Chronic disease management through patient-centred care : improving clinical and patient-reported outcomes among chronically ill patients using an enhanced primary care model in Sydney, Australia

Abstract

The growing burden of chronic diseases presents significant challenges to health care systems worldwide and emphasises the need to explore better strategies towards chronic disease management. There has been a growing advocacy to revisit strategies to provide patientcentred care that better targets patients' health care needs to achieve better outcomes. Evidence suggests that the Patient-Centred Medical Home (PCMH) model of primary care is more effective than standard care in improving chronic disease management. However, the strength of the evidence base, especially in Australian context, is unclear. This study used the originally collected GP data for the novel PCMH based program called 'WellNet' delivered across several general practices in the Sydney North Health Network (SNHN) region. The primary aim of this thesis is to examine the outcomes of an enhanced primary care model in improving patient outcomes related to chronic disease management. Specifically, this thesis aims to: (a) generate a current synthesis of relevant studies on the effectiveness of PCMH model of primary care versus standard care in chronic disease management; (b) examine the feasibility of program design, recruitment, early implementation experiences of general practitioners (GPs), and results of the 12-month 'WellNet' program; and (c ) evaluate the effectiveness of WellNet's PCMH based care in improving clinical and patient-reported outcomes (PROs) among primary care patients whilst making comparisons with a matched group of standard GP care patients. The WellNet study is one of the first studies to evaluate the clinical outcomes and PROs of PCMH-based care in Australian primary care practices. Findings from this study would enable policymakers to provide recommendations that would inform practice and implementation guidelines. This, in turn, could result in a paradigm shift in the efficiency of primary care in Australia and other health systems worldwide.

Date of Award	2021
Original language	English