Primary Health Care Research and Information Service PHCRIS PICE Community Planning, Integration and Engagement Personal Medical Services PMS. Historically, general practice has been the main access point for health care provision in the Australian community.
Aims
Evidence increasingly suggests that integrated primary health care (PHC) is an effective way to optimize the efficient delivery of services and improve patient outcomes. Therefore, enabling healthcare to be integrated across different service providers in diverse organizations is a major challenge.
Scope
Alongside the growing trend in specialized care, there has been an increased fragmentation of healthcare services, particularly for patients with multiple and/or complex conditions. In Australia and elsewhere, governments recognize that there are multiple health, social and economic consequences of fragmented healthcare; and an integrated healthcare system is an integral element of the healthcare reform.
Findings from the literature review
- Australian models of meso level integration
- International organisations and models of meso level integration
- Mechanisms identified in the models
- Challenges and enablers of integration
- Summary
Few research studies have evaluated the effectiveness of mechanisms at the meso-integration level. There is little empirical evidence on the impact of meso-level integration on the subsequent delivery of integrated health care.
Conclusions
5 Integrated micro care: What can be done at the micro level to influence integration in primary health care. The main actors at the micro level are: health care professionals in all organizations, patients and the local community.
Defining meso level integration
Models and mechanisms - terminology
Stakeholders in integrated health care
- Primary Health Care (PHC)
- Secondary Care: Medical specialists and specialised services
- Tertiary care: Acute and sub-acute care services
- Non-health services
- State/Territory and Local governments
Primary health care is appropriate, universally accessible, scientifically sound first-level social care provided by health services and systems with an appropriately trained workforce. For decades, general practice has been the "primary" health care service in the Australian community.
Limitations
Canada - http://www.health.gov.on.ca/en/, https://www.divisionsbc.ca/provincial/home UK - http://www.dh.gov.uk/en/index. htm US - http://www.hhs.gov/safety/index.html Organization websites with relevant. International models of integrated care that can contribute to our understanding of integration in the Australian context (6.4).
Australian meso level organisations that influence integration in PHC
- Primary health care organisations (PHCOs)
- Community Health
- Allied Health
- Hospitals
- Medical Specialists
- Non-Health Services
- Research Organisations
As part of the Australian National Health Reform, Medicare Locals (MLs) were introduced as the new PHCOs (Commonwealth of Australia, 2010, National Health Performance Authority, 2012). These organizations were introduced in July 2011 as part of the National Health and Hospitals Network agreement (Council of Australian Governments, 2011).
Australian models of integrated care
- Primary Care Partnerships
- Connecting Healthcare in Communities (CHIC) (Queensland)
- Primary Care Integration Program
- Comprehensive Primary Health Care
- Aboriginal and Torres Strait Islander organisations and models that influence
Feelings of uncertainty about the future of PHC have also been expressed in the context of the most recent health reform (Powell Davies et al., 2010). Cessnock Uni-Clinic, also known as "The Clinic", was established in September 2004 to address the lack of PHC services in the Cessnock and Kurri Kurri local authority areas.
International meso level Primary Health Care Organisations
New Zealand
The lasting legacy of the IPA movement is the creation of improved primary and community health infrastructure and management services (Thorlby et al., 2012). A review of the IPA in New Zealand identified several limitations, including a lack of community governance and little involvement of the wider PHC and social services sectors. In order for IPA general practices to be able to access the new government subsidies for PHC resources for chronic disease management or health promotion, they had to become part of the new PHOs.
These services are intended to improve and maintain the health of the entire enrolled PHO population, and to provide services in the community to restore people's health when they are not feeling well.
United Kingdom
Case study websites provide clear descriptions of work that has been done or is currently in progress. There are fewer case studies on the extent to which integrated care enables significant increases in the cost-effectiveness of health services, and the evidence base could be strengthened by conducting longitudinal studies (Curry and Ham, 2010, Dixon and Alakeson, 2010). There is constant change, with many aspects of the NHS (and associated local authority structures) changing, creating at the same time.
A Quality and Outcomes Framework (QoF) has been established (National Institute for Health and Clinical Excellence (NICE), 2004) and is primarily the responsibility of NHS Commissioning Boards.
Canada
The Government of Ontario contracts FHT to provide a range of services based on the needs of the local population. Primary Care Networks, part of the Primary Care Initiative, have been operating as PHCOs in Alberta since 2005 (Government of Alberta et al., 2012). Collaboration is not just the relationship between doctors and allied health professionals, but also between doctors and the rest of the healthcare system.
Since 2005 in British Columbia (BC), this PHCO has been sponsored by the General Medical Services Board, a joint board of the Ministry of Health and the Medical Association of BC.
United States
In March 2010, it completed the rollout of its computerized system — the world's largest for private healthcare (The Economist, 2010). There are 21 regionally based integrated service networks responsible for resources in all care settings (Perlin et al., 2004). Professionals work to the limits of their licenses to maximize quality and minimize costs (Maeng et al., 2012).
