In order to protect confidentiality, some practice and personal details have been changed where they are not crucial to the exploration of the case study. Initially, we describe the practice and how chronic illness was managed at the time of the study – “the present”. We then examine the “past” 23 year story of the practice, focusing on the development of the elements of good quality chronic illness care. Finally, we return to the “present” of 2007 and explore the participants’ understanding of how change occurred/occurs and describe current patterns of interaction at the practice.
The practice and chronic illness care: the present
The practice is located in an inner city suburb with a demographic of ageing working class immigrants and recent influx of younger middle class professional families. It has five full-time equivalent GPs (three of whom own the practice in a legal partnership), one full-time equivalent practice nurse, a part-time business manager, full-time office manager, and two full-time equivalent reception staff. All staff consistently identified core values of the practice – good quality care, ethical professional practice, and patients come first – while also judging it to be a democratic and friendly place to work. They saw clearly that these values outweighed financial interests, but acknowledged that this had been a source of tension at times.
Chronic illness care according to key elements of ACIC is an explicit priority focus at the practice. The doctors are aware of the burden of illness in their ageing patient population and describe how these patients need new ways of working, such as risk management, planned care and follow-up, and patient self-management. Practice nurses play a key role as care coordinators. They have their own appointments, conduct health assessments, help to prepare care plans, maintain registers, arrange reminders and conduct reviews. They also undertake preventive, clinical and organisational tasks.
Financial and administrative arrangements support chronic illness care. The business manager (BM) promotes use of Medicare items for chronic illness care and works with the office manager and nurses on appropriate care processes. The different members of the practice team have a reasonably clear and shared understanding of their own and each others’ roles, which generally corresponds to the organisational chart in the practice manual, with the three partners clearly in the senior management role. Arrangements for delivery of care are reviewed as needed at the monthly practice meeting.
The practice doctors utilize community resources, public and private, to provide multi-disciplinary care. There is an intentional process to maintain awareness of the role and quality of such community-based services, including visiting new services and discussion at the practice meeting. Practice members participate in their local Division of General Practice (indeed, PN1 is used by the Division as a resource for education about chronic illness care) and numerous professional networks.
Doctors and nurses work together to provide education to help patients understand and participate in their own management. Practice staff describe a strong culture of patient-centeredness and clinical staff emphasize the need to engage patients with chronic illnesses in learning how to participate in their own care (although with variable success). The doctors are aware of a broad range of up-to-date guidelines for management of chronic illness, although have some reservations about the plethora of materials and the robustness of the sources. They all participate in continuing professional development. The practice meeting is explicitly used to share individual learning and the meetings observed revealed both wide knowledge and critical appraisal in the area of chronic illness care.
The practice uses a blended paper and electronic medical record system, with a register of patients with chronic illness used to provide patient reminders. At the time of data collection, they did not routinely evaluate their chronic illness care through regular record audit. Two principals (P1 and P3) were aware that this was desirable and occurred in other practices.
Within the Australian context [
42], this level of development in all aspects of the Chronic Care Model validates the practice’s reputation for good quality chronic illness care.
Chronic illness care: how it developed
In this section we present both a chronological history of change within the practice and exploration of how and why it happened this way from the memories and interpretation of the participants involved in the action. Table
2 shows a detailed timeline of key developments at the practice correlated with key developments in the policy environment of general practice in Australia.
Table 2
The story of the practice
P1 buys into practice | 1985 | |
| 1986 | |
P2 buys out remaining partner | 1987 | |
| 1988 | |
| 1989 | |
P3 joins as associate, then partner | 1990 | |
| 1991 | |
| 1992 | GP Strategy |
| 1993 | Better Practice Program, Divisions of GP, GP Research Program |
Move to new premises | 1994 |
Record audit | 1995 | |
Ceased bulk billing | 1996 | |
| 1997 | Immunization strategy |
PN1 starts | 1998 | |
| 1999 | Enhanced Primary Care (EPC) |
Accreditation | 2000 | |
| 2001 | Asthma 3+ Plan |
| 2002 | |
Re-accreditation | 2003 | “Red Tape” report, Medicare Plus, nurse rebates, simplified EPC |
BM starts | 2004 |
OM starts | 2005 | |
| 2006 | |
Case study | 2007 | |
Foundation of the practice: the first ten years
In 1985, P1 bought the practice, selecting this one among many because of its ethos that earning capacity was not the primary consideration. P2 and P3, sharing the same values, joined over the following five years and the partners acquired, renovated and moved into purpose designed premises in 1994. P3 came from an overseas medical school with a progressive primary care program, and was seen as an agent for change. The initial joining of the three principals, partly by chance but with shared values, led to a continuing intention towards delivering the best quality of care in the practice, which made them open, even eager, to change:
P3: the theme of change and improvement … has always been there… I mean P1 and P2 … if they knew there was a better way, they wouldn’t actually choose for conservative, to stay the way they are. If there was a better way, they would go the better way.
PN1: they like to be seen to be a bit more cutting edge … They like to be up front and like to be seen to be progressive…
BM: …a very strong values system … that was non-negotiable … always at the cutting edge of doing things differently … this place was always leading the charge.”
