The Primary Care Home is a model of integrated care focused on the needs of a defined local population between 30,000-50,000 patients. It involves multi-disciplinary teams of primary care, community, mental health and social care working together to provide and personalize care. The goals are improved health outcomes, quality of care and efficient use of local health resources for the population.

1. www.napc.co.uk/primary-care-home
@NAPC_NHS #primarycarehome
@SteveLaitner
Primary Care Home
A unique model of care
Dr Steven Laitner
GP and Clinical Advisor, NAPC
May 2017

2. © 2016 National Association of Primary Care
• An integrated-care provider model
• Focussed on the needs of a defined population
• Building on the strengths of registered list general practice
• Individual and population health responsibility
• The ‘home of care’ for a population
• The right size to scale and the right size to care
What is a Primary Care Home?

3. © 2016 National Association of Primary Care
The NAPC describes four core characteristics of
a Primary Care Home
Focus on a defined population of 30,000 to 50,000
An integrated, multi-disciplinary workforce
(1’ care, 2’ care, community, mental health, social and voluntary sector)
Provision and personalisation of care, individual
and population outcomes
Financial drivers aligned with the health needs of
the population
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2
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© 2016 National Association of Primary Care

4. © 2016 National Association of Primary Care
Transforming Primary Care – the Primary Care Home
Improved health and
wellbeing
Improved quality of care
for in local
communities
Improved utilisation of
local health and social
care resources
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2
3

5. © 2016 National Association of Primary Care
• Resilience of general practice, support of colleagues
• Flexibility of roles, careers and portfolios
• Team working (“teams” and “squads”)
• Better alignment of roles of functions
• Greater job satisfaction
• Better working lives and work-life balance
• Increased funding for primary care
Why a Primary Care Home?
(workforce perspective)

6. © 2016 National Association of Primary Care
The Patient Customer
One thing I have always found is that you
have got to start with the customer
experience and work backwards to the
technology.
Steve Jobs 1955-2011

7. © 2016 National Association of Primary Care
“

8. © 2016 National Association of Primary Care
Typical journey………..form follows function
Focus – on health and care needs of priority patient
cohorts as well as the whole population
Functions – develop new models of caring – new models
of service delivery
Form – what new organisations forms, if any, are required?
Funding – work with commissioners on funding,
contracting, incentives

9. © 2016 National Association of Primary Care
Population health management is a proactive approach to
managing the health and well-being of a population.
It incorporates the total care needs, costs and outcomes of the
population.
It involves segmenting the population into groups of people
with similar needs to enable targeted interventions for
both those population cohorts and the individual citizens within.
Population health management

10. © 2016 National Association of Primary Care
Segmenting the population
By people who share characteristics
Rather than just by disease group
e.g:
• Generally well
• Frail older people
• Adults with multiple, complex long term conditions
• Adults with drug & alcohol misuse, mental health and social problems
• Children with Learning Disability

11. © 2017 National Association of Primary Care
Generally well Long term condition(s)
Complexity of LTC(s)
and/or disability
Children and
young people
Working age
adults
Older people

12. © 2017 National Association of Primary Care
Generally well Long term conditions
Complexity of LTC(s)
and/or disability
Low risk High risk Low risk High risk Low risk High risk
Children and
Young People
• Neonates
• Infants
• Toddlers
• Children
• Adolescents
Working Age
Adults
• Young
• Middle aged
• Older working
age
Older People
• 65-80
• 80-90
• 90+
Mental Health Problems
Mental Health Problems
CVD
Cancer
Neurological (e.g. CP)
Respiratory (e.g. CF, Asthma)
Learning Disability
Smoking
Alcohol
Inactivity
Frailty
Dementia

13. Children and Young
People
Working Age Adults
Older People
Population health cube

14. Possible 1’ Care Streaming
REACTIVE CARE PROACTIVE CARE
Acute Acute - more complex patients Chronic care
Continuity not important Continuity important Continuity very important
Generally well or non-complex health problems e.g. multi-LTC, complex, learning disability,
nursing homes, residential homes
Single LTC Multi LTC Frailty,
complex
comorbidity,
dementia, end
of life etc
Patient
Call Handler
Any GP
Supported to Managed on GP face Nurse face
self care phone (eg Rx) to face to face
60% 40%
Patient
Call Handler
Named GP
Supported to Managed on GP face Nurse face
self care phone (eg Rx) to face to face
60% 40%
Single point of contact
Patient
Care plan
Case manager
Care coordinator/ Navigator
Named nurse
Named GP/Geriatrician
Community health coaches
Non-clinicalNon-clinical
Source: Dr Steven Laitner May 2015

15. © 2016 National Association of Primary Care
If you would like to join the
NAPC Primary Care Home
programme as a community
of practice site
Download the invitation letter and application form at:
http://www.napc.co.uk/primary-care-home