Background
[a] multi-level, multi-modal, demand driven and patient-centred strategy designed to address complex and costly health needs by achieving better coordination of services across the entire care continuum. Not an end in itself, integrated care is a means of optimizing system performance and attaining quality patient outcomes.
Necessary dimensions for effective integrationa
| Details |
---|---|
Organisational integration | How the organisation is formally structured |
Functional integration | How the non-clinical support and back-office processes are integrated |
Service integration | How the clinical services are integrated |
Clinical integration | How clinical team level care pathways are organised |
Normative integration | The role of shared values |
Systemic integration | The coherence of policies across organisational levels. |
Dimensions | Characteristics |
---|---|
Scope of care | |
Person-focused care | 1. Centrality of client needs |
Population based care | 2. Centrality of population needs |
Dimensions and level of system | |
Clinical integration (micro) | 3. Case management |
4. Continuity | |
5. Interaction between professional and client | |
6. Individual multidisciplinary care plan | |
Service/Professional integration (meso) | 7. Inter-professional education |
8. Agreements on interdisciplinary collaboration | |
9. Value creation for the professional | |
Organisational integration (meso) | 10. Inter-organisational governance |
11. Inter-organisational strategy | |
12. Trust | |
System integration (macro) | 13. Alignment of regulatory frameworks |
14. Environmental climate | |
Enablers of integration | |
Functional integration | 15. Learning organisations |
16. Information management | |
17. Regular feedback of performance indicators | |
Normative integration | 18. Shared vision |
19. Reliable behaviour | |
20. Visionary leadership | |
21. Linking cultures |
Methods
Consumers |
1. [This practice] is set up as an integrated primary health care centre. When I say “integrated primary health care”, what sort of things come to mind for you? |
2. What are your expectations of [this practice] for care for your chronic condition? |
3. Can you tell me about your experiences with [practice] services? |
4. We are particularly interested in the effect of integrated health care on the time people spend looking after their health. Can you talk about that? |
Providers/managers |
1. [This practice] is set up as an integrated primary health care centre. When I say “integrated primary health care”, what sort of things come to mind for you? |
2. What are your expectations of working in an integrated primary health care centre? |
3. Can you tell me about your experiences with providing services/working at [this practice]? |
4. How does [this practice] compare with other general practices where you’ve worked in the past? |
Analysis
Theme | Subtheme | Dimensions of integration from typologies |
---|---|---|
Consumers | ||
Making meaning from the term integration | - | |
Experience at the healthcare centre | Person-focused care | |
1. Access to services 2. Care continuity 3. Performing above expectations 4. Staff availability and competence 5. Appointments/services running on time 6. Friendly staff 7. Shared attitude | Clinical integration Clinical integration Clinical integration Functional integration Functional integration Functional integration Normative integration | |
Staff | ||
Making meaning from the term integration | Person-focused care | |
Experience at the healthcare centre | - | |
A cultural shift towards teamwork and care integration | Normative integration Clinical integration Professional/service integration Functional integration |
Results
Consumer experiences
Characteristics of participants
Services accessed | Number of consumers
N = 19 |
---|---|
Practice Nurse* | 17 |
Pathology | 8 |
Pharmacy | 7 |
Radiology | 5 |
Dietician* | 2 |
University training physio clinic | 2 |
Specialist* | 1 |
Physiotherapy* | 1 |
Psychology* | 1 |
Diabetes educator* | 1 |
Sleep clinic | 1 |
Perceptions, expectations and experiences
Making meaning from the term integration
“‘Integrated’ to me indicates that it’s not just a minor health centre where you go and see the GP for minor ailments and things like that but there are other treatments and things available where you can be interviewed for various other things besides just ordinary medical issues, like physiotherapies and things like that. I’ve noticed some of the signs around, you have a chemist available in the building and the X-ray facilities are also integrated into the building as well which makes it a very good medical centre to visit, in my opinion.” (Consumer 01).
“it [integrated primary health care] includes doctors, nurses, so I can get all my shots and my blood and everything done in the one spot, that I can get my X-rays… it’s like a kind of one-stop shop.” (Consumer 02).
Experience at the healthcare centre
“Well based on long experience with certain doctors here [laughs] we just mentioned that we’ve known [doctor] for 35 years plus and some of his staff are also here now. I have full confidence in the resources of [healthcare centre]. … the same people and the same good care.” (Consumer 05).
“I want to see the same doctor, because he's had, I don't know, 25, 30 years of contact with me, he's quite a busy man and so instead of being able to see him tomorrow, I might have to wait a few days. But I must say, the girls at the front are very good at fitting you in.” (Consumer 19).
