Dr Paresh Dawda is a practising GP and regional medical director for Ochre Health, a multi-site operator of integrated medical centres. He has academic affiliations with two universities and several leadership roles across the system. He is a member of the Regional Clinical Council, the Australian Commission for Quality and Safety Primary Care Committee, the Royal Australian College of General Practitioners’ National Expert Committee on Quality Care and the Department of Health’s advisory subgroup on healthcare homes. He chairs the Clinical Review Committee at the Canberra Hospital and is a GP advisor to the NSW Agency for Clinical Innovation. He has a passion for clinical leadership, quality and patient safety improvement with patient-centred medicine as the golden thread that unites all his interests.
Alice is a 79-year-old woman with multiple morbidities. She was taken to the emergency department after having a fall at home. Diagnosed with a fractured pelvis and probable dementia, Alice was discharged to residential aged care on a Friday afternoon. She was not given painkillers, and a non-urgent referral was made to a community palliative care service. Alice’s regular GP did not visit residential aged care homes, so a new GP was found. However, the new GP couldn’t see Alice until Tuesday, and no action had yet been taken by the community palliative care service. In pain from her fracture, Alice was left without painkillers or support from primary healthcare. Eventually, a nurse at the residential care facility identified the problem and scrambled to arrange emergency pain relief for Alice.
Alice is not alone. Data from the Commonwealth Fund shows patients in Australia and New Zealand experience problems with coordination of care at least a third of the time.
If we are going to help our patients, particularly vulnerable patients like Alice, we need better service integration, transitions of care and care coordination.
Concepts of integration
Integration is described in the literature as horizontal – strategies that link similar levels of care; and vertical – strategies that link different levels of care. The enablers of horizontal and vertical integration are professional integration – professionals coming together to coordinate services across different disciplines; clinical integration – the extent to which care services are coordinated; and functional integration – coordinated back office and support functions. These support normative integration (shared mission and values); system integration (alignment of rules and policies); and organisational integration (coordination of services across different organisations).
The problem with this view of integration is that the focus is on the delivery structures and processes, whereas every available definition of integration – and there are over 170 – has one common element: an organising principle around the patient.
Transitions of care
Transitions of care that focus on the patient are not just about the clinical handover of information. They also need to be about the patient’s needs, preferences and experiences, the suitability of the home environment, the availability of carers, and the patient’s ability to access healthcare and social services.
Getting transitions of care right helps to deliver all aspects of the Quadruple Aim: better clinical outcomes, less waste and a better patient experience and staff experience.
Transitions of care present opportunities for horizontal and vertical integration as well as cross-sectorial aspects, e.g. health and social care
A process for improving transitions of care would begin with asking whether each patient has a high risk of failed transitions. This is an opportunity that can be realised in primary care with care planning processes enabling greater levels of patient activation and supporting information transfer. All patients need a transitional plan, but for high risk patients the plan needs to go through a multidisciplinary transition planning stage. Interventions from multidisciplinary input to improve transitions of care take two forms: improving care coordination and case management; and enhancing patient and carer involvement. Every patient’s transitional plan should cover medication safety, information transfer and patient/carer involvement. We need to use reliability principles and prepare for failure and embed tracking systems – systems to track appointments, tests and referrals to mitigate any problems that may arise.
Transforming primary care for better integration
Primary care needs to move from traditional mindsets focused on episodic care, quality of care relying on the individual practitioner and patients being responsible for coordinating their own care to proactive health plans, system quality and care coordinated by a professional team.
The ‘medical home’ is a concept originating in the United States and is a form of organisational development of primary care with the potential to be transformational. Medical homes are patient-centred, accessible, comprehensive, coordinated and have a commitment to quality and safety. They involve the patient and carer being supported by a GP working with a team of healthcare professionals, the medical home, and hence present an increasing need for horizontal integration. In turn this medical or health home is in a neighborhood of other healthcare professionals, NGOs, outreach services, hospital and acute care providers, home health and allied health services to deliver care. They can be invited in and out and hence the composition of the care team varies according to the patient’s needs.
The nature of relationship-based care is critical to integration. In our own research in Canberra we found consumers of integrated primary health care were more focused on relational aspects of care and outcomes of care with less focus on the organisational structures and processes necessary to produce them. This was in the Health Hub, a facility at the University of Canberra, which co-locates GPs, allied health and student-led allied health clinics, and hence provides a lens on integration requirements as primary care health care teams grow in the future. Although a pilot study, our research showed normative integration beginning to happen after only one year. This demonstrates that we need to purposefully design clinical microsystems with integration in mind to provide the building blocks for broader integration at the system level.
As healthcare moves towards a more patient-centred, value-based delivery system we need to recognise that primary care will be an even more key component of the delivery system. Primary care teams need to expand, and this must go hand-in-hand with organisational development and support to ensure primary care teams have the structures, processes and capability to integrate those expanding teams at a microsystem level.