With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses. We aimed to investigate the WSICP’s effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement. Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors. The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.

/pdf/integrating-health-care-in-australia-a-qualitative-koccgb3og5.pdf

Integrating health care in Australia: a qualitative evaluation.

Despite a 3to 4-fold increase in the use of antidepressant medications, the prevalence of depression and anxiety disorders in Australia, Canada, the United Kingdom, and the United States has remained unchanged over the past 20 years. In the absence of compelling evidence that the incidence of these disorders is on the rise, a natural conclusion is that depressed or anxious patients who could benefit from treatment are still not identified and treated, or that the duration of illness has remained unchanged in those who are treated. This is a striking and troubling finding, considering the known efficacy of antidepressants and psychotherapies. It emphasizes both a well-delineated treatment gap, whereby many patients with depression or anxiety do not receive treatment, and a quality gap whereby those who are treated either do not need to be treated or do not receive effective treatment. Several factors contribute to these gaps. Even knowledgeable and well-intentioned physicians face competing demands, including the need to concurrently address medical comorbidities and social determinants of health, making identification and management of common mental disorders challenging. ‘Usual care’ for these disorders requires both a patient-initiated encounter and the clinician’s subjective impression of the presence of a treatment-responsive condition, leading to delays in the initiation and titration of treatments, high treatment dropout rates, and low recovery rates. A better integration of the care provided by primary care providers and specialists has been advanced as one solution to improve access to care and the quality of the care delivered. Integrated care encompasses models ranging from colocation (mental health providers delivering care within the primary care setting), to shared care (with increased coordination of care through provider-toprovider communication and shared health records), to the collaborative care model (CCM) (also known as ‘chronic care model’). The CCM is a well-established and effective approach to both mental and physical disease management that includes several key elements: 1) teambased care that includes patients as active member of the treatment team and establishes patient-centred goals and care plans; 2) measurement-based care where patient-reported outcomes are monitored using rating scales and treatments are regularly adjusted to reach predefined targets (e.g., a specific depression score corresponding to remission); 3) treatment selection and adjustments based on evidence (encapsulated in algorithms or care pathways) or, in the absence of evidence, expert opinion; and 4) population-based care whereby patients with a target condition are identified via systematic screening, tracked in a clinical registry, and reached proactively if they are disengaging from treatment. In primary care, where most common mental disorders are treated, more than 80 randomized controlled trials (RCTs) have shown that collaborative care is more effective than usual care to improve quality of care processes, clinical outcomes, patient and provider experience, health disparities, and cost-effectiveness. A recent commentary on collaborative care suggested that further RCTs on collaborative care were unnecessary and possibly unethical given the existing body of evidence supporting its implementation.

https://journals.sagepub.com/doi/pdf/10.1177/0706743717748884

Can Collaborative Care Cure the Mediocrity of Usual Care for Common Mental Disorders

Objective To contrast how Brazil’s and Canada’s different jurisdictional and judicial realities have led to different types of telemedicine and how further scale and improvement can be achieved. Composition of the committee A subgroup of the Besrour Centre of the College of Family Physicians of Canada and Canadian telemedicine experts developed connections with colleagues in Porto Alegre, Brazil, and collaborated to undertake a between-country comparison of their respective telemedicine programs. Methods Following a literature review, the authors collectively reflected on their experiences in an attempt to explore the past and current state of telemedicine in Canada and Brazil. Report Both Brazil and Canada share expansive geographies, creating substantial barriers to health for rural patients. Telemedicine is an important part of a universal health system. Both countries have achieved telemedicine programs that have scaled up across large regions and are showing important effects on health care costs and outcomes. However, each system is unique in design and implementation and faces unique challenges for further scale and improvement. Addressing regional differences, the normalization of telemedicine, and potential alignment of telemedicine and artificial intelligence technologies for health care are seen as promising approaches to scaling up and improving telemedicine in both countries.

https://www.cfp.ca/content/cfp/66/2/104.full.pdf

Telemedicine in the driver's seat: new role for primary care access in Brazil and Canada: The Besrour Papers: a series on the state of family medicine in Canada and Brazil.

