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Background: The impact of long‐term conditions is the "healthcare equivalent to climate change." People with long‐term conditions often feel they are a problem, a burden to themselves, their family and friends. Providers struggle to support patients to self‐manage. The Practical Reviews in Self‐Management Support (PRISMS) taxonomy lists what provider actions might support patient self‐management. Objective: To offer providers advice on how to support patient self‐management. Design: Semi‐structured interviews with 40 patient‐participants. Setting and participants: Three case studies of primary health‐care organizations in New Zealand and Canada serving diverse populations. Participants were older adults with long‐term conditions who needed support to live in the community. Main outcome measures: Qualitative description to classify patient narratives of self‐management support according to the PRISMS taxonomy with thematic analysis to explore how support was acceptable and effective. Results: Patients identified a relationship‐in‐action as the mechanism, the how by which providers supported them to self‐manage. When providers acted upon knowledge of patient lives and priorities, these patients were often willing to try activities or medications they had resisted in the past. Effective self‐management support saw PRISMS components delivered in patient‐specific combinations by individual providers or teams. Discussion and conclusions: Providers who establish relationships with patients can support them to self‐manage and improve health outcomes. Delivery of taxonomy components, in the absence of a relationship, is unlikely to be either acceptable or effective. Providers need to be aware that social determinants of health can constrain patients' options to self‐manage. [ABSTRACT FROM AUTHOR]

Background: Action research (AR) and randomized controlled trials (RCTs) are usually considered to be theoretically and practically incompatible. However, we argue that their respective strengths and weaknesses can be complementary. We illustrate our argument from a recent study assessing the effect of telemonitoring on health-related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals in two urban hospital services and one remote rural primary care service in New Zealand.Methods: Data came from authors' observations and field notes of discussions with three groups: the healthcare providers and healthcare consumers who participated in the research, and a group of 17 researchers and collaborators. The consumers had heart failure (Site A, urban), airways disease (Site B, urban), and diabetes (Site C, rural). The research ran from 2008 (project inception) until 2012 (project close-off). Researchers came from a wide range of disciplines. Both RCT and AR methods were recognised from early in the process but often worked in parallel rather than together. In retrospect, we have mapped our observed research processes to the AR cycle characteristics (creation of communicative space, democracy and participation, iterative learning and improvement, emergence, and accommodation of different ways of knowing).Results: We describe the context, conduct and outcomes of the telemonitoring trial, framing the overall process in the language of AR. Although not fully articulated at the time, AR processes made the RCT sensitive to important context, e.g. clinical processes. They resulted in substantive changes to the design and conduct of the RCT, and to interpretation and uptake of findings, e.g. a simpler technology procurement process emerged. Creating a communicative space enabled co-design between the researcher group and collaborators from the provider participant group, and a stronger RCT design.Conclusions: It appears possible to enhance the utility of RCTs by explicitly embedding them in an AR framework to shape stronger RCT design. The AR process and characteristics may enable researchers to evaluate telehealth while enhancing rather than compromising the quality of an RCT, where research results are returned to practice as part of the research process.Trial Registration: Australian New Zealand Clinical Trials Registry, reference ACTRN12610000269033 . [ABSTRACT FROM AUTHOR]

