Integrating health care in Australia : a qualitative evaluation

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses. We aimed to investigate the WSICP’s effectiveness through a qualitative evaluation focused on the 10 WSICP strategies. The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research

The Western Sydney Integrated Care Program: Qualitative Evaluation

Background: In 2014-17, the Western Sydney Integrated Care Program (WSICP) was implemented. It is a ‘Demonstrator’ partnership between the Western Sydney Local Health District and the Commonwealth’s Primary Health Network in Western Sydney - WentWest. Funded by the NSW Ministry of Health, it aims to integrate primary (community-based) and secondary (hospital-based) health care for patients with diabetes, cardiac failure and chronic obstructive pulmonary disease. Several strategies were used to build local community capacity in managing these conditions, integrate care between service providers, and develop shared-care protocols. Western Sydney University researchers here present a qualitative evaluation based on data from two interview rounds, conducted a year apart. These comprised 125 interviews with patients, carers, health care providers and WSICP management. Findings: By March 2017, after a slow start to the program, patients reported improved access to health services, including to Rapid Access Clinics. ‘Patient Hotline’ phone access to known clinic staff was an alternative to Emergency Department (ED) attendance and, sometimes, to clinic presentation. Community-based care facilitators (usually nurses), assisting patients to follow shared-care plans, were a vital link between hospitals and general practitioners (GPs); following up patients in transition from hospital to home; and sharing information across sectors. Interviewees valued holistic, team-based care provided by clinics, with their focus on giving patients knowledge and skill to better manage their illnesses. Shared patient-care plans and specialist action-plans improved communication and gave patients more confidence. Whereas relationships between GPs and hospital staff improved and disease-specific teamwork was demonstrated, inter-specialty collaboration did not improve as greatly. Although GPs were, at times, difficult to engage , they reported improved access to hospital specialist advice through telephone support, and improvements in clinical care as a result of practice-based education where specialists helped GPs and vice versa. Health Pathways assisted with evidence-based care, though some GPs found the on-line platform challenging. Information technology (IT) difficulties limited the use of shared records. Enrolment criteria were contentious. Many in need were excluded. Lack of transport and hospital parking were barriers, especially for the disabled. The fact of this being a short-term trial significantly impeded engagement with WSICP, staff recruitment and staff retention. Conclusions: We found achievement across all quadruple aims. Patients were better able to manage their health conditions, access hospital services and were highly satisfied with WSICP services. Improved population health is a likely longer term outcome, resulting from improved chronic disease management and a focus on preventive health care. Reduced health care costs were proposed as a consequence of reductions in ED attendance, admission rates, also through access to multiple providers in one hospital visit. Health care providers expressed satisfaction with team work, education, and strengthening of cross sectorial and interdisciplinary relationships

Evaluating the Diabetes–Cardiology interface: a glimpse into the diabetes management of cardiology inpatients in western Sydney’s ‘diabetes hotspot’ and the establishment of a novel model of care

Abstract Background Approximately two-thirds of individuals presenting to emergency departments in Western Sydney have glucose dysregulation, accelerating their risk of cardiovascular disease (CVD). We evaluated the prevalence and management of type 2 diabetes (T2D) in cardiology inpatients in Western Sydney. A novel model of care between diabetes and cardiology specialist hospital teams (joint specialist case conferencing, JSCC) is described herein and aimed at aligning clinical services and upskilling both teams in the management of the cardiology inpatient with comorbid T2D. Methods Cardiology inpatients at Blacktown-Mount Druitt Hospital were audited during a 1-month period. Results 233 patients were included, mean age 64 ± 16 years, 60% were male, 27% overweight and 35% obese. Known T2D comprised 36% (n = 84), whereas 6% (n = 15) had a new diagnosis of T2D, of which none of the latter were referred for inpatient/outpatient diabetes review. Approximately, 27% (n = 23) and 7% (n = 6) of known diabetes patients suffered hyper- and hypoglycaemia, respectively, and 51% (n = 43) had sub-optimally controlled T2D (i.e. HbA1c > 7.0%); over half (51%, n = 51) had coronary artery disease. Only two patients were treated with an SGLT2 inhibitor and no patients were on glucagon like peptide-1 receptor analogues. The majority were managed with metformin (62%) and therapies with high hypoglycaemic potential (e.g., sulfonylureas (29%)) and in those patients treated with insulin, premixed insulin was used in the majority of cases (47%). Conclusions Undiagnosed T2D is prevalent and neglected in cardiology inpatients. Few patients with comorbid T2D and CVD were managed with therapies of proven cardiac and mortality benefit. Novel models of care may be beneficial in this high-risk group of patients and discussed herein is the establishment of the diabetes-cardiology JSCC service delivery model which has been established at our institution

Key stakeholder experiences of an integrated healthcare pilot in Australia : a thematic analysis

Background: In Australia and other developed countries, chronic illness prevalence is increasing, as are costs of healthcare, particularly hospital-based care. Integrating healthcare and supporting illness management in the community can be a means of preventing illness, improving outcomes and reducing unnecessary hospitalisation. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health funded a range of key strategies through the Western Sydney Integrated Care Program (WSICP) to integrate care across hospital and community settings for patients with these illnesses. Complementing our previously reported analysis related to specific WSICP strategies, this research provided information concerning overall experiences and perspectives of WSICP implementation and integrated care generally. Methods: We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners and primary care nurses, and program managers. Half of the participants (n = 42) were interviewed twice. We conducted an inductive, thematic analysis on the interview transcripts. Results: Key themes related to the set-up and operationalising of WSICP; challenges encountered; and the added value of the program. Implementing WSICP was a large and time consuming undertaking but challenges including those with staffing and information technology were being addressed. The WSICP was considered valuable in reducing hospital admissions due to improved patient self-management and a focus on prevention, greater communication and collaboration between healthcare providers across health sectors and an increased capacity to manage chronic illness in the primary care setting. Conclusions: Patients, carers and health providers experienced the WSICP as an innovative integrated care model and valued its patient-centred approach which was perceived to improve access to care, increase patient self-management and illness prevention, and reduce hospital admissions. Long-term sustainability of the WSICP will depend on retaining key staff, more effectively sharing information including across health sectors to support enhanced collaboration, and expanding the suite of activities into other illness areas and locations. Enhanced support for general practices to manage chronic illness in the community, in collaboration with hospital specialists is critical. Timely evaluation informs ongoing program implementation