MLs are tasked with improving the responsiveness of the health care system to the primary health care (PHC) needs of the population in their area. Although several definitions are available, health care integration usually refers to.
Background
Primary health care in Australia
Integration and integrated care
PPs are involved in horizontal and vertical integration, reflecting links between health care providers at the same level (eg general practice and allied health), and between different levels of the health system (eg general practice and acute care). These include organizational integration (i.e. contracting or strategic alliances between health care institutions) and service integration (i.e. linking meso and micro levels of the system to integrate services within and between organizations).
Medicare Locals
Improve access Work to coordinate more health services locally within the PHC sector and across other sectors of health care to reduce visits to hospitals and to enable people to stay closer to home for their health care where possible. 3 Identification of local areas' health needs and development of locally focused and responsive services.
Approach for this series
Scope of the report
Aims of this report
This qualitative research project recruited CEOs from the MPs introduced in the first installment by asking for their participation in a semi-structured telephone interview. After responding to the email with an expression of interest, CEOs were sent a consent form (Appendix B) and asked to nominate a preferred time for the interview. After agreeing to participate in the study, CEOs received a copy of the interview questions (Appendix C) to allow them time to reflect on their responses.
The CEOs represented MLAs in rural (n = 2) and urban (n = 3) areas, with diverse local population compositions, across multiple states.
Findings
Medicare Locals’ place within Australia’s health care system
The meaning of ‘integration’
The areas described ranged from integration as experienced by consumers, to the provision of infrastructure that promotes integration (such as the GP Super Clinics), integration of funding and integration of service provision. For example, one of the things the government has done is put together GP superclinics and that's what they call integrated care.... I think similarly with Australia, we're very program driven when we talk about integrated care, we for example, pick a disease or a condition, whether it's mental health or diabetes and then apply a whole package to try and say we want to integrate care in that area and we want that program to do that. Some ML CEOs have identified that not all forms of integration are equal in terms of how they lead to coordinated care for patients.
There are different ways of integration and different degrees of integration, and I think that real integration actually requires integration of financing, integration of management, and integration of service delivery. One CEO believed that "true integration" was unlikely to be achieved, although a better coordinated system to improve the patient experience was possible. The reason [integration] is important in the Australian context is because the idea of care coordination is really important, if you don't have an integrated health care system, which we don't have in Australia, it becomes very important to collaborate - direct care as opposed to integration.
Although there was consensus among MLs that the integration of services was important, there appeared to be variation in the priority placed on the patient experience of coordinating care. Some ML CEOs felt integration was only important insofar as it improved the consumers' experiences. Integrated health care is basically all the health providers working together in the most effective and efficient way possible to deliver the best outcomes for the patients...probably broader than the patients, to the community.
The stakeholders involved in Medicare Locals’ integration activities
Ways Medicare Locals are currently working towards integration
MLs act as impartial mediators between different service providers, programs and organizations in their local areas. That will be the direction I will try to take with our collaboration with various other organizations in the primary care sector because I think it is important. I just think that the focus of our integration work will really be trying to improve the working relationship with the providers.” ML4.
I just think the focus of our integration work is really going to be trying to improve the working relationship with suppliers and we'll do that through things like roads. We are also heavily involved in the development of multidisciplinary education for community-based providers and other providers...” ML4. MLs are aware of the range of competing needs that exist in their communities, and address them through their needs assessments.
Needs assessments themselves have been a mechanism to promote integration, yet some PPs are struggling with differences of opinion about what is needed in their local areas. I think that by having the data and having the planning and everything that we have the health of the population. Contracting or direct provision of services in the absence of adequate services in their area (especially in rural areas).
Requisites for integration
We have one member on our board and the same on their advisory board in South Australia, so we have a member there as well. For cooperation with LHN, I have a key result that they haven't actually arranged yet. They advertised for people on the board and Canberra told us there would be a seat at the table for Medicare Local and we were told "no, there's no seat for you".
A further requirement for integration, consistently mentioned by ML CEOs, was a supportive financing model. It was suggested that supportive financing models should be established at different levels within the healthcare system, from the reimbursement of healthcare providers to the financing of the MLs themselves. And that flexible funding model, I'm so excited to see that newly tailored model that they're talking about in the next budget, but we're really pushing with Canberra that you need to quickly become flexible and the ideal for us in our rural region should have full flexible financing.
In fact, quite often it requires effort to set up systems that are outside the context of clinical service delivery which is how they generate their income. So one of the things that can really help with integration is if there are a lot of incentives, so if you want GPs to integrate with other providers then you need some incentives to encourage them to do that. Therefore, given their ability to 'make or break' an integrated health care system, flexible funding for PPs and a provider reward system that incentivizes service delivery organizations working in a coordinated manner are fundamental important to an integrated health care system in Australia.
Challenges to integration
Many MLs felt that the question mark over the likely outcome of the next election was putting significant pressure on their work. The political climate was also related to the community's perception of their health care needs. Some MLs noted that despite their efforts to put PHC 'on the map', many politicians continue to equate healthcare with hospital beds.
I think the undermining part of the process is where you can try to do it faster than is otherwise appropriate. Despite significant collective efforts to shape a reformed health care system, different priorities seem to have a significant impact on the ability of MLs to create integration in their areas. MLs also face challenges in building collaborative relationships with stakeholders in an increasingly fiscally constrained healthcare environment.
What we want is for Primary Health Care to really get on the map, and it made me realize that Primary Health Care is just not on the map. It's a cultural change and it's a contradiction to the way most of the system is funded right now, so there has to be levels to it and advocacy in using what we have to change bits and pieces of it and hopefully change some parts of the system as well. Nevertheless, there is definitely a drive and will that was not present during the days of the DGP.
Discussion
Medicare Locals’ interpretation of the principles of integrated health care
Nevertheless, MLs' activities often centered on chronic disease management and promoting communication to improve the patient journey.
Medicare Locals’ plans to improve integration of local health services
As discussed in Report 1 (Integrated care: What policies support and influence integration in health care in Australia?), national health reform is driven by the need for patient-centred care and. However, a change needs to occur to start including consumers as consultants in activities (Yen et al., 2010), especially with the emphasis of MLs on addressing the needs of local people. Coordinating flexible funding options and a system of incentives for providers will improve the likelihood of organizations forming links and provide motivation for this integration.
While MLs are the new 'model' for integration, the CEOs noted that there is a need to develop a logical argument for integration (reflecting the challenges of different priorities across stakeholders), and also the value of advocates/ change champions. Furthermore, the need for evidence to inform initiatives and best practice was mentioned. This has been the driving force behind many of the peak bodies mentioned in Report 3 (Integrated care: What policies support and influence integration in health care in Australia?) and forms part of the macro policies that promote capacity building for knowledge translation and exchange.
Medicare Locals’ plans to link with Local Hospital Networks
Challenges and possibilities for MLs as agents for integration
Limitations and future directions for integration research with MLs
Conclusions
Appendix A Participant Information Sheet
You can answer "no comment" or refuse to answer any question, and you are free to withdraw from the interview at any time without effect or consequence. The results from the project will be summarized and provided to you by the investigator if you wish to see them. If you have any questions or concerns about this project, please feel free to contact Dr Petra Bywood at or petra.bywood@flinders.edu.au.
This research project has been approved by the Flinders University Social and Behavioral Research Ethics Committee. Thank you for taking the time to read this information sheet and we hope you will accept our invitation to participate.
Appendix B Participant Consent Form
Appendix C Interview Schedule
