Our population medicine product, The Value Care Team (TVCT) is
structured as a multidisciplinary team of GPs, a consulting physicians
and associate allied healthcare professionals, directed by a Business
Manager and employs nurse care coordinators. There are subcontracts
for palliative care; with a 24/7 health support call centre and a hospital
case management service. The approach includes the POPI enrolling of
target patient populations, and the creation of complete and accurate
patient information. Care Coordinators assess severity using disease
specific, frailty, mental health tools as well as the degree of social
isolation. Multidisciplinary team forums then link every patient to
individual care plans which are then loaded into the workflow system
that specifies tasks and monitors progression. Forums include local
clinical and social partners such as from subacute hospitals, the local
hospice, and psychiatric facilities. Care plans provide comprehensive
proactive care that improves outcomes for patient populations. A
new Value Based Care Population healthcare project was launched
in September 2019 in Pretoria North, with the Government Employee
Medical Scheme (GEMS) as the anchor medical scheme, and this has
been renewed for 2021.
The GP Care Cell is a PEPFAR sponsored HIV focused product for
non-Scheme members that links our managed network of GPs to the
Gauteng Health Department for access to antiretroviral therapy and
NHLS pathology tests for the screening, identification and management
of people living with HIV. The GPCC has run projects in Tshwane,
Ekurhuleni, Johannesburg, and Sedibeng Health districts. It has the
potential to be a national franchise model for public private collaboration.
The Birthing Team is our maternity product, where the team is made up
of midwives backed by obstetricians, and the aim is to change the current
culture of the default delivery being the caesarean section (around 80%
currently in the private sector) and instead do normal vaginal deliveries
whenever possible. TBT has done some 2,000 deliveries for self funded
women, and two of the 3 major units have achieved 40% CS rates, with
ongoing reduction as the Teams mature. TBT is now contracting with
medical schemes.
The Cardiac Focused Factory is a product in development, which aims to
efficiently use cardiac catheterisation laboratories to provide angiograms
with or without coronary interventions plus pacemaker insertions at
significantly reduced prices, based on a Team model that achieves
economies of scale including staff substitutional and switching much of
the work up and post procedure care from the hospital back into the
PHC service.