Primary Care Sector Research Articles

Varicella-related Primary Health-care Visits, Hospitalizations and Mortality in Norway, 2008-2014.

Norway does not currently implement universal varicella vaccination in childhood. We aimed to characterize health care burden of varicella in Norway in the prevaccine era. We linked individual patient data from different national registries to examine varicella vaccinations and varicella-coded primary care consultations, hospitalizations, outpatient hospital visits, deaths and viral infections of central nervous system in the whole population of Norway during 2008-2014. We estimated health care contact rates and described the epidemiology of medically attended varicella infection. Each year approximately 14,600 varicella-related contacts occurred within primary health care and hospital sector in Norway. The annual contact rate was 221 cases per 100,000 population in primary health care and 7.3 cases per 100,000 in hospital care. Both in primary and hospital care, the highest incidences were observed among children 1 year of age: 2,654 and 78.1 cases per 100,000, respectively. The annual varicella mortality was estimated at 0.06 deaths per 100,000 and in-hospital case-fatality rate at 0.3%. Very few (0.2-0.5%) patients were vaccinated against varicella. Among hospitalized varicella patients, 22% had predisposing conditions, 9% had severe-to-very severe comorbidities and 5.5% were immunocompromised. Varicella-related complications were reported in 29.3% of hospitalized patients. Varicella zoster virus was the third most frequent virus found among 16% of patients with confirmed viral infections of central nervous system. Varicella causes a considerable health care burden in Norway, especially among children. To inform the policy decision on the use of varicella vaccination, a health economic assessment of vaccination and mathematical modeling of vaccination impact are needed.

Improving GP access to U/S – a multidimensional approach in collaboration with the Primary Care Division

Improving GP access to U/S – a multidimensional approach in collaboration with the Primary Care Division

Virtual care policy recommendations for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique

Background The development of new virtual care technologies (including telehealth and telemedicine) is growing rapidly, leading to a number of challenges related to health policy and planning for health systems around the world. Methods We brought together a diverse group of health system stakeholders, including patient representatives, to engage in policy dialogue to set health system priorities for the application of virtual care in the primary care sector in the Province of Ontario, Canada. We applied a nominal group technique (NGT) process to determine key priorities, and synthesized these priorities with group discussion to develop recommendations for virtual care policy. Methods included a structured priority ranking process, open-ended note-taking, and thematic analysis to identify priorities. Results Recommendations were summarized under the following themes: (a) identify clear health system leadership to embed virtual care strategies into all aspects of primary and community care; (b) make patients the focal point of health system decision-making; (c) leverage incentives to achieve meaningful health system improvements; and (d) building virtual care into streamlined workflows. Two key implications of our policy dialogue are especially relevant for an international audience. First, shifting the dialogue away from technology toward more meaningful patient engagement will enable policy planning for applications of technology that better meet patients’ needs. Second, a strong conceptual framework on guiding the meaningful use of technology in health care settings is essential for intelligent planning of virtual care policy. Conclusions Policy planning for virtual care needs to shift toward a stronger focus on patient engagement to understand patients’ needs.

Integrated Clinical Decision Support Systems Promote Absolute Cardiovascular Risk Assessment: An Important Primary Prevention Measure in Aboriginal and Torres Strait Islander Primary Health Care.

