Collaborative Primary Care Research Articles

Developing Research Capacity and Collaboration in Primary Care and Social Care

Recent research provides evidence of collaboration between health and social care agencies in the UK, but without specifically discussing research capacity. Shared concerns include critiques of the dominant hierarchy of methods in healthcare research, and of simplistic approaches to the research-practice relationship. A study carried out in 2000-1 found evidence of poor research infrastructure within social services. However, there is also evidence of innovative developments, utilizing specific expertise in user involvement and action research. Study participants welcomed joint health and social care research training; barriers to participating in research included lack of confidence, limited time or training for research, low recognition for research activity and uneven supervision. We describe the initiatives that have developed in response to the study, and comment on developments in research governance. These present opportunities for increased collaboration at the primary health care/social care interface, although there is a need to maintain a pluralistic approach.

Re-thinking approaches to undergraduate health professional education: Interdisciplinary rural placement program

The Interdisciplinary Rural Placement Program involved the development, implementation and evaluation of a common rural primary health care module. Designed for undergraduate nursing, medical and pharmacy students of the University of Tasmania, students undertook clinical experiences and a collaborative primary health care project at two different Rural Health Teaching Sites across Tasmania. The aim of the project was for interdisciplinary students to work and learn together to enhance their understanding of the cooperative and collaborative nature of professional practice among rural health care workers. This paper will describe the development and implementation of the Interdisciplinary Rural Placement Program and critically discuss the outcomes in relation to nursing. In this paper, three issues will be explored. Firstly, how student nurses questioned their sense of subordination when in fact the level of recognition by their interdisciplinary peers led them to refute this. Secondly, concerns with overcoming the difficulties of coordinating student recruitment and conflicting timetables, while working within existing curricula, will be discussed. The final issue explores the student nurses' recognition that despite inherent tensions and conflict, the need to work as a cohesive and cooperative interdisciplinary team was vital. This project highlighted the challenges that health professions continue to work through in contemporary practice and education sectors. A key recommendation for education providers is that true interdisciplinary education must be achieved through an experiential framework.

The Effects of a Collaborative Model of Primary Care on the Mortality and Hospital Use of Community-Dwelling Older Adults

This study evaluates the ability of a model of collaborative primary care practice to reduce mortality and hospital use in community-dwelling elderly persons. Four rural and four urban clinic sites in east central Illinois were randomized to form treatment and comparison clinics from which patients were enrolled and followed prospectively for 2 years. Patients from the practices of participating physicians were eligible if they were aged 65 and older, were living in the community, and had at least one risk factor as determined prior to the study. Medicare hospital data were obtained from the Health Care Financing Administration. Demographic and health status measures were obtained by telephone interview every 12 months throughout the study. The treatment group experienced a 49% reduction in all-cause mortality during the second year of the study (odds ratio, 0.51, 95% confidence interval, 0.29-0.91, p = .02). There were no significant differences between treatment and comparison patients in percentage of persons hospitalized, hospital length of stay, or Medicare payments. Although measures of health status indicated that the treatment group was significantly sicker at baseline at the end of 1 year, these differences disappeared by the end of 2 years. The collaborative primary care model evaluated in this study significantly reduced mortality in the second year, without increasing hospital use. These findings suggest that a collaborative primary care team that enhances primary care practice can result in better patient outcomes.

Predoctoral training in collaborative primary care: An exam room built for two.

Predoctoral training in collaborative primary care: An exam room built for two.

Parental preferences for primary and specialty care collaboration in the management of teenagers with congenital heart disease.

