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A systems approach to optimising primary care for working with vulnerability: Trialling a patient-centred medical home model to improve access


David Menzies

South Eastern Melbourne Primary Health Network, Heatherton, VIC, AU
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Young people living in residential out-of-home care (OOHC) settings due to abuse and neglect are some of the most vulnerable Victorians. Many young people enter OOHC exhibiting complex behaviours, and often with high unmet health needs. These young people need regular health checks and specialist assessments but face barriers in accessing timely and appropriate care. Whilst various policy levers exist to support access, there is no central mechanism to guide or coordinate delivery.

South Eastern Melbourne Primary Health Network (SEMPHN), in partnership with Victorian Department of Health and Human Services, identified general practice as a trial environment to co-ordinate and integrate care, by establishing a medical home for each young person living in OOHC.

A medical home provides a systems response for addressing the following needs:

•              improved service accessibility and responsiveness

•              increased residential staff capability to complete OOHC Health Assessments

•              improved youth engagement with health services

•              improved data custodianship and integration across Child Protection, OOHC and care teams.

Young people (aged 12-17) in residential facilities under state custodianship/guardianship orders were selected for testing the model, as they currently face significant barriers to accessing primary care.

A 12-month trial was completed in 2017, with a scaling phase currently underway (2018-2019).

The pilot trialled three different approaches to compare varying levels of flexibility in primary care delivery. Each model included: care coordinator; trauma-informed care training to general practice; practice systems review to optimise access; clinical secondary consultation for residential care staff.

The key benefits of a medical home for vulnerable young people include comprehensive, whole-person care, and shared decision-making. The development of a relational approach to care has resulted in increased trust and engagement, which has led to increased health assessments, self-management and improved health literacy.

While early outcomes have demonstrated promising and important new ways of working, the key relationship which requires continued investment is between PHN and DHHS, to facilitate continuing integration efforts. Key inter-departmental levers also need to continue being enabled between DHHS, OOHC and Child Protection, particularly in terms of data linkage and workforce development.

The current focus should remain on residential OOHC environments and on scaling local capability of primary care practitioners and medical home numbers, to support the entire catchment. Future development opportunities for the OOHC sector include trialing the approach in foster care and kinship care environments.

The trial developed a systems model to drive a whole-of-practice approach to supporting young people in OOHC. This project has identified ten key building blocks to underpin primary care approaches to working with vulnerable population groups: practice systems review; enabled priority access; multidisciplinary collaboration; assertive contact; cultural safety; welcoming physical environment; data sharing; patient communications; emphasis on confidentiality and security.

Achieving improved outcomes for vulnerable populations can be challenging and resource intensive. Improving care across the continuum requires continuous quality improvement and investment to build the capacity of care providers. This also includes investment into change management support required at appropriate levels.

How to Cite: Menzies D. A systems approach to optimising primary care for working with vulnerability: Trialling a patient-centred medical home model to improve access. International Journal of Integrated Care. 2021;20(S1):66. DOI:
Published on 26 Feb 2021.


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