How are co-located primary health care centres integrating care for people with chronic conditions?

摘要

Introduction : Governments are investing in new models of primary health care to meet contemporary challenges of chronic disease and that fit with their particular context. In Australia two levels of government have responsibilities for health policy and funding. Both have invested in new models of primary care involving GPs, nurses and allied health. Little is known about how they are developing the arrangements for integrating care and their capacity to respond given their context. The research question: How are co-located primary health care (PHC) centres integrating care in the Australian context and how have the contextual factors facilitated or constrained their developments? Theory/Methods : A modified version of the ‘rainbow’ model of integration was used to describe the arrangements for integrating care (1). Methods: A qualitative case study of 6 co-located PHC centres involving at least 3 different health professionals. The sample included centres developed through Commonwealth and State government policy models and an expanded private practice model. Data was collected from 88 semi-structured interviews and non-participant observations. Results : Organisational integration mostly comprised a series of low level, loosely coupled arrangements. The involvement of allied health in training, centre planning or review with other staff was limited. Clinical integration was strongest between GPs and practice nurses, but between GPs and allied health this had not advanced much beyond traditional referrals. Formal multidisciplinary planning or reviews of patients was less developed. Arrangements varied for sharing clinical information. Organisational factors, including the model type, ownership, number of practitioners, co-location of local health network staff, and business viability, defined the internal capacity for integration. External context factors included the Commonwealth/State government split and differing funding mechanisms. These provided support for some internal integration efforts, but limited the development of more formal integration arrangements at all levels and key functional enablers. Discussion : Co-location provided opportunities for informal communication and information sharing. More formal approaches required additional investment of time, money and intent. Higher level of professional and clinical integration and enabling structures found in State health models illustrated the possibilities when the organisational need and benefits are supported by the funding model. Conclusions & lessons learned : The scope for individual initiative and capacity to develop more formal integration approaches is limited by the external constraints. Tinkering with fee-for-service arrangements does little to enhance integration. While internal capacity is necessary, external stimulus is needed such as can be provided through capitated funding. Limitations : The findings apply to co-location and may not apply to other primary health care models where staff work from different sites. Patterns of care at individual patient level, and patient or consumer experiences of integration were not investigated. Suggestions for future research : Future research is needed to study the impact and outcomes of these new organisational models of primary health care and the influence of integration arrangements. References: 1. Valentijn P, Schepman S, Opheij W, Bruijnzeels M. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. 2013.