We examined parental preferences for locus of service delivery for their teenager's congenital heart disease (CHD) and the influence of disease severity, sociodemographic factors, and insurance on these preferences. A consecutive sample of parents of teenagers followed in a pediatric cardiology clinic completed a mailed questionnaire. Disease severity was classified as low (</=1 cardiovascular procedure), moderate (>1 cardiovascular procedure), and high (cyanosis or single ventricle physiology). Eighty-six of 148 parents responded (58%): 40, low severity; 36, moderate severity; and 10, high severity of illness. Parents preferred using primary care providers (PCPs) as a point of first contact for all 11 of 11 general health concerns and 5 of 7 potential cardiovascular-related concerns: chest pain (52%), syncope (73%), seeming seriously ill (79%), sports physical examination (79%), and endocarditis prophylactic antibiotics (94%). Increasing disease severity was significantly associated with preferring cardiologists for 6 of 7 cardiovascular-related concerns. Overall, 58% of parents viewed their care as a PCP-cardiologist comanagement model versus a cardiologist-dominated model. Lower family income (odds ratio [OR]: 1.5; confidence interval [CI]: 1.0-2.2) and severity of illness (OR: 2.1; CI: 1.0-4.4) were associated with a comanagement model of health care versus a cardiologist-dominated model. This study suggests that the majority of parents of teenagers with CHD prefer to use their teenager's PCP for all routine health care needs and many cardiovascular health needs. Severity of illness and family income are positively associated with greater preference for cardiologist care.

Primary Care in the Home: The Time is Now!

The Visiting Nurse Association of Greater Philadelphia is the first home health agency to provide primary health care in the home. A team of advanced practice nurses working with a physician provides much-needed medical care in patients' homes. Medicare B and other payors are reimbursing the organization for these services. This collaborative primary health care model integrates multiple health services and provides them to patients. This article describes the conception and implementation of this unique health service delivery model.

Prospects for collaboration in primary care: relationships between social services and the new PCGs

The article considers the relationships established between the new Primary Care Groups (PCGs) in England and Social Services Departments. It reports on qualitative research into localisation and collaboration in PCGs and reviews the main factors involved in the creation of collaborative relationships. Collaboration is a required element of planning in primary care but the extent and nature of its realisation is shaped by the particular interaction of local history with the new structures. Four localities were chosen for the qualitative stage of the research in order to learn how local configurations and existing relationships affected, and were affected by, the PCG. The article identifies the complex relationships which exist between PCGs and social services and the discusses the main features in promoting or undermining collaboration.

Prospects for collaboration in primary care: relationships between social services and the new PCGs

The article considers the relationships established between the new Primary Care Groups (PCGs) in England and Social Services Departments. It reports on qualitative research into localisation and collaboration in PCGs and reviews the main factors involved in the creation of collaborative relationships. Collaboration is a required element of planning in primary care but the extent and nature of its realisation is shaped by the particular interaction of local history with the new structures. Four localities were chosen for the qualitative stage of the research in order to learn how local configurations and existing relationships affected, and were affected by, the PCG. The article identifies the complex relationships which exist between PCGs and social services and the discusses the main features in promoting or undermining collaboration.

Personal and practice development plans in primary care in Wales

As part of the move towards a primary care-led NHS in the UK, a programme enabling general practices to identify and meet organisational development needs is under way in Wales. Personal and Practice Development Plans (PPDPs) are seen as a way of planning the integration of organisational development in general practice with the personal educational needs of multiprofessional primary health care team members. Given the current UK policy emphasis on continuing professional development and collaboration in primary care, PPDPs could be an appropriate way of facilitating such change. Based on a feasibility study in five Welsh Health Authorities, this paper describes the model used and the evolutionary process of implementing general practicebased PPDPs. It is one of the first projects of its kind. Reporting on an early stage, we have found planned timescales to be unrealistic and a degree of mismatch in expectations of process and outcomes among some key stakeholders which has led to some amendments of the model. Early feedback of potential problems has enabled key stakeholders to share lessons learned and ways of resolving initial difficulties have been found. It is likely that adaptation of the framework model at practice level will shape process and outcomes, which will be described in a subsequent paper. This paper addresses the complex reality of getting (government) policy into (general) practice.

Predoctoral training in collaborative primary care: An exam room built for two.

Predoctoral training in collaborative primary care: An exam room built for two.

