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Making a Difference: Patient Centred, Integrated Care in a General Practice Setting


Kylie Ormrod


Introduction: New Zealand’s population is growing, ageing and living longer with ensuing increases in chronic disease. At the same time, the healthcare system is under increasing financial and workforce pressure due to the pattern of demand. Sustainable intervention and new models of care are needed to meet and manage this demand and improve efficiency and effectiveness. This project is a government funded, year-long demonstration of a new model of integrated and patient-centred care that is delivered in primary care settings which supports and empowers patients with chronic disease to successfully manage their conditions.

Project description: An integrated model based on care planning where health goals are set in partnership with patient and clinician is being demonstrated in two general practices with different geographical locations, patient populations and business models. A shared information technology platform and access to multidisciplinary input is designed to enable coordinated management while flexible funding allows individualised interventions and more effective and patient-centred care. Emphasis has been placed on the change management processes and business modelling required to sustainably implement the model with transferrable lessons captured to inform the roll out of future initiatives.

Key findings: The shift from a traditional business model to an integrated and patient-centred care model requires considerable change support. It has been more successful with active and visible ‘executive’ sponsorship from within the practice, along with a dedicated change management coach. The model works best when implemented as a whole practice approach. It requires clear and effective internal communication and on-going training for all roles.

Quality care planning that incorporates psycho-social needs alongside the traditional medical focus and coordination of appropriate services is contributing to valuable patient outcomes. These include better engagement and patient experience, medication adherence, preliminary reductions HbA1c levels and continuity of care, among other benefits.

Highlights: Improved patient outcomes and stories are evident, for example; HbA1c reductions through ascertaining barriers to healthy eating (e.g. lack of an oven at home), or phobia of needles causing the patient to not want to take insulin.

The pace of change that can be achieved when you have an executive sponsor who can commit resources and get the practice team involved, on-board and engaged has been a highlight.

Conclusion: The approach is demonstrating improved patient outcomes. Implementation of a model of this scope requires investment in change management as well as consideration of the financial and time impacts on privately owned general practices; and has been specifically implemented in order to achieve sustainability and transferability.

How to Cite: Ormrod K. Making a Difference: Patient Centred, Integrated Care in a General Practice Setting. International Journal of Integrated Care. 2016;16(6):A124. DOI:
Published on 16 Dec 2016.


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