Objectives: To assess the effect of telecare on health related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals. Methods: Patients were randomly assigned either to usual care or to additionally entering their data into a commercially-available electronic device that uploaded data once a day to a nurse-led monitoring station. Patients had congestive heart failure (Site A), chronic obstructive pulmonary disease (Site B), or any long-term condition, mostly diabetes (Site C). Site C contributed only intervention patients – they considered a usual care option to be unethical. The study took place in New Zealand between September 2010 and February 2012, and lasted 3 to 6 months for each patient. The primary outcome was health-related quality of life (SF36). Data on experiences were collected by individual and group interviews and by questionnaire. Results: There were 171 patients (98 intervention, 73 control). Quality of life, self-efficacy and disease-specific measures did not change significantly, while anxiety and depression both decreased significantly with the intervention. Hospital admissions, days in hospital, emergency department visits, outpatient visits and costs did not differ significantly between the groups. Patients at all sites were universally positive. Many felt safer and more cared-for, and said that they and their family had learned more about managing their condition. Staff could all see potential benefits of telecare, and, after some initial technical problems, many staff felt that telecare enabled them to effectively monitor more patients. Conclusions: Strongly positive patient and staff experiences and attitudes complement and contrast with small or non-significant quantitative changes. Telecare led to patients and families taking a more active role in self-management. It is likely that subgroups of patients benefitted in ways that were not measured or visible within the quantitative data, especially feelings of safety and being cared-for. Trial Registration: Australian New Zealand Clinical Trials Registry [ABSTRACT FROM AUTHOR]

Background Primary health care does not adequately respond to populations known to have high needs such as those with compounding jeopardy from chronic conditions, poverty, minority status and age; as such populations report powerlessness. Objective To explore what poor older adults with chronic conditions who mostly belong to ethnic minority groups say they want from clinicians. Setting and Participants Participants were older adults whose chronic conditions were severe enough to require hospital admission more than twice in the previous 12 months. All participants lived in poor localities in Auckland, New Zealand's largest city. Methods Forty-two in-depth interviews were conducted and analysed using qualitative description. Results An outward acceptance of health care belied an underlying dissatisfaction with low engagement. Participants did not feel heard and wanted information conveyed in a way that indicated clinicians understood them in the context of their lives. Powerlessness, anger, frustration and non-concordance were frequent responses. Discussion and Conclusions Despite socio-cultural and disease-related complexity, patients pursue the (unrealised) ideal of an engaged therapeutic relationship with an understanding clinician. Powerlessness means that the onus is upon the health system and the clinician to engage. Engagement means building a relationship on the basis of social, cultural and clinical knowledge and demonstrating a shift in the way clinicians choose to think and interact in patient care. Respectful listening and questioning can deepen clinicians' awareness of patients' most important concerns. Enabling patients to direct the consultation is a way to integrate clinician expertise with what patients need and value. [ABSTRACT FROM AUTHOR]

