Barriers and facilitators for successful after hours care model implementation: Reducing ED utilisation

Abstract

Summary Background A systematic review examined the barriers and facilitators influencing the success and sustainability of after hours care models on acute care utilisation. Extensive research had been undertaken in many countries, particularly in the United Kingdom, The United States of America, Ireland, Canada, Denmark, Sweden, and to a lesser degree Australia. The literature covered the period from 1970–2008. The evidence demonstrated a positive impact on acute service utilisation patterns. There were few relevant randomised control trials. The evidence was largely based on quasi experimental (time series), before and after or comparative studies. Study results often noted barriers and facilitators for model success and sustainability. The relevant literature was largely international, so results may need to be interpreted in a considered way given geographical, cultural and social differences. This said the findings are relevant to the Australian context. Results The scope of the review focused on national and international studies of after hours care service models and their impact on acute care and ambulance services. The review identified six practicebased after hours care models: Telephone Triage and Advice services; GP Co-operatives services; Minor Injuries Units; Walk in Centres; Primary Care Health Centres; and, Ambulance Services (‘see and treat' and ‘treat and refer'). The models were not mutually exclusive from each other, Emergency Departments or General Practitioner clinics. The review identified seven barriers: Delivery and speed of Telephone Triage Services; Gate keeping practices of Medical Practitioners; Australian Triage Scale fails to accommodate primary health care patients; Ambulance paramedic role and referral options; Medical record system segregation between primary health and acute services; patient expectations and behaviour; and financial barriers. The seven key facilitators included: Integration, collaboration and identified outcome benefits; geographical location of after hours services; non-appointment systems and waiting times; financial incentives for increasing services; Nurse Practitioner role; expanding the Medical Benefits Scheme Rebate; and, media campaigns influence patient behaviour. Conclusions Many of the primary health care models implemented internationally are likely to have an impact within the Australian context and specifically on acute services. There is no doubt that primary health care type patients attend EDs. The identified barriers and facilitators provide a potential framework that could enhance primary health care reforms, integration, sustainability and acceptance of models and population health care outcomes.