Supports and hindrances to the integration of co-located services in multiple models of primary health care delivery Integration in co-located primary health care services

摘要

Introduction : In 2008 the Australian Government funded the establishment of GP Super Clinics based loosely on the UK Darzi polyclinic model. The intention was to collocate general practice and allied health services. The initiative was centred in primary care and integration between primary care and specialist medical or hospital services was not a prime objective. No specific model for how integration was to be achieved was mandated. This study is an evaluation integration of six GP Super Clinics in South Australia and Victoria funded by the Australian Primary Care Research Institute conducted between 2014-5. Methods : The design was a multiple case study (mixed methods design). Quantitative data was collected using three surveys (clinic manager survey, health professional survey, patient survey) and qualitative data from patient and health professional focus groups. Each collection tool was applied concurrently at each case study site. Survey tools were administered first, sample GP management plans collected, and then focus groups conducted. Explanatory sequential process was used as the basis for data analysis (quantitative data then qualitative data to explain findings). A case study database was established to collate information collected for each site. Each case study site was described in terms of the seven components (for example, level of variety of services co-located, level of internal service integration mechanisms). Quantitative survey data was manually coded, entered into a Microsoft Excel spreadsheet and imported into SPSS for analysis. Frequencies, means, standard deviation and range, as well as cross-tabulations with percentages were calculated. Results : There was mixed evidence that the health clinics were aligning their services to match surrounding community demand with only two centres basing their decisions on service development on local research. All clinics started with a core set of services that expanded over time usually starting with at least GPs. In Australia, all GP pathology, radiology, specialist services and some allied health services have a Medicare funded rebate. While often there was no out-of-pocket expense to clinic patients access for some services or for patients not considered disadvantaged required a ‘gap’ payment. This impact on access to comprehensive care for some patients The clinics had similar ways of reimbursing health care professionals but there was some variation for allied health professionals. Nurses were most commonly salaried across all organizations and the State funded clinics were able to provide allied health free to patients by having the resources to pay staff a salary. Patients and practitioners felt the collocation improved patient convenience and satisfaction. Practitioners identified a lack of formal integrated care structures. The important role of nurses working in these clinics at integrating care between other health professionals was identified. Patients participating in the focus groups sensed that integration was not occurring in the clinics. Conclusions : When contemplating integration health professionals focused on communication, trust, familiarity and the importance of process in defining if it could be successful. Integration tended to be understood in terms of sharing of information about an approach to treatment, treatment proposed for the patient and not about how treatment was delivered. Patients perceived an absence of communication and information sharing among health professionals. Lessons learned : Health professionals are the drivers of integrated care. There were low rates of integrated care across all health service models in our study. Currently there are few incentives to achieve integrated care in Australia Limitations : Limited resource study examining only 6 of the 64 funded clinics in a limited geographical area. Data coded by only one researcher. Suggestions for future research : To what extent have resources and infrastructural supports been concertedly reviewed for their facilitation or obstruction to integration within different co-located PHC models within GP Super Clinics?.