Abstract
Health and social care systems across western developed nations are being challenged to meet the needs of an increasing number of people aging with multiple complex health and social needs. Community based primary health care (CBPHC) has been associated with more equitable access to services, better population level outcomes and lower system level costs. Itmay be well suited to the increasingly complex needs of populations; however the implementation of CBPHC models of care faces many challenges. This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC). The key question being addressed is “What are the steps to implementing innovative integrated community-based primary health care models that address the health and social needs of older adults with complex care needs?” and will be answered in three phases. In the first phase we identify and describe exemplar models of ICBPHC and their context in relation to relevant policies and performance across the three jurisdictions (New Zealand, Ontario and Québec, Canada). The second phase involves a series of theory-informed, mixed methods case studies from which we shall develop a conceptual framework that captures not only the attributes of successful innovative ICBPHC models, but also how these models are being implemented. In the third phase, we aim to translate our research into practice by identifying emerging models of ICBPHC in advance, and working alongside policymakers to inform the development and implementation of these models in each jurisdiction. The final output of the program will be a comprehensive guide to the design, implementation and scaling-up of innovative models of ICBPHC.
Highlights
Health and social care systems across western developed nations are being challenged to meet the needs of increasing numbers of older adults with co-existing, multiple chronic conditions, the risks of which are exacerbated for socially and economically vulnerable populations [1]
Community-based primary health care (CBPHC) providers are striving to offer innovative models of care that meet the complex needs of this diverse population group [4, 5]
This paper describes a program of research by an international, multi-university, multidisciplinary research team that utilizes these frameworks to examine the implementation of Integrated CBPHC (ICBPHC) in New Zealand, and in Ontario and Québec, Canada
Summary
Health and social care systems across western developed nations are being challenged to meet the needs of increasing numbers of older adults with co-existing, multiple chronic conditions, the risks of which are exacerbated for socially and economically vulnerable populations [1]. Providers need to be skilled and committed to providing seamless transitions between services for their clients with closer communication between services [2, 3]. Within this context, community-based primary health care (CBPHC) providers are striving to offer innovative models of care that meet the complex needs of this diverse population group [4, 5]. The CCM is based on six essential elements that are fundamental to effective partnerships between informed, activated patients and prepared, proactive practice teams: 1) community resources and policies; 2) health care organization; 3) self-management support; 4) delivery system design; 5) decision support; and 6) clinical information systems. The focus of chronic care management is often centred on the management of single diseases for
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