Aboriginal and Torres Strait Islander Australians experience a greater burden of disease compared to non-Indigenous Australians. Around one-fifth of the health disparity is caused by cardiovascular disease (CVD). Despite the importance of absolute cardiovascular risk assessment (CVRA) as a screening and early intervention tool, few studies have reported its use within the Australian Indigenous primary health care (PHC) sector. This study utilizes data from a large-scale quality improvement program to examine variation in documented CVRA as a primary prevention strategy for individuals without prior CVD across four Australian jurisdictions. We also examine the proportion with elevated risk and follow-up actions recorded. We undertook cross-sectional analysis of 2,052 client records from 97 PHC centers to assess CVRA in Indigenous adults aged ≥20 years with no recorded chronic disease diagnosis (2012-2014). Multilevel regression was used to quantify the variation in CVRA attributable to health center and client level factors. The main outcome measure was the proportion of eligible adults who had CVRA recorded. Secondary outcomes were the proportion of clients with elevated risk that had follow-up actions recorded. Approximately 23% (n = 478) of eligible clients had documented CVRA. Almost all assessments (99%) were conducted in the Northern Territory. Within this jurisdiction, there was wide variation between centers in the proportion of clients with documented CVRA (median 38%; range 0-86%). Regression analysis showed health center factors accounted for 48% of the variation. Centers with integrated clinical decision support systems were more likely to document CVRA (OR 21.1; 95% CI 5.4-82.4; p < 0.001). Eleven percent (n = 53) of clients were found with moderate/high CVD risk, of whom almost one-third were under 35 years (n = 16). Documentation of follow-up varied with respect to the targeted risk factor. Fewer than 30% with abnormal blood lipid or glucose levels had follow-up management plans recorded. There was wide variation in CVRA between jurisdictions and between PHC centers. Learnings from successful interventions to educate and support centers in CVRA provision should be shared with stakeholders more widely. Where risk has been identified, further improvement in follow-up management is required to prevent CVD onset and reduce future burden in Australia's Indigenous population.

What constitutes successful commissioning of transition from children’s to adults’ services for young people with long-term conditions and what are the challenges? An interview study

ObjectiveWe explored what constitutes successful commissioning for transition and what challenges are associated with this. We aimed: (1) to identify explicit and implicit organisational structures, processes and relationships that drive...

Mixing it up: private, public, federal, state, seeking health outcomes in an integrated primary care centre – the Oran Park Family Health experience!

Oran Park Town is located within the Camden Local Government Area of greater south western Sydney. This greenfield development forms part of the first stages of the South Western Growth Centre (SWGC), which over the next 30 years will see over 100,000 additional houses and up to 300,000 additional residents. At present, its population is 3000 people. South Western Sydney Local Health District (SWSLHD) has publicly declared that the future health needs of this growth corridor will be best met through progressive investment in evidence-based primary and ambulatory care, not more hospital beds. The establishment of an Integrated Primary Care Centre network is a key deliverable for this vision. Oran Park Family Health (OPFH) is the first manifestation of this vision, aiming to provide multidisciplinary evidence-based care that is patient-centred and team-based, whilst respecting autonomy and choice. The model implemented in south western Sydney is unique to New South Wales, involving a long-term partnership between the SWSLHD, South Western Sydney Primary Health Network (SWSPHN), Western Sydney University, General Practice and the sole landholder for Oran Park Town, representing a fresh approach to the formation of a private/public partnership in the primary health care sector. It is a model that has been funded through the SWSLHD capital budget to ‘fit-out’ a medical centre in the town centre (shopping complex), purpose built by the developer in direct consultation with SWSLHD and SWSPHN. It is a model that has employed an outcomes-based commissioning framework to procure a General Practice Enterprise, soon to be complimented by commissioned pathology, medical imaging and allied health services, working in a shared space with an existing cluster of District funded primary and community health services. Operating in a federated environment, it is a model that is dependent on the effectiveness of cascading lease arrangements between all parties (landlord, tenant and subtenants), service agreements based on anticipated service utilisation and the good will of independent operators to function under a mandatory Centre Management Committee. The purpose of this presentation is to reflect on our success to date whilst also sharing our lessons learnt as we try to bring our diverse range of partners on our journey to create a truly integrated primary, secondary and tertiary care environment in a localised context where success is the only available incentive. The presentation will also consider our challenges in moving into the next manifestation (Phase 3) of a comprehensive and multidisciplinary health facility operating as a genuine alternative to hospital-centric care.

How did we do? An investigation into the suitability of patient questionnaires (PREMs and PROMs) in three primary care oral surgery practices.