The fact that P3 had trained overseas meant that she had no existing referral networks among the local specialists, so she visited them to help establish her in a new place. As a consequence, however, she thought that this brought her (and the practice) to notice and meant that they gained a reputation as interested and progressive, leading to her being approached to participate in a quality improvement research project that was an early initiative in Australian general practice reforms.
“Lots of things changing”: the next five years
This research project was seen by all three partners as highly significant – each referred to it when asked how the practice had developed into a leader in chronic illness care. It came not long after the move in 1994, among many other memorable changes, some related to the research project – directly or tenuously – and others apparently unrelated. The research involved a record audit of preventive care, including Pap smear, immunization and HbA1c. The results revealed rates lower than their anticipated excellence and this disturbed the partners. Having identified suboptimal care, the project explored possible remedial actions, particularly setting up recall and reminder systems. This played out differently in each of the three preventive care areas.
Setting up a Pap smear register and reminder system proceeded reasonably smoothly. Cervical screening was topical and an area of interest for P3 and the research team, and a way forward seemed clear:
P3: so ‘94 we didn’t have computers. Reflecting on what we had to do we had to have computers
So, in 1996, the practice introduced computers for clinical work, well before the 1999 Australian Government incentives for electronic management of clinical information in general practice.
The response to diabetes management through HbA1c testing was a different story. Although P1 reported a personal revelation about the different requirements for managing patients with chronic illness, there was little change in the pattern of how the practice delivered their care.
P1: I can give you the major change … the agenda of the consultation [in chronic illness patients]
Q: What happened? One day did you just think “Hmm, there’s a lot more chronic illness, I’ve got to have my own agenda when patients come in”?
P1: Yes! There was actually a revelation … it’s that sort of dis-ease, the discomfort that you live with when you think that you’re not doing things well
Q: Mmm, so how does something like [planned care] fit into that …was all that changed? – you just saw things in a different way?
P1: Yes!
Q: Did it just work immediately?
P1: No! (laughter).
The practice did, however, take action towards the end of this period on the third focus area in the research project – immunization – but this was in response to other influences in addition to the audit. At the same time as there was growing tension in the practice about financial matters (P2: …we got fed up with, um, constantly feeling like we were battling to make any kind of living …practicing the sort of medicine we did …), the Australian Government introduced a new immunization strategy that included incentive payments for general practice as well as social marketing to encourage immunization. At the practice, improving immunization became important both to re-affirm their value of leadership in quality of care and, at the same time, to provide some relief from their financial stress. They also felt that the task might not be too difficult, since the issue might be in the recording, rather than actual immunizations delivered.
The first practice nurse
As a consequence, in 1998, PN1 joined the practice, initially to update the immunization records. The employment of PN1, a senior nurse with some hospital management experience, was seen by P1, P2 and P3 as pivotal to many of the changes that subsequently led to better chronic illness management. However, there were slightly different interpretations from each of the principals and from PN1 herself as to how this came about. She was, in fact, the wife of P2, and according to him, flexible, part-time work at the practice was an ideal opportunity for her to “get out of the house” [P2]. It was a fortunate coincidence that someone who understood medical terminology and could find the way around a medical record was available to help update the immunization data. And then one thing led to another:
PN1: …it was then, oh no, no, we don’t want a nurse. And then … do you know how to work the ECG machine? oh yeah, I can do that. … oh do you want to work another day? oh, well, you know, all right, for a few hours… then what’s this Medicare change? I’ll read it and I’ll let you know. So my role sort of went from just doing the immunisations until … making sure things were done for PIP and then accreditation came and it was like, do you know what this means. And I said I’ll give it a go
However, PN1’s gradual increase in responsibilities was not easy for some of the doctors.
P1: I remember distinctly, when PN1 started, and, she started to do more I was very resentful. It was a huge issue for me and I’m sure for a couple of the other doctors of letting go. You know?
Enhanced primary care and accreditation
As practice accreditation was gaining momentum, the Australian Government launched the Enhanced Primary Care (EPC) Program that provided insurance rebates for planned chronic illness care – health assessments, case conferencing and written care plans – outside the traditional fee-for-service structure of episodic, reactive, time-based consultations. PN1 was invaluable as the practice decided to undertake its first accreditation and began to work out how to use the new item numbers. Being one of the first practices to be accredited was consistent with the practice’s “ahead of the pack” culture:
Q: How did you decide to get accredited? One of the first practices…
P2: I think we just felt like it was our duty to do it yeah, I don’t know. Well it was tied up with PIP payments and all that kind of thing as well so we thought, good practices do it, we should you know, maintain some sort of objective standard I suppose.
Accreditation was a key turning point for both PN1 and many of the processes for chronic illness care. It gave PN1 a pivotal and important role, and it involved considerable “tidying up” of existing processes. It was disruptive and met with some resistance, but the end result was a sense that the practice had gained quite a lot and PN1 was secure in a valued role for helping make changes happen smoothly in the practice.