Mayo is considered one of the top performing healthcare organizations in the United States and the world.
International Models of integrated care
Integrated Delivery Systems Model
The system is well prepared for receiving risk-based payments and has performed significant impact analysis. The system has very good, complete data on the sociodemographic characteristics, utilization, cost and health status of the populations it serves. The system's resources and services are well matched to the needs of the population served.
The main disadvantages of IDS are related to the lack of competition to reduce costs.
Accountable Care Organization Model
Recently, an application of the IDS model has been observed in the development of the Accountable Care Organization. The various providers within an ACO are encouraged to work with each other to provide coordinated care to the beneficiary population (i.e., the geographic population they serve), align incentives, and reduce overall health care costs (American Hospital Association Committee on Research, 2011). In the two-sided model, ACOs participate in both shared savings and losses for all three years.
A series of ACO pilots were implemented with commercial insurers and state Medicaid programs prior to enforcement of the guidelines specified in the Medicare Shared Savings Program (MSSP) (Department of Health and Human Services: Centers for Medicare & Medicaid Services, 2011).
Patient-Centred Medical Home Model (PCMH)
For example, a central part of the PCMH model is an adapted financing structure that includes a blended payment system. The treatment is coordinated and/or integrated across all elements of the complex healthcare system and the patient community. IT and other means to ensure that patients receive the indicated care when and where they need it. Quality and safety are hallmarks of the medical field.
Although various forms of PCMH have been introduced, common definitions and terminology are generally lacking; and few guidelines regarding development and evaluation, making adoption and evaluation more challenging (Carrier et al., 2009).
Mechanisms to facilitate integration
Stewardship
In addition, governance can be analyzed at the level of particular organizations, as in the governance of a district health system or a hospital. For example, healthcare governance considers whether improvements in the way services are managed affect the delivery of services. Several challenges in the current PHC system, such as power sharing, funding, care models, and the absence of effective relationships between organizations, can be addressed through appropriateness. This may exist in the form of clinical leadership, such as the role of the newly established National Lead Clinician Group (LCG), or it may refer to GP leadership, as was the case with the DGP.
One example of this can be seen in the ongoing changes in the structure of the health system in England, which have led to disruption, confusion and change fatigue associated with the formation and termination of CCGs and PCTs respectively (Boyle, 2011).
Creating Resources
The impact and sustainability of the SNAP program was limited by a lack of effective teamwork in practice, poor links with referral services and a lack of a business model to support SNAP in practice (Harris et al., 2005, p. S54). One example of the importance of investing sufficient effort in proper collaboration and communication is shown in the CALD community. A variety of resources are required for integration into the models described above.
In the CCG Pathfinder evaluation in England, a commonly identified issue was the cost in both time and labor to carry out sufficient needs assessment (Checkland et al., 2012).
Financing
The context in which PHC organizations and professionals operate has been shown to have a profound effect on service delivery (Bywood et al., 2011). However, research suggests that providing financial incentives to achieve certain activities can lead to "gambling" (Custers et al., 2008) (U.K. Quality and Outcomes Framework), which can have a negative impact on the delivery of care by high quality. In a comparison and critique of international health systems, McDonald et al. 2007) suggested that these elements are largely absent from the Australian health system and place significant limitations on the role of DGPs and PCNs/PCPs.
There is therefore a tension between the need to collaborate and the need to compete (Plochg et al., 2006).
Integration challenges and enablers
- Communication
- Organisational culture
- System and structural arrangements
- Information technology and resources
- Funding arrangements
Flexibility and adaptability in response to local needs and during periods of change (Center for Community Health and Evaluation, 2008, Boyle, 2011, Mattessich et al., 2004). Realistic timeframes, allowing sufficient time and resources for cooperation and collaboration (Cumming, 2011, Ham et al., 2011, Boyle, 2011). Appropriate collection and use of data to inform improvements (New Zealand Ministry of Health, 2006, Ham et al., 2011).
Partial funding schemes lead to a lack of coherence and make connections more difficult to establish and maintain (Cumming, 2011, Ham et al., 2011).
Risks and unintended consequences
Perverse incentives
Salary Practitioners receive an annual salary for a specified number of hours per week, regardless of the number of services (Gosden et al., 2000). Underservicing, skimming (Hutchison et al., 2011): Future payment may encourage providers to reduce costs; and encourage large patient lists to increase income, resulting in higher workloads and shorter consultations. GPs are paid a fee for each care provided, such as consultations, vaccinations and prescriptions (Gosden et al., 2000).
GPs are only remunerated for care items (as for FFS) if they reach a certain target level of service (Gosden et al., 2000).
Health insurance
Change fatigue
Primary Health Care Reform in Australia: Report in Support of Australia's First National Strategy for Primary Health Care. Integrated care: A position paper of the WHO European Office for Integrated Health Services. Innovative and diverse strategies toward primary health care reform: Lessons from the Canadian experience.
Funded by the Australian Government Department of Health and Ageing, PHCRIS is a national organisation, formed as part of the Primary Health Care Research, Evaluation and.
