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Practice-based Population Health Management Program

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Content last updated 8/01/2024

GCPHN Practice-Based Population Health Management Program

This document provides background information and insights gained by GCPHN during the two years (2015-17), while developing the Practice Based Population Health Management Program.

A component of this was the development of a person centred approach to managing complex patients 75 years and older based on a “seasonal approach”. This model ensures all aspects of care are covered over a twelve month period.

This model has now been adapted into a broader concept to include a broad range of vulnerable groups, known as the “Wellness Strategy”

To support the management for these vulnerable groups a range of CQI templates have been developed.

What is Person Centred Care? 

Person-centred care is widely recognised as a foundation to safe, high-quality healthcare. It is care that is respectful of, and responsive to, the preferences, needs and values of the individual patient. 

It involves seeking out, and understanding what is important to the patient, fostering trust, establishing mutual respect and working together to share decisions and plan care. 

There is good evidence that person-centred approaches to care can lead to improvements in safety, quality and cost effectiveness, as well as improvements in patient and staff satisfaction. (Australian Commission on Safety and Quality in Health Care) 

Gold Coast PHN statistics
https://gcphn.org.au/practice-support/support-for-general-practice/practice-based-population-health-management-program/#gold-coast-phn-statistics Copied to clipboard

Gold Coast median age of death is 82 years.

Source: The Australian Bureau of Statistics (2020 – 2022), Life expectancy

For Aboriginal and Torres Strait Islander peoples:

Gold Coast Median age of death, 2013-2017

  Male Female Persons
Aboriginal and Torres Strait Islander People 60 72.5 66.5

Source: The Australian Bureau of Statistics – Patient Experience Survey results 2018 -2019

For Gold Coast adult residents that completed the survey:

  • 43.1% identified having a long term health condition (Range for all PHNs 64.4% – 38.3%)
  • 86.8% reported that they felt their GP always or often spent enough time in the preceding 12 months (Range for all PHNS 94.5% – 85.9%)

Cycles of Care
https://gcphn.org.au/practice-support/support-for-general-practice/practice-based-population-health-management-program/#cycles-of-care Copied to clipboard

Seasonal Focus

Winter
https://gcphn.org.au/practice-support/support-for-general-practice/practice-based-population-health-management-program/#winter Copied to clipboard

Winter – Burden of Care

June – July – August

Spring
https://gcphn.org.au/practice-support/support-for-general-practice/practice-based-population-health-management-program/#spring Copied to clipboard

Spring – Clinical Coding

September – October – November

Summer
https://gcphn.org.au/practice-support/support-for-general-practice/practice-based-population-health-management-program/#summer Copied to clipboard

Summer – Advance Care Planning

December – January – February

Autumn
https://gcphn.org.au/practice-support/support-for-general-practice/practice-based-population-health-management-program/#autumn Copied to clipboard

Autumn – Prevention

March – April – May