“There’s more nurses and that they can fit you in just for a flu shot whenever, or if I needed to have something else done they can fit you in straightaway which is great, and the fact that I can go downstairs and have bloods done if [name] says, you need bloods, and there’s no waiting or expecting for me to go elsewhere, but compared to having to go to [other practice] one time it’s more friendly, everyone’s personable, everyone knows everyone, which is what I like.” (Consumer 02).
“… they said, oh well you need to go to a physio, you should see a physio, well – and this is what happened with the dietician with me, like, I probably honestly would not have got around to ringing up the dietician, to making the appointment, when someone had said – but I walked out the door and said, he wants me to see so-and-so, and she said, I’ll make the appointment for you now.” (Consumer 07).
“… you’ve pretty much got the one stop place where you can come, see your GP, if you need a referral to go and do something you can just go downstairs or up, wherever you need to go and it’s good because for people like me [with multiple sclerosis]. … I think your energy levels get worse and you just don’t have time and the energy to be going to three different places when you could be coming to one and go, I can do everything in the one hit here and it’s done.” (Consumer 10).
“When you’re on the health care plan you’re supposed to have access to certain other medical people like physio or whatever free. It’s not free. … I’ve got appointments with a physio coming up and it’s going to cost me $300 for five visits and then hello here I’m on a pension only, I don’t have other income and that was just, why do they keep saying you get access to these people [for] free. Five visits a year when it’s not free, it costs. I can just phone up and make an appointment with a physio and it costs me the same amount.” (Consumer 08).
“I know that they always send [a] report – even, like, the eye specialist and that who’d been recommended by or referred by here, they all send letters back to the doctor so I know that all the things are going onto my file. Yeah, so she would be my [laughs] primary source of information if anybody needed to know my whole history. I’m fairly confident that most of the stuff that I talk to with the other people actually do all get back to her in the end, yeah.” (Consumer 07).
“… they’ve gone out of their way to make me kind of comfortable. I’ve been going through chemotherapy and when I’ve been here at that time when I’m susceptible to infection I’ve asked about going into – rather than being in an ordinary – this is just an example of the cooperation – rather than being in the waiting room with all the other patients I’ve been allocated my own room there for isolation, to protect me from infection there.” (Consumer 05).
“I forgot to get a prescription repeat for whatever particularly, like, [nurse] and [nurse] and all of those who’ve known me for a long time, they’ll just look up my record and go, oh it’s this one, and they’ll double-check it and go, OK I’ll get [doctor] or [doctor] to write you out a script for that.” (Consumer 10).
“They’ll give me a choice of times, which is very good … There’s always someone who can answer the phone when you ring to make an appointment or a query, and they’ve always got the information available, which is very good.” (Consumer 01).
“If I walk in, and [receptionist] always knows, or [receptionist] knows…when have you got to come back. Oh gee, that's going to be difficult, but we'll find a spot for you, hang on. And they take the time. And they know when you go to the counter, OK, he's coming in, he needs to see the clinic, or he needs to see the doctor, or he needs… and nothing's a problem.” (Consumer 18).
“I ring up one day and I say I want an appointment for the current [day], no, we can't do it. I said, you know, just make an appointment. But you've got… she's this and that, and we have a few spots that we save through the day, and you've got to ring at 7 o'clock in the morning, on the day, and see if we've got… if we can slot you in. Because she only works 'till lunch time, right. And I was on the phone for 20 minutes the other morning before somebody answered. And I thought, well this is just hopeless you know.” (Consumer 15).
“I’m very impressed that everything seems to run on time, it’s efficiently run, which is a bonus, not sitting for hours and waiting. Whether that’ll continue or not I know, hopefully will, but that’s my first impression of – it’s very well run.” (Consumer 08).
“[doctor] is very quick, and likes to be on time, and we like that. We don't like waiting two hours, where we used to at a previous doctor.” (Consumer 14).
“I never feel rushed with [doctor] or any of the other doctors. They’re prepared to listen to either [name] or I with our medical problems and advise us what to do.” (Consumer 09).
“… she’ll exhaust every avenue until the appointment’s finished, so no I never feel – and even when I’ve seen [doctor] – never feel rushed, just do what I’ve got to do and that’s that, so it’s good.” (Consumer 10).
“I know that whenever I get out and I go to make my next appointment the receptionist staff is constantly asking, do you need a double appointment, do you need a double appointment, and it’s all, no I don’t. Like, it’s done, and that kind of makes me feel like, oh have I been in there too long, have I – do you know what I mean? It makes me feel like I’ve done something wrong. Yeah, that makes me feel a bit – that makes me feel more rushed, actually being in with the doctor.” (Consumer 06).
