How the puzzle fits together - what are the current and potential links between programs and between sectors
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Summary of discussion
Generally...
A number of reflections were made about the distribution of services on the pieces of the puzzle map. The map was not comprehensive (nor intended to be), and while it did include a large number of programs, these did not necessarily reflect the volume of work being done.
The map did however highlight for some the relative balance/imbalance across the spectrum of care. One example cited was children's services which appeared to have a focus on primary prevention, leaving parents to provide ongoing care for those children who are not well.
Clinical streaming in AHSs has introduced further complexity as there are a number of clinical groups/services running across each sector. While clinical streaming promoted better interfaces for specific groups of patients, it also introduced fragmentation within sectors. Linkage services across sectors would need to take this
complex context into consideration.
Gaps and duplication were evident, with delegates citing duplication in secondary prevention/risk factor management between community health and general practice. This raised questions about who is best placed to provide these services, implying a need to rationalise Commonwealth and state funded services.
The varied funding, structure and goals of each of the sectors presents real challenges to care coordination. Unless the goals (for example, safe discharge, decreased hospital admission, improved quality of life etc) can be agreed, providing comprehensive integrated care will remain a difficult endeavour.
The use of the term interface may itself be problematic as it can imply that the delivery of service in one sector ends and a service in another sector commences, at a single point in time. The experience is however quite different, with patients moving back and forth between sectors.
Given that some interfaces are inevitable, the focus should be on identifying when smooth transitions are most important and investing effort in achieving them. Clients/patients should not have such different experiences as they move between sectors that they feel they are lost or not in control.
A structured system of accountability for care on either side of a particular interface or transition, with outcomes and incentives associated with the transition process could provide greater responsibility for and attention to these transitions with the outcome of an improved patient experience.
Interfaces between sectors...
Delegates were of the view that a greater focus on the community health and care sector and its interfaces was required, particularly in an environment where considerable attention is given to hospital based services.
Community health lacks profile, in part because it lacks medical leadership and has little profile in medical undergraduate training. The clinical leadership of Community Health managers and GPs was seen as critical to raising the profile of the primary and community health sector, as was further implementation of undergraduate medical and allied health and nursing training opportunities in environments such as HealthOne NSW.
Models of care/programs within hospital based services need to be streamlined to enable more efficient communication with general practice. A GP may for example be contacted by a number of different staff from hospital services, all providing separate pieces of information relating to the one patient. Relationships are difficult to establish in this environment, and trust may suffer.
Professional respect and trust between various sectors (hospital, community, aged care, general practice) was identified as an important enabler to ensure improved communication and interfaces.
GP liaison personnel (such a liaison nurses) have been shown to be effective in bridging the interfaces, for example between community health and general practice.
Information exchange and communication across the sectors and with other sectors (eg. housing, legal, financial) is an important platform to improving the patient journey. Yet it was evident to delegates that communication (or for that matter colocation) alone is not sufficient.
A view was put forward that the way the whole system operates needs to be reformed to enable solid partnerships to be formed (particularly between the community sector and general practice), in order to provide comprehensive integrated primary health care.
Evidence shows that GPs feel they are poorly equipped to play the role of care coordinator across the different sectors. Furthermore, the current MBS structure and lack of incentives to be involved in care partnerships, and integrated care were additional barriers.
Conclusion...
A 2nd and 3rd edition of the map were suggested. The 2nd edition would consider current care across the spectrum for various population groups (for example children, older people). The 3rd edition would identify what is ideally needed in practice, for example, identifying hospital based resources/staff that could reach into the
community sector. This latter map was probably best planned at the local level.
Evidence shows that it is relatively easy to create coordination links between various service providers within existing arrangements. More challenging is planning and reconfiguring services when we are dealing with very different systems, for example Commonwealth and state funded systems. Primary Care Partnerships in Victoria
have developed an important coordination role over the past 8 years, however are only now starting to attempt to address service planning issues.
Intellectual and clinical leadership provides the impetus, but for lasting change delegates felt that comprehensive structural and funding changes were required. Demonstration models such as HealthOne NSW may help to highlight the need for this type of system wide change.
This web page is managed and authorised by Inter-Government & Funding Strategies of the NSW Department of Health. Last updated: 30 March, 2009