Background: Collaborative management of kidney disease relies on coordinated and effective partnerships between multiple provider teams. Siloed care contributes to limited access between physicians, resulting in delays in the diagnosis and treatment of kidney disease and inappropriate use of healthcare resources. These gaps contribute to dissatisfied and disempowered providers and patients. Digital systems such as eConsult can support collaborative management and address these gaps, thereby streamlining the consultation and referral process between primary care physicians (PCPs) and nephrologists. In this study, we evaluated an established eConsult platform integrated with a central triage process for a network of PCPs and nephrologists. The study aimed to assess the acceptability, feasibility, and impact on access to nephrology when using eConsult integrated into the management of kidney disease between PCPs and nephrologists. Methods: We conducted a 1-year pilot study and used mixed methods to measure the acceptability and feasibility of using eConsult for the management of kidney disease. We compared eConsult and traditional referrals with respect to types of consultation, referrals, and times to response to determine impact on access to kidney care. We conducted semi-structured interviews of PCPs and nephrologists to assess physician experience. Results: From January 8, 2018, to January 11, 2019, 52 PCPs and 23 nephrologists participated in the study, with 250 traditional referrals and 106 eConsults submitted during that period. The median response time for eConsult was 15 (3–64) h, with 25% originating outside the central Toronto region. The median time to first clinic appointment from a traditional referral was 4 months (111 [61–163] days). PCP and nephrologist interviews revealed high user satisfaction, citing efficiency and timely response as key facilitators. Conclusion: The eConsult platform was acceptable, feasible, and facilitated access to nephrology care compared to traditional referrals. Physicians report improvements in physician care delivery, nephrology care gaps, patient experience, and healthcare utilization.

An Integrated Kidney Care eConsult Practice Model: Results from the iKinect Project.

Overcoming Barriers to Accessing Obstetric Care in Underserved Communities.

Problem addressed Timely access to specialist care is an important issue for patients with mild to moderate symptoms, and wait times for referrals are currently quite long.

Objective of program To provide FPs with quick telephone access to other specialists for treatment advice for patients with nonserious conditions that they would otherwise refer to specialist care.

Program description The RACE (Rapid Access to Consultative Expertise) program is a telephone hot-line providing FPs and nurse practitioners in the Vancouver, BC, area with timely access to specialist consultations. An evaluation of data from RACE found 60% of RACE calls prevented patients from visiting a specialist and 32% of calls prevented FP referrals to hospital emergency departments.

Conclusion Supported by RACE, FPs can more effectively remain the locus of patient care, calling on other specialist expertise when appropriate and providing better coordination of care for their patients. Evaluations to date suggest RACE helps reduce system costs by reducing unnecessary emergency department visits and face-to-face specialist consultations.

Family physician access to specialist advice by telephone

Problem addressed Timely access to specialist care is an important issue for patients with mild to moderate symptoms, and wait times for referrals are currently quite long. Objective of program To provide FPs with quick telephone access to other specialists for treatment advice for patients with nonserious conditions that they would otherwise refer to specialist care. Program description The RACE (Rapid Access to Consultative Expertise) program is a telephone hot-line providing FPs and nurse practitioners in the Vancouver, BC, area with timely access to specialist consultations. An evaluation of data from RACE found 60% of RACE calls prevented patients from visiting a specialist and 32% of calls prevented FP referrals to hospital emergency departments. Conclusion Supported by RACE, FPs can more effectively remain the locus of patient care, calling on other specialist expertise when appropriate and providing better coordination of care for their patients. Evaluations to date suggest RACE helps reduce system costs by reducing unnecessary emergency department visits and face-to-face specialist consultations.

https://www.cfp.ca/content/cfp/62/11/e668.full.pdf

David Thompson

Papers

Family physician access to specialist advice by telephone

Family physician access to specialist advice by telephone: Reduction in unnecessary specialist consultations and emergency department visits.