Purpose: Evidence suggests that Patient-centred Medical Home (PCMH) model facilitates person-centred care and improves health-related quality of life for patients with chronic illness. This study aims to evaluate changes in health-related quality of life (HRQoL), before and after enrolment into a 12-month integrated care program called ‘WellNet’. Methods: This study includes 616 eligible consented patients aged 40 years and above with one or more chronic conditions from six general practices across Sydney, Australia. The WellNet program included a team of general practitioners (GPs) and clinical coordinators (CCs) providing patient-tailored care plans configured to individual risk and complexity. HRQoL was recorded using the validated EuroQol five dimensions five levels (EQ-5D-5L) instrument at baseline and 12 months. Additionally, patients diagnosed with osteoarthritis also reported HRQoL using short versions of Knee and/or Hip disability and osteoarthritis outcome scores (KOOSjr and HOOSjr). A case-series study design with repeated measures analysis of covariance (ANCOVA) was used to assess changes in mean differences of EQ-5D index scores after controlling for baseline covariates. Additionally, backward stepwise multivariable linear regression models were conducted to determine significant predictors of EQ-5D index scores at follow-up. Results: Out of 616 patients, 417 (68%) reported EQ-5D scores at follow-up. Almost half (48%) of the WellNet patients reported improved EQ-5D index scores at follow-up. After controlling for baseline covariates, the adjusted mean difference was statistically significant whilst also meeting the bare minimal clinically important difference (MCID) with a change of 0.03 (95% CI 0.01, 0.05). The multivariable regression models determined that baseline EQ-5D scores and positive diagnosis of a respiratory illness were significant predictors of HRQoL at follow-up. There were significant improvements across both KOOS and HOOS assessments, specifically, the pain and symptom scores in both scales met statistical significance in addition to meeting the MCID.Conclusion: Patient-tailored chronic disease management (CDM) plans designed by team of GPs and CDM clinical coordinators could lead to better HRQoL among primary care patients.

Background: Studies report that increased levels of patient activation is associated with increased engagement with the health care system, better adherence to treatment protocols, and improved health outcomes. This study aims to evaluate outcomes based on a 12-month Patient-Centred Medical Home (PCMH) model called ‘WellNet’ on activation levels of patients with one or more chronic diseases in general practices across Sydney, Australia.Methods: A total of 636 patients aged 40 years and above with one or more chronic conditions consented to participate in the WellNet program delivered across six general practices in Northern Sydney, Australia. The WellNet intervention includes a team-based care with general physicians and trained chronic disease management care coordinators collaborating with patients in designing a patient-tailored care plan with improved self-management support and care navigation according to the level of risk and health care needs. Level of patient activation was measured using the validated PAM 13-item scale at baseline and follow-up. A before and after case-series design was employed to determine adjusted differences between baseline and 12-months using repeated measures analysis of covariance (ANCOVA). Additionally, backward stepwise multivariate regression models were employed to identify significant predictors of activation at follow-up.Results: Of the 626 patients, 420 reported their PAM scores at follow-up. The mean (SD) baseline PAM score was 57.9 (13.0). The adjusted model showed significant mean difference in PAM scores of 6.5 (95% CI 5.0-8.1; p-value<0.001) after controlling for baseline covariates. Multivariate regression models showed that older age (B = -0.14; 95% CI -0.28, -0.01) and private insurance (uninsured patients) (B = -3.41; 95% CI -6.50, -0.32) were significantly associated with lower PAM scores at 12 months whereas higher baseline PAM scores (B = 0.48; 95% CI 0.37, 0.59) was significantly associated with higher follow-up PAM scores.Conclusion: The WellNet study is the first of its kind in Australia to report on changes in the patient activation levels among patients with one or more chronic diseases. PCMH has the potential to improve patient activation and engagement which can lead to long-term health benefits and sustained self-management behaviours.

