Integrated care – a Nirvana we can reach for
by Dr Paresh Dawda, Adjunct Associate Professor Walter Kmet, Dr Andrew Knight and Leanne Wells.
Integrated health care is now commanding more attention in Australia than ever. Evidence of this includes local collaborative care projects and two federally sponsored trials, one on chronic care and the other for electronic health records, and state based demonstrator projects. A central aim of all of these is the development of integrated care.
Evidence and experience suggests that integration can play a vital role in taking us towards improved care, better experience for both consumer and clinician and better economic outcomes.
To many people with chronic and complex conditions, integrated care would be Nirvana. It need not be an impossible dream but will require significant changes in attitudes and behaviour to become a reality, and an investment in this process.
When we ask people who are actively interested in integrated care whether this Nirvana is possible, their responses tend to focus on the need for consumer and community empowerment and the need for sustainability.
Then when asked about the barriers to Nirvana, the respondents mention a variety of issues including funding, state-federal divide, the siloed nature of health care, clinician workload and attitudinal/relationship issues.
So there are significant but not insurmountable hurdles to integrated care and the benefits outweigh the perceived negatives change. Recognition of the need to manage the change process and the importance of partnerships are important factors to consider.
Integrated care can mean many things to many people. Here we are considering it particularly from the consumer’s perspective. Person-centred care imposes the patient’s perspective as the organising principle and enables health and social care that is flexible, personalised and seamless.
The patient becomes the centre of attention rather than being subject to the priorities of hospitals and clinicians.
The principles of organising care around the consumer include that services should be coordinated, comprehensive, accessible, affordable, given with trust and respect and determined in consultation with the patient.
Such goals are hard to achieve when primary care in Australia is so often fragmented, where system and funding barriers limit providers working with consumers effectively as one team, particularly those with chronic and complex conditions. In addition consumers encounter difficulty finding services and feel disempowered.
Following on from the work of the Australian Primary Care Collaboratives program some projects to overcome these hurdles have been established as “integrated care collaboratives in Townsville/Mackay and the North Coast of NSW.
Through workshops and quality improvement training involving the full range of hospital, medical and allied health professionals, the objective was to halve emergency department presentations and to provide a full scale integrated care team for 90 people with high care needs.
This exercise involved clinicians and hospital staff meeting and working more closely together. The result has been a revelation to many.
As a hospital participant of the Townsville Integrated Care Collaborative said, you take a process from a patient’s perspective “and they are the ones who truly see everything when it comes to how health is delivered to them…the patient is the middle, and everything else is about delivering a service in a seamless way, that they get the maximum outcome.”
The collaborative exposed different clinicians to different perspectives: the emergency department clinicians learn from a cardiac nurse about patient discharge; the pharmacist gets greater insight from the GP about the need to go through medications with patients after discharge.
A GP says that hearing more about patient experiences in hospital helps understanding: “…you are sending patients up there the whole time, you never get to hear what they think about you and what you could do as a GP to make their lives easier”.
The trial of opt-out electronic My Health Records which means people will be automatically enrolled in the national system unless they actively seek to opt out of the system, opens up more opportunities for integrated care by facilitating individual patient records of medical, medication, diagnostic and hospital discharge summaries.
The wider implementation of My Health Records should deliver significant benefits to consumers, making health care easier and more convenient, empowering patients, enabling transparent access to information and reducing costs of the health system.
The Western Sydney Primary Health Network, WentWest, has identified significant opportunities to redistribute overall health spending through strengthening primary and community care. An important aspect of this this work is the partnership with Western Sydney Local Health District
Focusing more resources and funding on community public health programs, individual prevention, long term condition management avoids expensive hospital admissions.
The need for stronger support outside health care is demonstrated by figures which show health relates very significantly to a person’s socio-economic status. Those of low socio-economic status are several times more likely to suffer cardiovascular disease and diabetes than better-off people.
We need a system in which health is not just about health.
This article draws on the contributions of four speakers from different health spheres who participated in a recent APAC conference session, Integration of care: is Nirvana possible?
The speakers were: Dr Paresh Dawda, clinician and medical educator, who chaired the session, Adjunct Associate Professor Walter Kmet, CEO of WentWest, Dr Andrew Knight, a GP and medical practice educator and chair of the Nepean Blue Mountains PHN, and Leanne Wells CEO of the Consumers Health Forum.