Better, sooner, more convenient health care in Midlands

Our NetworkA focus on workforce knowledge, skills and attitude6PHO seed-funding for local initiativesEach PHO will be encouraged to contribute 10% of any retained earnings generated in their regiondirectly into their community to support local community activities. This will encourage greaterengagement between the network and their communities, and build on the public’s perception ofprimary health as a local force for good.Medical PAs, Flow Teams and Patient AdvocatesTo enable Integrated Family Health Centre to work as they are designed to, new roles must beestablished in order to redirect work priorities to where they are best suited. The IntegratedFamily Health Centre has a bold new set of goals that are largely felt to be impossible by thefrontline workforce.Significant change will need to occur for the Integrated Family Health Centre to work as intended.The diagnostic role of the generalist is the most important. Position and longevity of contact aswell as local context and cultural understanding improve efficacy of diagnoses. The vision is for theGeneral Practitioner to be the highly skilled, highly motivated diagnostic generalist at the heart ofthe team. Everything around the General Practitioner supports the diagnostic machine that is ourGeneral Practitioner. New roles will be established inside the Health Team to enable this to occur.Medical PAsThis role works directly with the General Practitioner. They are the conduit between the Flow Teamand the General Practitioner, the patient and the General Practitioner and the patient and the FlowTeam. They work to anticipate visit needs with the patient, support the needs of the patient duringthe visit and provide connectivity to the General Practitioner post visit. This role uses the CUTmethod in all interactions with the patient regarding medical instructions or information. They arealso the administrative service that enables General Practitioner time to be freed up. They are servicefocused and patient centred in everything they do.Flow TeamsFlow Teams work to support the patient. Each Flow Team has a number of different componentsbut their central aim is to keep the highest possible number of patients with a complete and upto date baseline health screen, making them by definition - engaged. The Flow Team works as theconduit between the in-situ team and the community team. They ensure case conferencing occurs ina manner which ensures Duty of Care is top of mind at all times. The Flow Team coordinates pre andpost visit screens, follow ups, may assist with procedures, make planned care outreach calls, followup with post visit contact and prescription pick ups. They work with the Medical PA and pharmacy toensure any medication queries are cleared up as fast as possible. Liaison with the Regional ReferralCentre is an important part of their day ensuring transfer of care is maintained for all enrolledpatients being discharged from hospital.Patient AdvocatesThe Patient Advocate role is a resource dedicated specifically to keeping the number of disengagedpatients to a minimum. Often work with those who have disengaged from the system is confusedwith a team that provides health care in the community. Patients disengage for a number of reasons- sometimes the patient may not wish to receive health care but all too often it is simply life or theway the primary care chooses to interacts with their patients that gets in the way and forms the keybarrier to engagement. The Patient Advocate works in their community and inside the boundaries ofprivacy law to ensure the highest possible level of engagement. Engagement is defined as having afull baseline health screen that has been updated either online or manually on an annual basis.The role of Patient Advocate requires a specific skill set, that of knowing one’s community, andacknowledgement that this requires resources and time. It is not an administration task necessarily(although much of it can be done via the phone). It is about managing networks of people and70