Introduction With the expansion of oral surgery services into the primary care sector there is a need to monitor the quality of the care provided. The Guide for Commissioning Oral Surgery and Oral Medicine proposed a set of questions to be used as patient related experience and outcome measures (PREMs and PROMs).Aim The British Association of Oral Surgeons (BAOS) primary care group (which includes the authors) were tasked by the Chief Dental Officer for England to test the suitability of these PREMs and PROMs.Method The questions as published in the commissioning guide were piloted in primary care oral surgery practices and patient feedback was sought. The authors then proposed and implemented an amended series of questions that they felt would be more practical as generic templates for oral surgery services.Results Our data demonstrates that the revised questions have produced data that is easy to interpret and attracted a greater number of feedback comments from patients.Discussion and conclusion The revised questionnaires incorporate the NHS Friends and Family Test as the collection of this data is normally a contractual requirement for providers of NHS services. They also use questions from other validated healthcare satisfaction survey tools. The use of Likert scales provides a richer data set which makes the interpretation of data easier and highlights areas for improvement. It is important to note that the data provided by PREMs and PROMs is subject to a number of biases and should be used for local quality improvement and longitudinal analysis of outcome data rather than comparison between providers.

Challenges for gatekeeping: a qualitative systems analysis of a pilot in rural China

BackgroundGatekeeping involves a generalist doctor who controls patients’ access to specialist care, and has been discussed as an important policy option to rebalance the primary care and hospital sectors in low- and middle-income countries, despite thin evidence. A gatekeeping pilot in a Chinese rural setting launched in 2013 has offered an opportunity to study the functioning of gatekeeping under such conditions.MethodsIn this qualitative study within a mixed-method evaluation of the gatekeeping pilot, we developed an innovative systems analysis method, combining the World Health Organisation categorisation of health system building blocks, the “Framework” approach of policy analysis and causal loop analysis. We conducted in-depth interviews with 20 stakeholders from 4 groups (patients, doctors, health facility managers and government administrators) in the pilot area over two years. Based on information extracted from the interviews, we drew a causal loop diagram which highlighted the feedback loops within the system that had self-reinforcing or self-balancing characteristics, and used the diagram to examine systematically the mechanisms of intended and actual functioning of gatekeeping and analyse the systems level challenges that affected the effectiveness of gatekeeping.ResultsHad the gatekeeping pilot programme worked as intended, it would incentivize both providers and patients to increase service utilization at primary care level, as well as establish and enhance two reinforcing feedback loops to shift balance towards primary care. However, a performance-based salary policy undermined the motivation for clinical primary care. Furthermore, the primary care providers suffered from three reinforcing feedback loops (related to primary care capacity, human resource sustainability, patients’ faith) that trapped primary care development in vicious cycles. At the interface between hospitals and primary care providers, there were also feedback loops exacerbating the existing hospital dominance. These feedback loops were intensified by the unintended consequences of concurrent policies (restrictions on technologies and medicines) and delayed reform in hospitals. Furthermore, the gatekeeping policy itself faced resistance to further development, due to the prevailing ineffective and ritualistic nature of gatekeeping, which formed a balancing loop.ConclusionsThe study shows that the intended benefits of gatekeeping were illusionary largely due to weak and worsening primary care conditions, and delay, ineffectiveness or unintended consequences of several other ongoing reforms. One particularly dangerous development of the system, which deserves urgent attention, is the harming of the professional prospects of primary care doctors. Our findings highlight the need for coordination and prioritization in designing policies related to primary care and managing changes with multiple on-going reforms. The approach used here facilitates comprehensive study of intended and actual mechanisms, and demonstrates the challenges of a complex health system intervention in a dynamic environment.

Evaluation of the Gold Coast Integrated Care for patients with chronic disease or high risk of hospitalisation through a non-randomised controlled clinical trial: a pilot study protocol

IntroductionChronic diseases are the leading cause of illness, disability and death in Australia. The prevalence and associated health expenditure are projected to soar. There is no ‘whole system’ approach to...

Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice.

In Denmark, general practice is responsible for 75% of antibiotic prescribing in the primary care sector. We aimed to identify practice-related factors associated with high prescribers, including prescribers of critically important antibiotics as defined by WHO, after accounting for case mix by practice. We performed a nationwide register-based survey of antibiotic prescribing in Danish general practice from 2012 to 2013. The unit of analysis was the individual practice. We used multivariable regression analyses and an assessment of relative importance to identify practice-related factors driving high antibiotic prescribing rates. We included 98% of general practices in Denmark ( n = 1962) and identified a 10% group of high prescribers who accounted for 15% of total antibiotic prescriptions and 18% of critically important antibiotic prescriptions. Once case mix had been accounted for, the following practice-related factors were associated with being a high prescriber: lack of access to diagnostic tests in practice (C-reactive protein and urine culture); high use of diagnostic tests (urine culture and strep A throat test); a low percentage of antibiotic prescriptions issued over the phone compared with all antibiotic prescriptions; and a high number of consultations per 1000 patients. We also found that a low number of consultations per 1000 patients was associated with a reduced likelihood of being a high prescriber of antibiotics. An apparent underuse or overuse of diagnostic tests in general practice as well as organizational factors were associated with high-prescribing practices. Furthermore, the choice of antibiotic type seemed less rational among high prescribers.

Evaluating the impact of contracting out basic health care services in the state of São Paulo, Brazil.

As a means of dealing with shortcomings in the coverage, quality and efficiency of the public health care sector, several municipalities in the state of São Paulo, Brazil, have started to contract pre-certified non-profit or non-governmental organizations to take part in the delivery of health care services.This paper explores the impact of introducing these contracts in the primary health care sector. Using data on the 645 municipalities in the state of São Paulo and difference-in-differences methods, we estimate the effect of contracting out in the primary health care sector on various dimensions of mortality and health care use. The results show that implementation of the contracting out strategy significantly increases the number of primary health care appointments by approximately one appointment per user of the national health care system per year. Point estimates indicate a reducing effect on hospitalization for preventable diseases.

Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions

BackgroundEquity is one of the major goals of China’s recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions.MethodsData of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates.ResultsThe Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions.ConclusionSignificant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system.

Institutional Tipping Points in Organizational Climate Change Adaptation Processes

Despite increasing awareness of the urgency to respond to climate change through adaptation, progress with climate change adaptation differs considerably across social contexts, even within seemingly uniform institutional environments. Only a part of these differences in engaging in adaptation can be explained by differentiated exposure or sensitivity to climate change hazards. Institutions, and institutional change, play important roles in enabling or constraining adaptation at the social group scale. This paper borrows the concept of tipping points from the natural sciences (Lenton et al. 2008; Lenton 2013) and applies it to social processes of climate change adaptation by focusing on processes of institutional change towards and beyond ‘institutional’ tipping points. Different stages of institutional change, where social groups switch from one dominant attractor regime to another, are discussed and illustrated. Empirical research conducted in two organizations in the local government and primary health care sector in Australia are used as examples for how institutional adaptation occurs and how institutional tipping points can be identified. Reflecting on these examples, the paper reviews the conceptual value-add of the institutional tipping points concept, while also discussing its epistemological and methodological limitations.

Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

ABSTRACTMental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurement-based care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care.