Pediatric Asthma Outcomes After Implementation of a Disease Management Model: The Asthmatter of Fact Program

Asthmatter of Fact is a comprehensive pediatric asthma disease management program designed for use in an independent practice association (IPA) model managed care organization (MCO). To improve the quality of care received by children with asthma and to increase adherence to evidence-based guideline recommendations, as manifested by reductions in emergency room and hospital utilization and in activity days missed. The program features intensive home-based patient education; a unique alignment of incentives with primary care and specialist collaboration; and continuous quality improvement (CQI) based on provider and ancillary staff education and performance feedback. The outcomes measures included hospitalizations and emergency room visits, missed activities days, medication usage and patient satisfaction. Measured outcomes after the first year of the program demonstrated major reductions in hospital admissions (63%), emergency room visits (71%), and urgent care costs ($670 annual savings per patient), accompanied by improvements in quality of life and pharmacy profiles and a high level of patient satisfaction. These results suggest that the Asthmatter of Fact Program for pediatric asthma disease management might serve as a useful prototype in other IPA-model MCO settings.

Commentary: collaboration in pediatric primary care: a pediatrician's view.

Although neither pediatricians nor psychologists can provide alone for the vast needs of children and families in our increasingly complex society, these needs can be met through effective collaboration. An ideal model for collaboration would exist if pediatricians and psychologists worked together in practice teams, for which developmental-behavioral pediatricians might serve as consultants. Together, these professionals could take responsibility for professional education, expanded clinical care, liaisons with schools and other community-based resources for children and families, and research that addressed questions about the development, coping, and correction of children's and families' difficulties.

Advancing Mental Health and Primary Care collaboration in the Public Sector

The integration of primary care and mental health in the public sector promises both financial savings and improved care for patients, who benefit from the collaborative treatment of their physical and mental health. Yet integration quickly proves a complex task. With their different models of care, histories, and priorities, the primary care and mental health domains have trouble communicating, much less collaborating. In this issue of Directions for Mental Health Services, mental health and primary care providers come together to discuss the opportunities and challenges posed by integration. Drawing from their experiences, the authors examine the forces both for and against integration; offer suggestions for effective cooperation between the specialties; and explore the issues of gatekeeping, authorization, and confidentiality This is the 81st issue of quarterly journal New Directions for Mental Health Services.

Public health and primary care collaboration--a case study.

This paper describes the approach of one total purchasing project (TPP) to health needs assessment (HNA) and identifies issues that require consideration when undertaking HNA in primary care. It discusses the advantages of adopting a Health Authority (HA) HNA strategy and the development of a decision-making process for implementing this and other strategies to address possible areas of identified need. The prerequisites, advantages and potential difficulties of this approach are highlighted and related to the needs of primary care groups (PCGs) for addressing health needs and population health.

Parental Preferences for Primary and Specialty Care Collaboration in the Management of Teens with Congenital Heart Disease

Parental Preferences for Primary and Specialty Care Collaboration in the Management of Teens with Congenital Heart Disease

A community collaborative practice experience between med/peds and family practice