“Respondent: … now they’ve got the chemist downstairs, and a coffee shop …, so I think you’re pretty much covered in most of your…Interviewer: Cover your caffeine as well as your meds [laughs].Respondent: Yeah especially depending on the appointment yeah [laughs].Interviewer: They make a good coffee, too, I had a couple this morning [laughs].Respondent: Oh they’re fabulous and the guy there’s really lovely, I like him, so he’s good value, so…Interviewer: Yeah seems like a nice guy.Respondent: Yeah that makes it nice too especially if you’re feeling a bit stressed or something, you just need a friendly face to have a bit of a laugh.” (Consumer 10).
“I think someone new coming in would find the experience almost overwhelming, it's all here, and if they actually get the care and treatment that makes it even better. And I think it's important they're all on that… the wavelength of wanting to help people.” (Consumer 18).
“I’ve certainly brought my mother – like, my mother had to have some imaging things done and she’s going … cause [other clinic] is such a pain to, you know, go to as well. There’s one at [healthcare centre] so I’ve made sure she came here and things like – because of the convenient parking and the, you know, cause it’s closer proximity and yeah. Mainly the parking has a lot to do with that.” (Consumer 07).
Staff experiences
Making meaning from the term integration
“Integrated primary health care should be where there’s good co-ordination between allied health and medical practitioners and nursing staff, working towards the better health of patients.” (Health professional 01).
“… communication, liaison, the ability to not just send emails, and it’s to actually to be able to verbally communicate via telephone, or even walking into each other’s rooms. And that’s… what I see from that, patient coming in with a complaint or a condition, it’s not just handled by one person, and then have to either (a) not contact the other person at all and just feed through the patient, but rather the patient can turn up to the clinic and go, “Does the physiotherapist know all my background,” and the idea is, yes, because all the information that we store between the physio, the doctor, the podiatrist, and even the dietician, is all stored on our system, and therefore we’ve got a good rounding knowledge about what it is that this patient’s complaint is, and we can also liaise quite easily on our same system, and through other physical means, of how we can interact around their care.” (Health professional 02)
Experiences at the healthcare centre
“Just you know broader range of knowledge. I’ve learnt a lot since I’ve been here about the different you know areas of health and things like that.” (Manager 01).
“… that’s a very important part of I think integrated health, that you’ve got a team of people that the patients feel connected with, that they can ask for advice from, and get different levels of expertise and in different areas.” (Health professional 01).
A cultural shift towards teamwork and care integration
“Yeah, definitely the communication channel is a lot more open. Not only the… can you knock on the door, or go and talk to another health professional directly, but we have on the computer system all the patient notes available, we can send… you know request to have meetings with other health professionals to set up more… more flexibility I guess with catching up with people … I think the whole philosophy here is so embraced by all the staff members. Everyone is so helpful and welcoming. I think it’s the culture of what [the practice] is trying to promote really does resonate with everyone that works here. I think it’s a very supportive environment not only for the clients, but also for the staff members.” (Health professional 04).
“I think GPs and Allied Health sometimes struggle with the concept, and they need to just be open to the thoughts of their files being shared, their clinical notes being shared. Generally a GP initially shares clinical notes with … their colleagues, not with external providers such as Allied Health, so I think the knowledge basis of what integration can do, can be improved.” (Manager 02).
“Communication, it has to be strong, and it’s time consuming. And obviously communication can be taken, especially written communication, can be taken in many ways, so just being careful of how things are communicated, to what extent, what detail.” (Manager 02).
“I found that obviously as physios we have our own acronyms, and I think GPs have their own acronyms, so I think it’s something that I try to portray to the other physios here too, because this is the first time they’ve worked in this environment. If they write TVA, or if they write FIS, … FIS for a doctor could mean FIS differently to what we think. So we’re starting to write flexion standing, rather than FIS.” (Health professional 05).
“… someone having counselling, that they may disclose something that they would never have told me, you know, or… yeah. And that’s a difficulty of how much. And I’m not sure with the psychologist here how much… I think she keeps a lot of her own records, so I’ve never looked to see. But I know the physio does put records in, and I know he looks at what we’ve got as well, too, to help him, and I’m the same. So they can look, and for instance the dietician can look and see what the latest cholesterol was, and you know things like that that are very useful to be… so it’s just when you get that sort of super confidential bit of information, and that’s probably more policies and procedures. … they will give us a summary, or you know when there’s times that we’ve got to perhaps do a referral to a psychiatrist, and give us some information there. But they actually keep totally separate notes.” (Health professional 01).
“I love the communication here. I love the fact that like in our section there, we’re all… like the room that we’re in right now it’s an Allied Health room, which means everyone’s to work as a team. It’s not like the physiotherapist’s room, or like the podiatrist’s room, it’s the Allied Health room, so it’s got a really strong outlook in that getting everyone on board.” (Health professional 05).
“[we do] A lot of horse trading in the corridors and tearooms. … it’s quite… a bit of a different flavour to what people are willing to type as opposed to as what they’re willing to say” (Health professional 06).