Q: who … brings things in from the outside or comes up with new ideas?
A2: PN1, … she gets a lot of information sent to her on new things …through the [local Division of General Practice] …
The practice was now well placed to respond to further government refinements of the EPC program, such as incentive payments for achieving more steps in the cycle of care for chronic illness and including mental health within the program. The next four years were ones of incremental changes, refining the use of EPC and easily navigating the second accreditation cycle.
Attending to business
Despite this, the practice remained under financial pressure during 2000 – 2004. In particular, P3, as a female GP with an interest in women’s health, tended to have longer and more complicated consultations, but these did not receive proportionally higher Medicare rebates, limiting the fees that could be charged.
P1: P3 more than all of us, … was making the least amount of money for the effort she was putting in, … but all of us had noticed that our incomes had not done very well in the previous 3 or 4 or 5 years and P3 was the one who was feeling it most…
P3: you know it wasn’t sort of working for us financially, and that was a bit uncomfortable, …We were actually not making money, … you know, here you are working day in, day out …
As a consequence, the practice brought in a small business consultant, the cousin of P3’s husband, to review the financial situation. His analysis identified some ways to improve cash flow, but he also suggested more extensive changes to work processes and staffing to improve business viability and efficiency. He was subsequently engaged as an external, part-time business manager. He negotiated new remuneration arrangements with the GP associates and reviewed how the front office worked, encouraging more responsibility among the receptionists. His stated aim for both was to change the management style to improve teamwork:
BM: the non-clinical staff – there was all care, but no empowerment … and the big change I’ve had is … to empower the staff to become more involved and … seeing themselves as … a critical part of the whole team from start to finish.
It was a time of rapid change and discomfort, both for staff and the partners.
BM: when I first came in, to introduce those changes, they happened in a very short period of time and there was a lot of pain about that and there was a lot of reluctance [by partners] … to let go of decision-making…
Subsequent steps were to appoint an office manager and second practice nurse, and to more clearly delineate their roles to free the practice nurses from administrative tasks. This allowed greater priority to be given to chronic illness care, with more intentional and systematic use of the EPC items, which carried significantly higher rebates. The office manager and practice nurse then worked together to refine processes to make this new staffing structure work.
OM: the staff out the front … they didn’t know what all these things were and that, … care plans sometimes took 45 minutes or an hour …It was chaos, it was chaos, … so yeah it was like “no hang on a minute, we’re just getting into a mess here”.…it wasn’t like a formal meeting, it was more just “PN1 have you got 10 minutes?”, you know, “this isn’t working”.
And the process seemed to be successful.
BM: So that’s a significant change … you can actually …empower and give them the tools to make their decisions, … then you start to see the improvements. You …start to see productivity increase and you start to see happier people and we’ve got a very happy workforce here.
A3: … at the time we were all really cranky. I was really cranky, I was you know about to leave really cranky you know that sort of thing. And now I’m really happy, …
R3: Everyone here sort of tries generally speaking to do their best to … cooperate in getting what needs to be done, done.…I did work for another medical practice before this one … here … we work with the medical staff rather than for them.
At the end of this period, the practice was effectively in the form it was during the case study.
Participants understanding of change
The participants struggled to explain how their good chronic illness care came about. They all described plenty of change, but no-one could readily point to a planned, targeted strategy for chronic illness care (although there were several examples of planning, trialling and implementing improvements for more discrete problems, such as handling pathology results). Some (A2, R1 and R2) seemed content to focus on their personal story and how things worked in the present. Most skipped about within the history of the practice and across clinical areas, making connections and identifying key events or turning points in the way chronic illness care developed. BM related a process of planning and change to bring financing and staffing more in line with modern business practice, and this had a significant impact on chronic disease management through increasing use of the EPC items. Financial incentives were important but not as a simple lever: there were several nuanced understandings of how they influenced change.
P1: I think that by far the biggest force for change has been money, you know … incentives, … So if somebody says you’re going to get and extra $300 to achieve 98% immunisation rate rather than 95%, I think the $300 is not all that important but it becomes an interesting exercise to see if you can achieve it. Because you know that’s an area that you should be going, because it’s an important thing to do, so if somebody else recognizes that it’s an important thing to do I think…umm …it can drive it in chronic disease management.
Q: So why did you decide to get involved in EPC in the first place then?
P2: Um I don’t know, well I can personally see the advantages, … it um sits well with me ideologically that the government is trying to do chronic care properly and, and de-emphasise the acute reactive kind of medicine. So for a start I thought the principles were fine.”
A3: …actually getting the nurses involved in that process, … and able to … write a sensible care plan ….
Q: So who made that happen?
A3: BM essentially …because it was a money making exercise … I mean it’s useful for us because care plans are a useful thing. But I think it was a financially driven decision in many ways.
The financial incentives allowed for new way of organising.
Q: Did the money make a difference?
P1: Yes! … not so much for the income but for the fact that you feel you can support the appointment of a nurse. That’s become important. … I mean, virtually all our money goes into the employment of a nurse, that we get from those extra items, …umm, but that’s useful, yes.