Background: Studies report that increased patient activation is associated with increased patient engagement with the health care system, better adherence to treatment protocols, and improved health outcomes. This study aims to evaluate outcomes based on a 12-month Patient-Centred Medical Home (PCMH) model called ‘WellNet’ on activation levels of patients with one or more chronic diseases in general practices across Sydney, Australia.Methods: A total of 636 patients aged 40 years and above with one or more chronic conditions consented to participate in the WellNet program delivered across six general practices in Northern Sydney, Australia. The WellNet treatment includes a team-based care with general physicians and trained chronic disease management care coordinators collaborating with patients in designing a patient-tailored care plan with improved self-management support and care navigation according to the level of risk and health care needs. Level of patient activation was measured using the validated PAM 13-item scale at baseline and follow-up. A before and after case-series design was employed to determine adjusted differences between baseline and 12-months using repeated measures analysis of covariance (ANCOVA). Multiple imputation was used to compute missing follow-up scores using Markov Chain Monte Carlo (MCMC) algorithm known as fully conditional specification (FCS). Additionally, backward stepwise multivariate regression models were employed to identify significant predictors of activation at follow-up.Results: Of the 626 patients, 420 reported their PAM scores at follow-up. The mean (SD) baseline PAM score was 57.9 (13.0). The adjusted model showed significant mean difference in PAM scores of 6.5 (95% CI 5.0-8.1; p-value<0.001) after controlling for baseline covariates. Multivariate regression models showed that older age (B = -0.14; 95% CI -0.28, -0.01), baseline activation score (B = 0.48; 95% CI 0.37, 0.59), and private insurance (uninsured patients) (B = -3.41; 95% CI -6.50, -0.32) were significant predictors of patient activation at follow-up.Conclusion: The WellNet study is the first of its kind in Australia to report on changes in the patient activation levels among patients with one or more chronic diseases. PCMH has the potential to improve patient activation and engagement which can lead to long-term health benefits and sustained self-management behaviours.

Background: Studies report that increased levels of patient activation is associated with increased engagement with the health care system, better adherence to treatment protocols, and improved health outcomes. This study aims to evaluate the outcomes of a 12-month Patient-Centred Medical Home (PCMH) model called ‘WellNet’ on the activation levels of patients with one or more chronic diseases in general practices across Northern Sydney, Australia.Methods: A total of 636 patients aged 40 years and above with one or more chronic conditions consented to participate in the WellNet program which was delivered across six general practices in Northern Sydney, Australia. The WellNet intervention includes team-based care with general physicians and trained chronic disease management care coordinators collaborating with patients in designing a patient-tailored care plan with improved self-management support and care navigation according to the level of risk and health care needs. The level of patient activation was measured using the validated PAM 13-item scale at baseline and follow-up. A before and after case-series design was employed to determine the adjusted mean differences between baseline and 12-months using repeated measures analysis of covariance (ANCOVA). Additionally, the backward stepwise multivariable regression models were employed to identify significant predictors of activation at follow-up.Results: Of the 626 patients, 420 reported their PAM scores at follow-up. The mean (SD) baseline PAM score was 57.9 (13.0). The adjusted model showed significant mean difference in PAM scores by increase of 6.5 (95% CI 5.0-8.1; p-value<0.001) after controlling for baseline covariates. The multivariable regression models showed that older age (B = -0.14; 95% CI -0.28, -0.01) and private insurance (uninsured patients) (B = -3.41; 95% CI -6.50, -0.32) were significantly associated with lower PAM scores at 12 months whereas higher baseline PAM score (B = 0.48; 95% CI 0.37, 0.59) was significantly associated with higher follow-up PAM score.Conclusion: The WellNet study is the first of its kind in Australia to report on changes in the patient activation levels among patients with one or more chronic diseases. PCMH has the potential to improve patient activation and engagement which can lead to long-term health benefits and sustained self-management behaviours.

Purpose Evidence suggests that Patient-centred Medical Home (PCMH) model facilitates person-centred care and improves health-related quality of life for patients with chronic illness. This study aims to evaluate changes in health-related quality of life (HRQoL), before and after enrolment into a 12-month integrated care program called ‘WellNet’. Methods This study includes 616 eligible consented patients aged 40 years and above with one or more chronic conditions from six general practices across Sydney, Australia. The WellNet program included a team of general practitioners (GPs) and clinical coordinators (CCs) providing patient-tailored care plans configured to individual risk and complexity. HRQoL was recorded using the validated EuroQol EQ-5D-5L instrument at baseline and 12 months. Additionally, patients diagnosed with osteoarthritis also reported HRQoL using short versions of Knee and/or Hip disability and osteoarthritis outcome scores (KOOSjr and HOOSjr). A case-series study design with repeated measures analysis of covariance (ANCOVA) was used to assess changes in mean differences of EQ-5D index scores after controlling for baseline covariates. Additionally, backward stepwise multivariable linear regression models were conducted to determine significant predictors of EQ-5D index scores at follow-up. Results Out of 616 patients, 417 (68%) reported EQ-5D scores at follow-up. Almost half (48%) of the WellNet patients reported improved EQ-5D index scores at follow-up. After controlling for baseline covariates, the adjusted mean difference was statistically significant whilst also meeting the bare minimal clinically important difference (MCID) with a change of 0.03 (95% CI 0.01, 0.05). The multivariable regression models determined that baseline EQ-5D scores and positive diagnosis of a respiratory illness were significant predictors of HRQoL at follow-up. There were significant improvements across both KOOS and HOOS assessments, specifically, the pain and symptom scores in both scales met statistical significance in addition to meeting the MCID. Conclusion Patient-tailored CDM plans designed by team of GPs and CDM clinical coordinators could lead to better HRQoL among primary care patients.