Introduction: Adult patients who are very high intensity users (VHIU) of hospital emergency departments have complex medical and psychosocial needs. Their care is often poorly coordinated and expensive. Substantial health and social resources may be available to these patients but it is ineffective for a variety of reasons. Description: In 2009 Counties Manukau District Health Board approved a business case for a programme designed to improve the care of VHIU patients identified at Middlemore Hospital, Auckland, New Zealand. We will describe attempts to systematically study the issue of frequent presenters at the Emergency Department (ED), and our plans to formally trial a targeted intervention whereby increasingly the process will be driven from primary care. Our main aim is to design systems that integrate secondary and primary care and thus reduce hospital use for people with long-term conditions. The VHIU team was established to attend to the current presenting problems, however the main emphasis was on optimising ongoing care and reducing subsequent admissions especially by connecting patients with primary health care. The model of care includes medical and social review, a multidisciplinary planning approach with a designated 'navigator' and assertive follow-up, self and family management, and involvement of community-based organisations, primary care and secondary care. The model has been organised around geographic localities. In New Zealand, the South Auckland region (population 500,000) has a multi-ethnic and socioeconomically deprived population. Hospital care is free. General practitioners (GPs) provide care from single or group private practices and they employ practice nurses. GPs are members of Primary Health Organisations. Practices receive a capitation fee from the Government but can also charge the patient a co-payment. Key findings: The current definition of frequent presenter used at Middlemore Hospital includes any adult presenting to the ED on five or more occasions in the preceding twelve months. In the year 2010, 64,409 patients presented to the ED 88,565 times. Of these, 1711 patients age 15 or over, in 8756 presentations, were 'flagged'. Of these presentations, (5312, 61%) resulted in an overnight stay; total bed days for the year were 25,768, with a median per patient 10, interquartile range 4 to 23. The median age of those 1711 patients was 56 years (i.e., not frail elderly). According to the patient cost system, the total cost of flagged patients was approximately $31.5million. Since 2010 over 3000 patients have been enrolled in the VHIU programme. In a before and after comparison hospital use is substantially reduced - bed days decreased by 40% and attendance at ED by 43%. However concerns about regression to the mean led us to conduct a randomised controlled trial in 2011-2012. It was not possible to interpret the randomised controlled trial because of contamination of the control group. We suggest this is common in trials done in the setting of active clinical service delivery. Also such trials are difficult to "control". The patients and interventions are complex (Hawe et al. Complex interventions: how "out of control" can a RCT be? BMJ, 2004; 328:1561-1563). As an alternative to the RCT we have done a time series analysis. In a cohort of over 1,000 patients enrolled in the calendar year 2013 hospital use for 12 months before has been compared to hospital use for 12 months after enrolment: 1. The difference in total bed days is significantly different from zero. Median 3 days. The mean absolute total bed day reduction is 1.1 days. 2. The slope of cumulative days in hospital for 12 months before is significantly different to the slope for 12 months after enrolment. 3. We used a mixed effects analysis of variance adjusted for total hospital days (on log scale), age, number of morbidities, ethnicity, gender - the ratio of bed-days before and after is 1.08 which indicates an 8% relative reduction (Barnett et al. Regression to the mean: what is it and how to deal with it. International Journal of Epidemiology, 2005; 34:215-220). Highlights and Lessons Learned: We underestimated the degree of change required in general practice e.g., longer consultation, home visits etc. We describe a programme that incentivises this change. At Risk individual programme (ARI) - General practitioners are asked to identify patients at risk of hospitalisation. The programme has started by targeting patients with long-term conditions. The District Health Board funds the GP for ARI enrolled patients. Elements of the programme include: 1) risk stratification, 2) holistic assessment (including psychosocial and self-management ability), 3) development of a care plan which is visible on an e-shared care record, 4) access to multidisciplinary care conferencing, and 5) a flexible funding pool which can be used to fund home visits, extended consultation etc. Conclusion: Eighteen thousand patients have been enrolled in the first 9 months of the ARI programme. Funding has been used to increase practice nursing resource. Multidisciplinary Team meetings with allied health, specialists and social workers has started to produce clinical networks. Some of the new funding will be allocated on outcomes. The ARI programme is based on the VHIU model of care. If it has similar outcomes this "scaling up" will have substantial effect on hospital use. [ABSTRACT FROM AUTHOR]

Abstract: Aims: We sought to determine whether systematic care can reduce the gap in diabetes control between Maori and non-Maori. Methods: A Primary Health Organisation implemented a chronic care management programme for diabetes in 2005. The data constitute an open, prospective cohort followed for approximately two years. Data describing process were also collected. Results: There were 1311 people with diabetes (354 Maori, 957 non-Maori). Maori started with higher HbA1c (mean 8.1%, SD 1.9) than non-Maori (7.1%, SD 1.4) but over about 2 years HbA1c for Maori improved to that of non-Maori. LDL and systolic blood pressure decreased for both groups. Improved glucose in Maori was not due to starting insulin or metformin, and rates of sulphonylurea prescription increased in both groups. Urinary albumin:creatinine ratio remained higher for Maori throughout. Smoking rates and Body Mass Index (both higher in Maori) did not change. There is no evidence of selective retention in the cohort. Conclusion: Likely essential components of the programme were that governance was equally shared between Maori and non-Maori; prolonged nurse consultations were free to the patient; nurses used a formal written wellness plan; nurses were formally trained to support patient self-management; and a computer template supported structured care. [ABSTRACT FROM AUTHOR]