For a PHO implementing the Health Care Home programme several steps must be considered prior to implementation.
The below image depicts one pathway for a practice (or PHO) considering implementing the model of care.
Dr Andrew Miller,
GP Bush Road Medical
I really like the idea of revisiting the concept of risk stratification. Even renaming the element to "opportunity stratification" would change the mindset of seeing patients as "risks". We should be looking for opportunities to find out "what matters to people" and engage with people to try and resolve the things that are getting in the way of well being.
This means looking a data that sits outside of health and takes into consideration the social determinants that impact on well being. It also means having care planning that starts with social determinants and patient activation measures before making our business as usual medical model plans.
