Expression of Interest - WellNet Integrated Care Program

Hunter New England Central Coast PHN is pleased to offer practices in the region the opportunity to take part in this new initiative focusing on patients with chronic disease who are at high risk of complications and/ or hospitalisation.

The primary objective of the initiative is to deliver better health outcomes through the Patient Centred integrated medical home model.

Practices involved in the WellNet Program will be provided with assistance to implement the integrated care model with a “GP-led” team based care, particularly in the management of chronic and complex patients. Working within the current Medicare funding structure practices will have access to additional resources, including:

• A dedicated resource (Care Coordinator) will join your team to provide additional support for your patients, including care coordination and planning functions, at no cost to the practice
• Free access to an extensive suite of resources (templates, patient education materials, practice kit)
• Free licensing for cdmNet
• Progress reports specific to your practice and final program evaluation results
• Initial and ongoing support and training for the entire practice

Eligibility Criteria

Practices must meet the following eligibility criteria to be considered:

• A medium sized practice with a minimum of 4 FTE GPs.
• The majority of the practice must be willing to engage in all aspects of program for a period of 16 to 18 months
• Must use a combination of one of the following clinical management and practice management systems:
  • Best Practice (CMS) and Best Practice (PMS)
  • Best Practice (CMS) and PracSoft (PMS)
  • Medical Director (CMS) and PracSoft (PMS)
• Be willing to install and use the ‘cdmNet’ platform to assist with care planning, care coordination and data analytics
• To consent to providing access to their clinical data to facilitate risk stratification (proactive patient identification and selection). Patient privacy is maintained at all times.
• An available room and access to clinical systems for the Care Coordinator on at least 3 days per week

If you would like more information about the program our project team will organise a site visit.

Please contact Melissa Cromarty on mcromarty@hneccphn.com.au to express an interest or to obtain more information.

EOI closes on October 25 2018