Search

Aim: To evaluate a collaborative model that integrates secondary care support into general practice, targeting the main health problems of patients with long-term conditions., Methods: The model was tested in two general practices in an area of high deprivation. Eligible patients were high users of the Middlemore Hospital Adult Medical Service. Model elements included nurse home visiting, record review, inter-professional case conference, and assertive follow-up and intervention. Data were collected from clinical records and interviews with patients and clinicians. Interviews were analysed using a general inductive approach., Results: Record review and home visiting uncovered clinical and social information buried in the 'systems records' or unknown. Inter-professional case conferences resulted in prioritising interventions before assigning to practitioners for follow-up. Home visiting led to advocacy for social services, not possible in earlier general practice or emergency department (ED) consultations. Specialist hospital physician support in accessing hospital services strengthened the relationship with general practice. Case finding was an unexpected outcome of home visiting with individuals from the same household as the index patient assisted to access services., Conclusion: All model elements -- nurse home visiting, record review, inter-professional case conference, and assertive follow-up and intervention -- were essential to resolving problems seriously impacting health status.

The introduction of the Primary Health Care Strategy has offered opportunities to take a population health approach to the planning and delivery of primary health care. The lack of a common understanding of population health between primary care and public health has been the prompt for a group of academics and practitioners to join forces and produce this statement on a population health approach to primary care, through primary health care. This paper takes the position that the features of a population health approach (such as a concern for equity, community participation, teamwork and attention to the determinants of health) enhance general practice care rather than undermine it. We conclude that the contribution of the health sector towards population health goals can be achieved through collaboration between GPs, nurses, other primary health care workers, and communities, together with health promotion and public health practitioners. Finding common language and understanding is an important step towards improving that collaboration.