Primary Care Partnership Research Articles

Gold Coast Primary Care Partnership Council: partnership and innovation that makes a difference

The Gold Coast Primary Care Partnership Council is bringing together diverse stakeholders to improve the health and wellbeing of their community. The inaugural chairperson and coordinator reflect on the high level of enthusiasm to work together as a promising start to building sustainable partnerships.

Fit for purpose – a regional case study in primary care research partnerships

AimsTo describe the context, mechanisms and outputs of a regional primary care partnership for research facilitation over a three-year period, and evaluate factors which were likely to be worth replicating in the new UK Clinical Research Network (UKCRN) structures.BackgroundThe revision of NHS research and development structures into the UKCRN has presented organizational challenges to pre-existing partnerships. This raises questions of whether pre-existing arrangements had already delivered effective research facilitation in NHS settings, and makes evaluation of successful practice a crucial part of organizational learning for the current management of research delivery in the UK.MethodsA mixed methods case study in one R&D consortium (Norfolk and Waveney, England). Using a model of realistic evaluation, we analysed context, mechanisms, working practices, and outcomes for research delivery in the primary care context – covering key priorities of research governance and ethics, hosting and recruiting to studies, and training and support approaches.FindingsFrom January 2005 to December 2007, 35 general practices opted into a host practice research network, each hosting an average of 10 studies over that period, with 278 projects being active overall. By the last year, an extension of network activity to all practices in Norfolk, Great Yarmouth and Waveney had led to 96% of all practices delivering at least one study, and a turnaround, from application to commencement of approved studies, of 28 days for 74% of studies. This level of activity can act as a baseline for future UKPCRN activities, and the factors associated with it may be helpful for others seeking to provide an effective networking structure. The larger structures of the new UKCRN regional networks will be able to draw on extensive good practice in some areas, and should be sure to preserve these, as they may already be fulfilling the important goals for which UKCRN was created.

First Link: Strengthening Primary Care Partnerships for Dementia Support

While primary care faces many challenges, including an increasing prevalence of older individuals, emerging knowledge about the potential benefits of collaborative partnerships has encouraged the development of new means of providing and supporting primary care. First Link™ is an innovative program involving collaborations among primary care providers, Alzheimer Societies, and other health professionals. The program aims to support persons with Alzheimer's and related diseases after the diagnosis is made and to link them with support services earlier in the disease course. This paper describes the First Link program, provides an overview of a study currently underway to evaluate it, and identifies some of the benefits and challenges associated with this partnership.

Physician Roles, Payment Models, and Partnerships in Primary Care

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Physician Roles, Payment Models, and Partnerships in Primary Care—Reply

Physician Roles, Payment Models, and Partnerships in Primary Care—Reply

Making Partnerships Work: Issues of Risk, Trust and Control for Managers and Service Providers

Trust is widely recognised is a core feature of partnership relationships and one that facilitates joint work. It is an issue that must be addressed if partnerships are to enhance service system integration. In recent literature trust has been linked to concepts of risk and control. In this study of trust within a Primary Care Partnership (PCP) in Australia the experiences of risk and uncertainty, and control, of participants in different structural positions, were explored in detail. The data used in this paper was qualitative, derived from 63 interviews with managers and service providers participating in committees of the PCP. This paper reports on the differences in the experience of risk and uncertainty, trust and control, of managers and service providers working as boundary spanners through the committees of a PCP. For managers there were significant risks and uncertainties, and trust and control were important. For service providers there were few risks and uncertainties, and trust and control were of much less importance. Some policy implications of the differences in perspective are discussed, as are important areas for further research.

Partnerships in primary care in Australia: Network structure, dynamics and sustainability

Partnerships represent a prescriptive form of network governance, based on the idea of cooperation. This article has four aims. The first is to describe why network governance and partnerships are important now, and what one particular example – Primary Care Partnerships – is addressing. The second is to analyse the network structure of two of these partnerships, and the third is to examine network dynamics. The fourth aim is to explore relationships and sustainability over the longer term. Two government-funded and steered partnerships, which were established to increase coordination between primary care services in Victoria, Australia, were examined. Annual interviews at three points in time between 2002 and 2005 were used to explore relationships between organizations within these two partnerships. The structure of two different communication networks, based on contacts for work and contacts for strategic information, were examined using social network analysis. Tracing network structures over time highlighted partnership dynamics. The network structures changed over the three years of the study, but an important constant was the continuing centrality of the independent staff employed to manage the partnerships. Over the longer term, it seems to be more important to fund independent partnership staff, rather than people who connect partnerships to the funding agency. If partnerships are seen as valuable in improving service coordination and health outcomes, then long term rather than just start-up funding support is required.

Variations in hospitalizations for chronic obstructive pulmonary disease in rural and urban Victoria, Australia

Effective and timely management of COPD should reduce the risk of hospitalization. The purpose of this study was to describe variations in COPD hospital admission rates as an indicator of the adequacy of primary care services. Age- and gender-standardized hospital admission rates of COPD (2003-04) were computed using the Victorian Admitted Episodes Dataset. Potential predictors of COPD admission rates were identified from various sources of data. These included degree of remoteness, socio-economic status, number of general practitioners per population, percentage of Aboriginal or Torres Strait Islander people, percentage of smokers, and co-morbidities. These data were aggregated at the primary care partnership level, which are voluntary alliances of one or more local government areas in Victoria. Weighted least squares regression was used to identify the predictors of COPD admission rates. Hospital admission rates for COPD were higher in rural than in metropolitan areas of Victoria. Multiple logistic regression analysis showed significant associations between COPD admission rates and socio-economic status, smoking rates and remoteness of the area. Small-area analyses of COPD admission rates highlighted significant differences between urban and rural areas. The influence of socio-economic status and degree of remoteness on COPD admission rates highlights opportunities for policymakers to develop targeted public health and health service interventions.

The Application of Cognitive-Behavioral Therapy for Psychosis in Clinical and Research Settings

This study compared the practice of cognitive-behavioral therapy (CBT) for psychosis across research and routine clinical settings. An observer-rated adherence measure was used to compare the content of 40 therapy sessions of clients with positive psychotic symptoms. Twenty therapist-client dyads came from a research setting in the United Kingdom and 20 from three clinical settings, two in the United Kingdom and one in the United States. In the research setting CBT was provided by research clinical psychologists and trained local therapists. In the clinical settings CBT was part of a case management service by trained therapists. Therapist adherence to CBT for psychosis did not differ between the research and clinical settings. However, clinicians in the research settings scored significantly higher on items for schema work (z=-1.98, p<.05), relapse prevention interventions (z=-2.08, p<.05), and formulating a model of relapse (z=-2.61, p<.01). CBT for psychosis conducted in clinical settings was more strongly characterized by assessment of symptoms and work on coping strategies and less so by relapse prevention and schema-level work. Relapse prevention interventions and schema work could be considered more challenging for therapists to undertake. The findings suggest that therapists working in routine clinical settings are able to establish good therapeutic relationships with people with psychosis and to work on assessing and coping with their psychotic symptoms. However, some therapeutic approaches may be more challenging in this context.

A Tertiary Care–Primary Care Partnership Model for Medically Complex and Fragile Children and Youth With Special Health Care Needs

To evaluate the impact of a tertiary care center special needs program that partners with families and primary care physicians to ensure seamless inpatient and outpatient care and assist in providing medical homes. Up to 3 years of preenrollment and postenrollment data were compared for patients in the special needs program from July 1, 2002, through June 30, 2005. A tertiary care center pediatric hospital and medical school serving urban and rural patients. A total of 227 of 230 medically complex and fragile children and youth with special needs who had a wide range of chronic disorders and were enrolled in the special needs program. Care coordination provided by a special needs program pediatric nurse case manager with or without a special needs program physician. Preenrollment and postenrollment tertiary care center resource utilization, charges, and payments. A statistically significant decrease was found in the number of hospitalizations, number of hospital days, and tertiary care center charges and payments, and an increase was found in the use of outpatient services. Aggregate data revealed a decrease in hospital days from 7926 to 3831, an increase in clinic visits from 3150 to 5420, and a decrease in tertiary care center payments of $10.7 million. The special needs program budget for fiscal year 2005 had a deficit of $400,000. This tertiary care-primary care partnership model improved health care and reduced costs with relatively modest institutional support.

Partnership Management: Working Across Organisational Boundaries

The short paper that follows is fundamentally about evidence-based practice. In Kuruvilla, Mays, Pleasant and Walt's (2006) terms it was an exercise in the application of research to service development and evidence-based practice. In Walter, Nutley, and Davies' (2003) taxonomy it resulted in a professional intervention, the development of which was led by research users seeking evidence to inform practice development. The team emerged out of a social network of individuals interested in partnership development issues (Kalucy, McIntyre, &amp; Jackson-Bowers, 2007). The resulting paper was the foundation for a significant investment, by the Department of Human Services, in building capacity for partnership leadership in Victoria. The team that undertook this research-to-practice project consisted of three Primary Care Partnership (PCP) executive officers/managers, one of whom was also executive officer to the Statewide Chairs and Managers Group, a university researcher, and a final year undergraduate student working as a volunteer. The executive officer to the Statewide Chairs and Managers Group formed the team to explore broad issues of PCP development and to report to the chairs. The Statewide Chairs and Managers Group was the pathway through which the group's work would reach decision-makers. After a series of meetings to clarify the issues to be addressed, a developmental process for working with the chairs and managers was designed. The executive officers/managers were key to clear issue definition and appropriate process; the researcher to linking the issues to the partnership evidence base. The process relied on tapping the tacit knowledge of PCP managers and chairs and relating this to the relevant body of research. In this process implicit learning needs in regard to partnership leadership were articulated within a framework developed out of a complex research project undertaken with similar partnerships elsewhere. The university researcher on the team had a long history of research into partnerships and networks in the field of primary health care. The specific research project in question was a National Health and Medical Research Council-funded study of trust in the relationships between organisations in a Primary Care Partnership. The study of trust in a partnership is necessarily a study of partnership processes more generally. It was the general learning about partnership processes from this and related research that turned out to be so useful for the service system. The report of this work, that follows, was written in a form suitable for decision-making. It is not a research report but it is built on strong research-based frameworks that were "tested" in the local context. The recommendations are specific to PCPs in Victoria but will also be familiar to partnership workers elsewhere. The predicted effects of the recommendations are supported by research evidence.

Integrated Disease Management Programs: Reflections and Learnings from Implementation

Integrated Chronic Disease Management (ICDM) is a key focus of recent Victorian Government primary care partnership (PCP) and community health policy direction documents. Planning for a more ICDM approach has been informed by earlier integrated disease management (IDM) projects funded through the PCP Strategy. In 2001, five IDM pilot projects were funded, for three years, under the Department of Human Services (Victoria) IDM Initiative. The IDM projects aimed to inform future planning for chronic disease care by developing models of care that sought a better quality of life, fewer complications for individuals, and reduced overall use of health care resources. The projects trialled different processes and components of IDM to accommodate local priorities, resources and existing care practice with more than 1000 consumers collectively involved. The experience of building community programs targeting consumers with chronic disease resulted in key learnings about IDM and effecting change. Enablers and barriers were identified, and the relationship between best practice and key learnings explored in the areas of partnerships, service coordination and consumer engagement, to further understand the best approaches to improve care for people with chronic disease.

11. SEX AND SPORT: A COMMUNITY BASED PROJECT OF CHLAMYDIA TESTING AND TREATMENT IN RURAL AND REGIONAL VICTORIA

Chlamydia is the most common notifiable infectious disease in Australia with the number of notifications increasing 92% over the past 5 years. The "Sex and Sport" Project is piloting a community based chlamydia testing and treatment program reaching young people in a specific community setting, sporting clubs. This multifaceted approach utilises health education, population screening and collection of data on risk taking behaviour as the first steps in enhancing health and shaping future service provisions. The project's primary aim is to assess the feasibility of an outreach testing and treatment program. Secondary aims are to measure the prevalence of chlamydia and assess sexual risk behaviour in this population. Strong community collaborations and integration into local health services through the Primary Care Partnerships is important in the project's sustainability; in particular key community members respected by sporting clubs needed to be identified, capacity developed to deliver effective health promotion messages and improve young people's access to sexual health services. Additionally, local knowledge has guided overall program implementation and provides opportunities for capacity building to regionally based services. For example, poor access to sexual health services is being addressed by the participants being able to access services via telephone consultation with Melbourne Sexual Health Centre. Approximately 1000 Victorians aged 16-25 years from the Loddon Mallee region of Victoria will be tested between June and September 2007. This paper will report on the feasibility, challenges and possible solutions in establishing a community based outreach testing and treatment program.

Managing risk: Risk perception, trust and control in a Primary Care Partnership

In this article, managers’ perceptions of risk on entering a newly formed primary health care partnership are explored, as are the mechanisms of trust and control used to manage them. The article reports a qualitative component of a 2-year National Health and Medical Research Council funded study of trust within the structures of a Primary Care Partnership (PCP) in Victoria, Australia. Multiple methods of data collection were employed. We found that managers identified risks at system, partnership and agency levels, and that as trust was built, concern about risks diminished. Trust effectively facilitated joint action, but it was betrayed on occasions, in which case the informal power of group process was used to contain the problems. The implications of this study for policy makers are in terms of understanding how perceptions of risk are constructed, the ways managers use social control to create a safer context in which to locate the trust-based relationships that facilitate joint action, and the importance of institutional arrangements. Without trust, joint action is hard to achieve, and without control, it is difficult to prevent breaches of trust from inhibiting joint action.

Euroaction: challenges for nurses working in preventive cardiology???smoking behaviour in high risk patients and their partners in primary care

Euroaction: challenges for nurses working in preventive cardiology???smoking behaviour in high risk patients and their partners in primary care

Shared Decision Making and the Experience of Partnership in Primary Care

Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care. From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients' and physicians' subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype. The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)--22%; simulated engagement (SDM present, subjective experience negative)--38%; assumed engagement (SDM absent, subjective experience positive)--21%; and nonengagement (SDM absent, subjective experience negative)--19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership. Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics.

A network approach for researching partnerships in health

BackgroundThe last decade has witnessed a significant move towards new modes of governing that are based on coordination and collaboration. In particular, local level partnerships have been widely introduced around the world. There are few comprehensive approaches for researching the effects of these partnerships. The aim of this paper is to outline a network approach that combines structure and agency based explanations to research partnerships in health. Network research based on two Primary Care Partnerships (PCPs) in Victoria is used to demonstrate the utility of this approach. The paper examines multiple types of ties between people (structure), and the use and value of relationships to partners (agency), using interviews with the people involved in two PCPs – one in metropolitan Melbourne and one in a rural area.ResultsNetwork maps of ties based on work, strategic information and policy advice, show that there are many strong connections in both PCPs. Not surprisingly, PCP staff are central and highly connected. Of more interest are the ties that are dependent on these dedicated partnership staff, as they reveal which actors become weakly linked or disconnected without them. Network measures indicate that work ties are the most dispersed and strategic information ties are the most concentrated around fewer people. Divisions of general practice are weakly linked, while local government officials and Department of Human Services (DHS) regional staff appear to play important bridging roles. Finally, the relationships between partners have changed and improved, and most of those interviewed value their new or improved links with partners.ConclusionImproving service coordination and health promotion planning requires engaging people and building strong relationships. Mapping ties is a useful means for assessing the strengths and weaknesses of partnerships, and network analysis indicates concentration and dispersion, the importance of particular individuals, and the points at which they will fragment. A narrative approach adds an assessment of whether the partnerships are being used and valued. The approach outlined here, which examines structure and agency as separate but related explanations, has much to offer in examining partnerships.

Disease Burden in the Managed Care Population at an Academic Medical Center: The Effect of Adding Local Partners

Academic medical centers (AMCs) have traditionally cared for the most severely ill patients. AMCs' effort to meet the challenges of managed care contracts may be nullified by adverse selection unless payment mechanisms adequately consider the health risk of the AMC's managed care population. The authors compared the disease burden between the University of Michigan Health System (UMHS) and its community competitors and assessed the effect of adding local primary care partners through strategic outsourcing on these differences in disease burden. This is a population-based study from one managed care plan in Michigan. The study population was commercial members (n = 127, 892) enrolled in the plan for the entire 12 months of 2001. The authors derived several morbidity measures from age and sex, Adjusted Clinical Groups, and Aggregated Diagnosis Groups using administrative data. Compared to community groups, the UMHS consistently had a higher disease burden, while the nonacademic groups as a whole had more young members with acute conditions. After the UMHS partnered with two local primary care practice groups in their area, this AMC-local partner group had an equal or lower disease burden than the remainder of the community groups that experienced a slightly higher proportion of members with multiple medical conditions. The higher disease burden borne by AMCs is a complex phenomenon. Without local partners, the UMHS did experience higher disease burden, although the degree depends on the measurement of morbidity. Partnering with carefully selected local primary care groups may ameliorate the AMC's disproportionate disease burden.

Small Area Analysis of Diabetes Complications: Opportunities for Targeting Public Health and Health Services Interventions

The objective of this paper is to present small area analyses of diabetes complications in Victoria, Australia, and to illustrate their importance for targeting public health and health services interventions. Local government areas in Victoria were aggregated into 32 Primary Care Partnerships (PCP), which are voluntary alliances of primary care providers. The 32 PCP areas were used as the basic geographic units for small area analyses. Admission rates for diabetes complications were age and sex standardised using the direct method and the 1996 Victorian population as the reference. Admission rate ratios were calculated using the Victorian admission rates as the reference. The 95 per cent confidence intervals for the standardised admission rate ratios were based on the Poisson distribution. There was a wide variation (almost fivefold) in admission rates for diabetes complications across the PCP catchments, with the lowest standardised rate ratio of 0.37 and the highest of 1.75. There were 11 PCPs (seven metropolitan, four rural) with admission rate ratios significantly higher than the Victorian average. The seven metropolitan PCPs contributed more than 43% of all admissions and bed days for diabetes complications in Victoria. Small area analyses of diabetes complications are an exciting new development aimed at stimulating an evidence-based dialogue between local area health service providers, planners and policy-makers. The purpose is to provide opportunities to target public health and health services interventions at the local level to improve the management of diabetes complications in the community.

Advancing consumer participation in primary health: The case of a Victorian Primary Care Partnership

This paper presents an overview of the North Central Metro Primary Care Partnership (NCMPCP) process to strengthen consumer participation. The NCMPCP is a voluntary alliance of 60 health and community services in Melbourne's Northern metropolitan region that aims to make positive, sustainable improvements to services from the perspective of clients, their carers and their families. The population of the NCMPCP catchment includes significant cultural and linguistic diversity and social and economic disadvantage. In strengthening consumer participation, consumers and service providers from NCMPCP member agencies identified the need for a consumer participation training resource to be developed to support the ongoing engagement of consumers in participation opportunities in primary health services. The development of a consumer participation training resource involved consumers and service providers from 14 agencies. Consumers were involved in all stages of needs identification, design, implementation and evaluation. The process to develop the consumer participation training resources has contributed to a greater understanding of consumer participation for the NCMPCP member agencies and has increased the level of engagement and participation by consumers. The process has highlighted the need for consumers and service providers to be trained, resourced and supported to carry out consumer participation work.