My Care Partners
Information for general practice and other health professionals
My Care Partners is an innovative new program for general practices in South Western Sydney. Eligible general practices joining My Care Partners become part of a healthcare neighbourhood, providing enhanced care to patients with chronic and complex conditions who are at risk of frequent hospitalisations.
The My Care Partners Program adopts a ‘medical neighbourhood’ model of care, co-designed by SWSPHN, SWSLHD and members of the community.
The goal of My Care Partners is to:
- Improve coordination between the patients’ medical home, primary and community services and acute care
- Improve outcomes for patients with complex and chronic conditions who are at risk of potentially preventable hospitalisations
- Improve patient and provider experience by encouraging continuity of care and team-based care to reduce the risk of omission or duplication of services
My Care Partners is an ongoing program. The vision is for My Care Partners to expand geographically within South Western Sydney, as well as expanding across different patient cohorts within each My Care Partners practice.
My Care Partners aims to create:
My Care Partners practices will receive ongoing support to transform into a Patient Centred Medical Home (PCMH). Practices will be supported to complete models of improvement to improve key areas within the PCMH model; patient centred care, coordinated care, comprehensive care, accessible care and safe, high-quality care. Practices will also receive ongoing support from SWSPHN to implement My Care Partners into their workflow processes.
My Care Partners practices will be supported to become a Patient Centred Medical Home (PCMH) through access to:
- Ongoing support from SWSPHN My Care Partners team and SWSLHD Care Enabler team to improve outcomes for patients living with complex chronic conditions
- Training in digital health readiness and enrolment readiness from the PHN team and Care Enabler team
- Free workshop attendance
- Access to ‘shared cost savings’ distributed across the ‘medical neighbourhood’ for practices who achieve patient outcomes
- Payments to the practice for setting up as a My Care Partners practice, and ongoing patient enrolment and activity payments
- Opportunities to network with other My Care Partners practices and external providers in your ‘neighbourhood’ to improve communication and enhance relationships
GPs will enrol patients with complex and chronic conditions who have been identified as at risk of potentially preventable hospitalisation.
To become a My Care Partners practice, you commit to
- Working with a SWSLHD Care Enabler and patient care teams to continue to provide team-based care to identify patients’ needs
- Completing set activities for each enrolled patient
- Completing a Practice Self-Assessment Tool (PSAT) to identify the practice’s strengths as well as areas for improvement. Based on the results, the practice will complete action plans to help them work towards becoming a Patient Centred Medical Home
- Providing protected time to allow for staff training and innovation
- Identifying eligible patients for My Care Partners and enrolling them into the program
- Installing and enabling digital health applications to improve communication between providers and to track patient journeys
- Reviewing reports and working with patients and their care team to identify needs that can assist in reducing a patient’s risk of potentially preventable hospitalisations
- Contributing to the evaluation of My Care Partners by providing qualitative and quantitative de-identified practice data to an evaluation team
Download the My Care Partners - Expression of Interest
Contact our My Care Partners project team for more information about joining the program.