Exploring the role of pharmacists in private primary healthcare clinics in Malaysia: the views of general practitioners

AbstractBackgroundPrivate general practitioners (GPs) in Malaysia mainly operate solo practices with little interdisciplinary collaboration or co‐ordination with other healthcare providers which potentially fragments and limits patient care. Pharmacists as medication experts can contribute to the private primary care sector using their influence to ensure quality use of medicines.AimTo explore the views of private GPs in Malaysia on integration of pharmacists into private primary healthcare clinics.MethodA combination of purposive and snowballing sampling was used to recruit private sector GPs to participate in focus groups and semi‐structured interviews in Malaysia. Sessions were audio recorded, transcribed verbatim and thematically analysed using NVivo 10.ResultsThirteen private GPs participated in one focus group and ten semi‐structured interviews. Four major themes were identified: (i) poor understanding of pharmacists’ roles; (ii) readiness to accept pharmacists in private primary healthcare clinics; (iii) lack of confidence and trust in pharmacists; and (iv) perceived increased costs with pharmacist integration. Results indicated participants’ views and acceptance were largely influenced by the amount of exposure and experience they had working alongside pharmacists. Participants viewed a lack of confidence in pharmacists and increase in costs associated with an employed pharmacist within private primary healthcare clinics as barriers to integration.ConclusionPrivate GPs expressed reservations toward this new model due to the lack of understanding of pharmacists’ roles and responsibilities. There is a need for awareness among private GPs on pharmacists’ roles to improve their acceptance of the integration of pharmacists into private primary healthcare clinics in Malaysia.

Beyond the four walls: an exploratory survey of location, employment and roles of pharmacists in primary health care.

INTRODUCTION Recognition of the need to reduce harm and optimise patient outcomes from the use of medicines is contributing to an evolution of pharmacy practice in primary health care internationally. This evolution is changing community pharmacy and leading to new models of care that enable pharmacist contribution beyond traditional realms. There is little information about the extent of these changes in New Zealand. AIM The aim of this study was to investigate emerging roles of pharmacists in primary health care. METHODS A 10-question electronic survey was used to collect quantitative data about location, employment and roles of pharmacists practising in primary health care. RESULTS There were 467 survey responses. Although most pharmacists are employed by (78%, n = 357/458) and located in (84%, n = 393/467) community pharmacies, small numbers are dispersed widely across the primary health care sector. Of the 7% (n = 31/467) working in general practices, most are employed by Primary Health Organisations or District Health Boards. Limited cognitive pharmacy service provision is evident in the sector overall, but is much greater for pharmacists spending time located within general practices. DISCUSSION The large proportion of pharmacists practising in community pharmacies emphasises the importance of the Community Pharmacy Services Agreement in facilitating increased cognitive pharmacy service provision to optimise patient outcomes. The small numbers of pharmacists located elsewhere in the primary health care sector suggest there is scope to improve collaboration and integration in these areas. Flexible funding models that promote innovation and support sustainable practice change are key.

A Competition between Care Teams Improved Recording of Diagnoses in Primary Dental Care: A Longitudinal Follow-Up Study.

Introduction A playful competition was launched in a primary dental health care system to improve the recording of diagnoses into an electronic patient chart system and to study what diagnoses were used in primary dental care. Methods This was a longitudinal follow-up study with public sector primary dental care practices in a Finnish city. A one-year-lasting playful competition between the dental care teams was launched and the monthly percentage of dentists' visits with recorded diagnosis before, during, and after the intervention was recorded. The assessed diagnoses were recorded with the International Classification of Diseases (ICD-10). Results Before the competition, the level of diagnosis recordings was practically zero. At the end of this intervention, about 25% of the visits had a recorded diagnosis. Two years after the competition, this percentage was 35% without any additional measures. The most frequent diagnoses were dental caries (K02, 38.6%), other diseases of hard tissues of teeth (K03, 14.8%), and diseases of pulp and periapical tissues (K04, 11.4%). Conclusions Commitment to the idea that recording of diagnoses was beneficial improved the recording of dental diagnoses. However, the diagnoses obtained did not accurately reflect the reputed prevalence of oral diseases in the Finnish population.

The role of the care sport connector in the Netherlands.

