Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

Health Information Technology in the United States, 2008

Provides updated survey data on health information technology (HIT) and electronic health records adoption, with a focus on providers serving vulnerable populations. Examines assessments of HIT's effect on the cost and quality of care and emerging issues

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background Dementia has an enormous impact on the lives of individuals and families, and on health and social services, and this will increase as the population ages. The needs of people with dementia and their carers for information and support are inadequately addressed at all key points in the illness trajectory. Methods The Unit is working specifically on an evaluation of the impact of the Mental Capacity Act 2005, and will develop practice guidance to enhance concordance with the Act. Phase One of the study has involved baseline interviews with practitioners across a wide range of services to establish knowledge and expectations of the Act, and to consider change processes when new policy and legislation are implemented. Findings Phase 1, involving baseline interviews with 115 practitioners, identified variable knowledge and understanding about the principles of the Act. Phase 2 is exploring everyday decision-making by people with memory problems and their carers

nalysing Change Resistance to an Information Systems-Supported Process in a South African Public Hospital

Introducing technological change to an organization’s normal processes can potentially bring about positive or negative results, depending mostly on the manner in which the change was facilitated and integrated into the organization. However, very little research has been done on information technology (IT) investment among hospitals, its effect on the personnel, as well as how it influences patient care and financial performance. Consequently, little is known about users’ resistance to new technologies and the precedents of technology rejection in healthcare. Therefore, this study seeks to fill the gap of understanding South African hospital staffs’ perceptions towards change, caused by introducing an information system into one of the hospital’s daily processes. Where resistance towards change is identified, the study aims to understand the reasons behind such resistance. Finally, it aims to find appropriate intervention strategies to deal with and minimize resistance. In doing so, the study seeks to contribute to the body of research regarding change resistance to information systems in public South African hospitals. By adopting a descriptive and exploratory interpretivist paradigm, in conjunction with an inductive approach, the study aims to get a better understanding of hospital staffs’ perceptions through shared meaning. The study adopted a case study research strategy, as it affords the researcher the opportunity to participate in the study, and as such contributes to the subjective interpretation of the findings. Data was collected using a mixed method approach, and was used to describe the difference between the current and proposed process. In addition, it was used to explore the reasons for change resistance to information system-supported change, and to explore methods of successfully introducing change to tertiary public hospitals in South Africa. Fourteen participants (7 medical interns and 7 ward clerks) who were directly involved in the process being studied, were interviewed. Two other participants (the head of the pharmacy and the patient flow manager), who were indirectly involved in the process, were interviewed, to verify the observed and mapped process. Interview data was analyzed qualitatively, firstly through coding techniques before using sentiment and thematic analysis. While the mapped process followed Business Process Modelling Notation conventions. In addition to a mapped proposed process, a change resistance conceptual model was developed from a conjunction of the findings and extensive review of literature. The conceptual model asserts that five main factors contribute to change resistance: unclearly defined duties; fear of job security and technology usage; years of service; resource availability and resource mismatch; as well as insufficient training resulting from the lack of a learning culture. These factors can be moderated by: the existing state of affairs referred to as status quo; management involvement; and communication. The conceptual model can be used to better understand the causes of change resistance, as well as how to minimize change resistance and successfully introduce change into a health organization. Change agents should aim to understand the status quo that exists in the organization and find ways of incorporating that into the change process. Furthermore, management should aim to involve and communicate with all affected stakeholders during a change process. This research has provided a better understanding of hospital staffs’ reactions to change, their reasons for resistance, and ways to minimize change resistance while successfully introducing change into a health organization

Record Linkage Techniques: Exploring and developing data matching methods to create national record linkage infrastructure to support population level research

In a world where the growth in digital information and systems continues to expand, researchers have access to unprecedented amounts of data. These large and complex data reservoirs require creative, innovative and scalable tools to unlock the potential of this ‘big data’. Record linkage is a powerful tool in the ‘big data’ arsenal. This thesis demonstrates the value of national record linkage infrastructure and how this has been achieved for the Australian research community

Textbook of Patient Safety and Clinical Risk Management

Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties