrated Family Health CentreA local focus on taking control of the dayAs a proof of concept the health burden model has been developed using demographic informationwithin mesh blocks, and disease prevalence ratios, checked against available disease coding data, toproject concentrations. The application of health burden becomes far more useful when applied tosmaller populations within areas covered by Integrated Family Health Centres, where the particularcharacteristics of the population and actual disease coding data can be used to refine the method tosub mesh block geographic coding.Incorporating other patient characteristics of engagement and their capability for healthmanagement against the health burden provides the ability to determine the nature of servicedelivery to the population within the Integrated Family Health Centre and other allied primary andsecondary health providers. The determination of the health service burden within a particular areaallows for far better planning of the health service resources required to support it.Integrated Family Health Centre Commissioning ToolGenderEthnicityIFHC EnrolledpopulationQuintileAge BandsPOPULATIONPrevalence RatesDiabetesCardio VascularMental HealthHealth BurdenYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeopleUserNeedsProfileEngagedNot EngagedSelf-ManagementSupport AvailableSelf-ManagementSupport RequiredNo Self-ManagementSupport RequiredNeeds ProfileService BurdenYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeoplePick UpDeliveryRequired HealthProvider Capacity(IHFC and AlliedProvider FTEs)Service StandardYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeoplePick UpDeliveryHealth ProviderBy Service TypeYouth HealthWell / LifestyleDiabetesCardio VascularMental HealthOlder PeopleConceptual model of the Commissioning Tool: Helping plan both staffing structure and workflowaccording to patient needs.47
The Integrated Family Health CentreA local focus on taking control of the day4Pharmacy as a valued part of the Health TeamIn an Integrated Family Health Centre, the Community Pharmacy and the Pharmacists will not onlybe included as part of the core Health Team but have access to the same MedTech system used bythe Centre. Pharmacists will be able to view patient records as part of the team. Communicationbetween the Flow Team, GPs and the Pharmacist will be seamless and the Pharmacist will be ableto double check any scripts with items of concerns with General Practitioners instantly. The DrugInteraction Alert System will be used regularly by General Practitioners and learnings reinforced byall parties.Community Pharmacies and Pharmacists will move to become part of the core Health Team. Theirprofessional knowledge will become a significant component of the working day and the circle ofpatient knowledge. The Integrated Family Health Centre will capitalise on a pharmacist’s ability toprovide follow up knowledge and support.As a member of the Health Team the Pharmacist will fill a key role in every patient’s coordinated caseconferenced Care Plan. In addition to this, Community Pharmacy will support the Integrated FamilyHealth Centre by providing the following services:• Comprehensive Warfarin Counselling;• Smoking Cessation Counselling;• Medicine Use Reviews;• Free Emergency Contraception for under 25 year olds;• Flu Vaccination Campaigns;• Waste Management Contract and DUMP (Disposal of Unwanted Medicines Programme);• Medication Counselling Service for patients initiated on medicines for mild tomoderate depression.Integrated Family Health Centres will work to ensure that scripts written by General Practitioners formedication are up to date. The aim is to reduce the number of scripts that are never picked up andincrease communication between all parties. Using a central record will mean that Health Teams willbe able to see instances where a prescription was never filled and enquire as to the reasons why.Follow up will form a central part of the new model of working for the Pharmacist. TXT forprescription pick up and follow up will become a central component of all Integrated Family HealthCentres. Anyone who doesn’t fill their script within 24 hours will receive a text follow up or reminderfrom the Pharmacist or Flow Team. Prescriptions will be able to be ordered and refilled online andpicked up or couriered directly by the pharmacist.Self-Management - support to self-manageIt is acknowledged (Doolan-Noble: 2009, Bycroft and Tracy: 2006, MOH: 2009) that patients have thegreatest influence on the outcome of their health, they decide when and what to eat, when they willexercise, when they will rest, when they will take their medication yet WHO states that ‘patients andtheir families are the most undervalued assets in the health care system’ (WHO: 2002).In order to capitalise on the influence of patients and their families in the management of long termconditions, health sector designers and funders state more emphasis needs to be placed on theconcepts of self-management, self care and self-management support.Telephone Support allowing Patients to self-manage their own health outcomesTele-health involves the use of tools and resources that connect patients and providers both at aninteraction level and a health information level. Examples include, at the simpler level, the use oftelephone, text message or email interactions to improve contact between the health service andthe patient to interactive monitoring of long term conditions which activates remote health careservices and adjustments of treatment plans.48
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Better, sooner, more convenient health care in Midlands

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