The medical literature has followed educational outcomes of Medicine-Pediatric (Med/Peds) physicians, but limited studies exist as to clinical outcomes for these combined specialty physicians. Although a variety of practice environments are available for a growing number of Med/Peds physicians, a collaborative practice setting with family physicians may optimize the Med/Peds practice potential. This study investigates clinical practice outcomes and utilization efficiencies of collaborative Med/Peds family practice physicians within a community, which should provide an effective model in a growing managed care environment. Two collaborative practice settings in a moderate size Midwest community were analyzed with respect to patient demographics and utilization scores provided by a practice management group and a nationally based health care network. Current Procedural Terminology (CPT) coding was used to follow demographic trends for over 45,000 patient visits for 1 year. Efficiency ratings (Z-scores) were used over the same year for over 6,000 health care network patient visits to 10 collaborative practice-based physicians, which were then compared to 141,101 community family practice patient encounters, 26,617 general internist patient encounters, and 29,995 patient encounters to pediatricians for utilization trends. Med/Peds and Family Practice patient care data reflected nearly identical patient demographics between specialties with only a few exceptions. Med/Peds physicians cared for three times the total number of children less than 2 years old. Med/Peds physicians experienced a higher complexity of illness, in part due to a 40% increase in internal referrals from family practice colleagues in the ambulatory care setting, while maintaining a third of the proportion of outpatient referrals. Cost-effective interoffice utilization was still maintained, supported by a more optimal efficiency rating for Med/Peds physicians compared to collaborative family practice colleagues. Inpatient efficiency was demonstrated for Med/Peds specialists even though a threefold increase in hospitalizations was observed, in part resulting from physicians within these collaborative practices arranging all newborn nursery and pediatric admissions be covered by Med/Peds physicians. Both collaborative primary care specialists demonstrated more cost-effective overall practice utilization scores when compared to community-based primary care specialists. Med/Peds physicians in this study have been trained to provide cost-effective patient care in both outpatient and inpatient settings. Decreased outside referrals by collaborative family practice physicians through utilization of Med/Peds colleagues serves to optimize practice economy by eliminating the threat of competition that exists among community-based generalists. Such a model helps to control an overused referral system to subspecialists.

Quality and customers: Type 2 change in mental health delivery within health care reform.

The traditional separation of mental health and medical programs is problematic because mental health issues are inseparable from the larger medical system. By contrast, a collaborative primary care model of mental health care, augmented and supported by secondary specialty mental health services, has the potential to optimize quality and cost goals while reinforcing health care reform principles. The flexibility of mental health treatment in this delivery structure provides opportunities to customize services according to patient and purchaser expectations.

Development of a measure of professional collaboration in primary health care.

The aim was to develop indices of the degree of collaboration between district nurses, general practitioners, and health visitors. Semistructured interviews were conducted with each member of a pair of professionals who had patients in common. In each district a stratified random sample of six general practitioners and six community nurses was drawn, and for each a "partner" of the other profession was sampled. A stratified random sample of 20 district health authorities in England. Complete interviews were obtained with 148 doctor-nurse and 161 doctor-health visitor pairs. Only 27% of general practitioners and district nurses with patients in common and 11% of general practitioners and health visitors collaborate. Stepwise logistic discriminant analysis was used to develop measures of collaboration between general practitioners and district nurses and between general practitioners and health visitors. The indices of collaboration were calculated from the responses of the community nurse to at most 10 questions. The indices developed here might be used as a measure of one aspect of the quality of service offered by a primary health care team or to assess the effect of changes in working patterns or the degree of collaboration within the organisation.

Periodontal status and treatment needs in the Chiangmai/Lamphun provinces of Thailand.

As part of an oral health survey concerned with the evaluation of a collaborative primary oral health care program, the CPITN system was used to determine the periodontal status and treatment needs of 2009 Thai people aged 12-44 yr. Calculus dominated the CPITN scores. The percentage of persons with healthy periodontal tissues was small, ranging from 0.7% at age 35-44 to 4.1% at age 12. Ranges for other highest scores were bleeding-0.4% at age 35-44 yr to 6.1% at age 12 yr; calculus-62% at age 35-44 yr to 92.6% at age 17-18 yr. Pocketing did not occur to any significant extent until age 35-44 where 23.9% had 3-5 mm pockets and 12.8% had pockets 6 mm or deeper. 15-18-yr-olds who had received prior care from a Village Scaler had a significantly higher number and proportion of healthy sextants than those who had not received such care. No such effect was demonstrated in 35-44-yr-olds. The need for caution in the interpretation of this result is stressed. Attention is drawn to the desirability of differentiating between supra- and sub-gingival calculus in the CPITN scoring system and to the excessive treatment requirements that arise from classifying everyone with calculus as requiring prophylaxis and scaling. A great deal of improvement will need to be affected if the Thai national and global goals for periodontal health are to be achieved in the districts covered by this survey.