Integration through co-location of allied health services into general practice: a demonstration trial in north coast nsw medicare local.

Introduction: An impediment to integrated care in Australia is the fragmented nature in which care is delivered, without coordination, in the public, private, acute and community settings. This paper describes the evaluation of an initiative to determine whether the co-location of local health district (LHD) employed community and allied health professionals in general practice (family physician) settings results in better service integration and improved patient access and experience. The project aimed to improve the integrated care by facilitating skills transfer between specialist allied health and nursing staff and the general practice team while testing the feasibility of partnership arrangements for co-location and the establishment of shared governance between agencies. Practice change implemented: Between April 2014 and April 2015, 11 general practices were involved in the project across two Local Health Districts (Government public hospital and ancillary services sector). They worked with 4 co-located practitioners: 2 nurse practitioners (NPs) (chronic kidney disease and chronic cardiac and respiratory disease) and 2 clinical nurse specialists (CNSs) (respiratory failure and asthma). Three data sources were used in the evaluation: audit and activity data, surveys, and interviews. Data were synthesised into a logic model using Valentiijn and colleagues' (2013) integrated care framework. Key findings: The co-located practitioners delivered 294 consultations across 77 clinics to 217 patients. Practitioner co-location enhanced service integration by providing patients with accessible and appropriate services by: providing a timely and convenient service (the pathway from referral to receipt of services, distance travelled, ease of referral, and making the appointment). Co-location facilitated improved coordination of patient care by enabling practice staff to participate in team care plan reviews and case conferencing and facilitating skills transfer between the co-located staff and the general practice team. The project supported the development of service processes that enabled more streamlined integration. These processes can inform an operational plan to support implementation in other contexts (e.g. referral pathways, practitioner communication, formalised organizational governance relationships, shared records). Service integration resulted in a more positive patient experience (satisfaction and expectations); greater uptake of appropriate services by patients; and increased staff satisfaction (co-locating LHD staff and general practice staff). Highlights: The mechanisms to support integration included: - Clinical level: communicating / marketing the service to patients; patient identification and case finding - Professional level: engaging GPs; developing personal relationships between stakeholders; joint patient consultation; case finding tools and processes - Organisational level: processes to support referrals and bookings; clarify funding models; project management support; information sharing systems - Systems level: formalised agreements between agencies (memoranda of understanding) - Normative integration: joint integration strategies. Challenges to achieving integration were disparate accountability structures and funding models. Conclusions: There are currently no financial or policy levers at the primary / community level to truly integrate care around the patient. However, this project has demonstrated the need for, and benefits of, changes that evolve from the patient up. Starting with a small number of pilot sites, this project has identified various processes that can be implemented at the clinical, professional, and organisational levels to effectively improve the experience of integration from the perspective of patients and staff. [ABSTRACT FROM AUTHOR]