To stimulate physical activity and guide primary care patients towards local sport facilities, Care Sport Connectors (CSC), to whom a broker role has been ascribed, were introduced in 2012 in the Netherlands. The aim of this study was to explore CSCs' role in connecting the primary care sector and the PA sector. Fifteen CSCs were selected to participate in this study and were followed in their work of connecting both sectors. Over the course of one year, three rounds of interviews were held with these CSCs on the topics of their role and the connection between the primary care and the PA sector. Both top-down and bottom-up codes were used to analyse the interviews. CSCs fulfilled three roles: 1) broker, 2) referral, 3) organiser. The extent to which CSCs fulfilled these roles was influenced by the way municipalities implemented the CSC funding. CSCs set up two forms of collaboration structures: 1) project basis and 2) referral scheme. CSCs perceived the following barriers to connecting the primary care and the PA sector: lack of knowledge and time, primary care professionals' own interests, and lack of suitable sport activities for the target group. The CSC role seems to hold the promise of improving collaboration between the primary care and the PA sector, especially, because the roles that CSCs perceive themselves as having seem to be directed at eliminating barriers in this connection. Future research is needed to study whether CSCs are capable of establishing a connection over time.

Using Patient Flow Information to Determine Risk of Hospital Presentation: Protocol for a Proof-of-Concept Study.

BackgroundEvery day, patients are admitted to the hospital with conditions that could have been effectively managed in the primary care sector. These admissions are expensive and in many cases are possible to avoid if early intervention occurs. General practitioners are in the best position to identify those at risk of imminent hospital presentation and admission; however, it is not always possible for all the factors to be considered. A lack of shared information contributes significantly to the challenge of understanding a patient’s full medical history. Some health care systems around the world use algorithms to analyze patient data in order to predict events such as emergency presentation; however, those responsible for the design and use of such systems readily admit that the algorithms can only be used to assess the populations used to design the algorithm in the first place. The United Kingdom health care system has contributed data toward algorithm development, which is possible through the unified health care system in place there. The lack of unified patient records in Australia has made building an algorithm for local use a significant challenge.ObjectiveOur objective is to use linked patient records to track patient flow through primary and secondary health care in order to develop a tool that can be applied in real time at the general practice level. This algorithm will allow the generation of reports for general practitioners that indicate the relative risk of patients presenting to an emergency department.MethodsA previously designed tool was used to deidentify the general practice and hospital records of approximately 100,000 patients. Records were pooled for patients who had attended emergency departments within the Eastern Health Network of hospitals and general practices within the Eastern Health Network catchment. The next phase will involve development of a model using a predictive analytic machine learning algorithm. The model will be developed iteratively, testing the combination of variables that will provide the best predictive model.ResultsRecords of approximately 97,000 patients who have attended both a general practice and an emergency department have been identified within the database. These records are currently being used to develop the predictive model.ConclusionsRecords from general practice and emergency department visits have been identified and pooled for development of the algorithm. The next phase in the project will see validation and live testing of the algorithm in a practice setting. The algorithm will underpin a clinical decision support tool for general practitioners which will be tested for face validity in this initial study into its efficacy.

A Mixed Methods Evaluation of the Northwest London Integrated Care Pilot

The National Health Services (NHS) within inner Northwest London implemented a transformational change pilot program for integrated care from 2011-13. This pilot focused on two populations within the inner northwest quadrant of London: diagnosed diabetics and the elderly over 75 years of age. An information technology (IT) tool was used to pool data across primary, secondary, community, social, and mental health care sectors in order to assess an integrated approach to care coordination. The network of service providers included: 5 social care services; 3 community care services; 106 primary care practices; 2 mental health facilities; 2 hospitals; and 2 non-profit organizations. Some of the main goals of the pilot were to: improve health outcomes among diabetics and the elderly; improve patient experience; reduce service outcomes such as emergency hospital admissions; create care plans for the targeted populations; and establish multidisciplinary case reviews of high-risk patients with the most complex needs. A mixed methods evaluation was essential for assessing the care process and health outcomes of the pilot. Results of the evaluation will be presented, particularly as they relate to clinical outcomes and quality of care, as well as patient and professional experience throughout the integrated care process.