National Health and Hospital Reform Commission final report and patient-centred suggestions for reform

Strategies for engaging older adults and informal caregivers in health policy development: A scoping review

BACKGROUND

Care for older adults is high on the global policy agenda. Active involvement of older adults and their informal caregivers in policy-making can lead to cost-effective health and long-term care interventions. Yet, approaches for their involvement in health policy development have yet to be extensively explored. This review maps the literature on strategies for older adults (65+ years) and informal caregivers' involvement in health policy development.

METHOD

As part of the European Union TRANS-SENIOR program, a scoping review was conducted using the Joanna Briggs Institute's methodology. Published and grey literature was searched, and eligible studies were screened. Data were extracted from included studies and analysed using the Multidimensional Framework for Patient and Family Engagement in Health and Healthcare.

RESULTS

A total of 13 engagement strategies were identified from 11 publications meeting the inclusion criteria. They were categorized as "traditional", "deliberative" and "others", adopting the World Bank's categorization of engagement methods. Older adults and informal caregivers are often consulted to elicit opinions and identify priorities. However, their involvement in policy formulation, implementation and evaluation is unclear from the available literature. Findings indicate that older adults and their informal caregivers do not often have equal influence and shared leadership in policy-making.

CONCLUSION

Although approaches for involving older adults and their informal caregivers' involvement were synthesized from literature, we found next to no information about their involvement in policy formulation, implementation and evaluation. Findings will guide future research in addressing identified gaps and guide policy-makers in identifying and incorporating engagement strategies to support evidence-informed policy-making processes that can improve health outcomes for older adults/informal caregivers.

What constitutes a quality community aged care service-client perspectives: An international scoping study

Overwhelmingly, older Australians (people aged 65 years and older or 50 years and older for Aboriginal and Torres Strait Islander people) prefer to remain living in their own home rather than moving into residential care. To enable older Australians who require assistance to remain living at home, the Federal Government provides a wide range of community care services, the provision of which has increased substantially over the last 15 years. The importance of client preferences, prefaced by the introduction of consumer directed care across community aged care services, has gathered momentum in Australia following legislation in 2015. Older peoples' preferences differ in comparison to younger people with disability and those with mental health concerns. Older people focus more on the provision of services rather than the notion of independent living itself. This scoping review aimed to explore what aspects people aged 65 years and older consider to be important qualities of aged care services delivered in the community. A computerised search in MEDLINE, CINAHL, PubMed and PsychINFO and hand searches of the Cochrane database and Google Scholar were completed in May 2022. Sixty-two articles met the selection criteria and were included in the review. Data were extracted using a fit-for-purpose protocol and analysed using the Miles and Huberman Model for thematic analysis. Results identified five themes representing quality domains that describe features that are important to clients: staff knowledge, respect for clients, a person-centred approach, a collaborative partnership with clients and clear communication. When providers of community aged care services are planning to assess the quality of their services, these findings could be used to guide their evaluation. This will ensure that future services delivered accommodate the needs and preferences of clients who receive them.

Framework for patient, family-centred care within an Australian Community Hospital: development and description

OBJECTIVE

To describe the development of a patient and family-centred care (PFCC) conceptual framework within a small community Australian Hospital.

METHODS

A scoping review of scientific and grey literature and community hospital stakeholder discussions were used to identify and design a conceptual framework for PFCC across five core pillars of leadership, engagement, service delivery, learning and environment.

RESULTS

107 publications were identified and 76 were included for data extraction. A draft framework was constructed and modified following consultation with hospital stakeholders across a small Australian Community Hospital. The 'Caring Together' framework outlines three core layers: (1) the focus of our care is the experiences of our consumers and staff; (2) concepts of leadership, environment, service delivery, engagement and learning; and (3) the overarching fundamental values of being heard, respected, valued and supported by staff and consumers at all levels in an organisation.

CONCLUSIONS

The conceptual Caring Together framework structures key PFCC concepts across organisational priority areas within an Australian healthcare setting and can be used to guide implementation of PFCC at other small hospital facilities. Changes to national and state healthcare funding may help facilitate improved hospital facility implementation of PFCC, and ultimately improve consumer healthcare satisfaction and clinical outcomes.

Psychologists' Leadership Roles and Leadership Training Needs in Academic Health Centers

Psychologists are increasingly called upon to become more involved in academic health centers (AHCs) as leaders across a range of leadership roles in areas such as the clinical, teaching, and research missions, and in the administration thereof. Similarly, expansion of psychologists' service in national associations, boards, and other forums is increasing. This paper attempts to delineate the nature and extent of psychologists' involvement in leadership roles and their needs for professional leadership development to assist them in securing and succeeding in these positions. Members of the Association of Psychologists in Academic Health Centers (APAHC) were invited to complete a survey to identify current leadership roles and training needed to enhance leadership capabilities. Most (75%) of the respondents (total n = 105; 42% of APAHC full members; 70% female) were currently serving in leadership roles (range 1 to ≥ 10 positions). Years since degree conferred was positively associated with the number of leadership positions. Diversity of roles was delineated across AHC missions including psychology training (49.5%), clinical service (33.3%), and research (26.7%). An important subgroup (11.5%) served in upper-level administrative leadership positions. Leadership roles external to AHCs were common, particularly service ion committees (30.5%) and boards (27.6%) in state and national professional organizations. Half (51.4%) of survey respondents endorsed at least one leadership development need, with approximately 10% endorsing leadership development needs in all areas. The most common leadership development need was financial management skills, endorsed by nearly two-thirds of the sample. Early career respondents recognized more needs than advanced career respondents. AHC psychologists are expanding their leadership roles and distinguishing themselves as important contributors in AHCs. Despite this, many identified needs for further leadership training.

Contextual Analysis of Stakeholder Opinion on Management and Leadership Competencies for Undergraduate Medical Education: Informing Course Design

BACKGROUND

The study aimed to conduct a contextual analysis of interviews intended to assist with the future design of a feasible and relevant leadership and management course for undergraduate medical students at King Abdulaziz University (KAU), Saudi Arabia.

METHODS

This was a cross-sectional study conducted at King Abdulaziz University (KAU), Saudi Arabia, during 2019. An exploratory qualitative approach, utilizing systematic content analysis, was used. Data were collected using semi-structured interviews that were conducted with 10 leaders who were stakeholders at KAU, health service providers at KAU hospital, and stakeholders in the Ministry of Health.

RESULTS

This study revealed critical findings that highlighted the areas in which KAU could instill better and adequate leadership and management skills in their undergraduate medical students. Multiple core categories for a leadership and management curriculum emerged with many interrelated themes. Most participants mentioned that leadership can be taught and that early exposure is beneficial for developing skills. Additionally, they stated that leaders should have a vision and the ability to articulate that vision.

CONCLUSIONS

Different implementation challenges were described in relation to the availability of human resources, the current short supply of suitable teachers, and program design. Teaching methods recommended included simulations, lectures, and a project-based approach. Assessment methods that were recommended included objective structured clinical examination (OSCE), formative and summative assessments, self-assessments, and portfolios.

Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies

Patient-centred care is tailored to the needs of patients and is necessary for better health outcomes, especially for individuals with limited health literacy (LHL). However, its implementation remains challenging. The key to effectively address patient-centred care is to include perspectives of patients with LHL within the curricula of (future) healthcare providers (HCP). This systematic review aimed to explore and synthesize evidence on the needs, experiences and preferences of patients with LHL and to inform an existing educational framework. We searched three databases: PsychInfo, Medline and Cinahl, and extracted 798 articles. One-hundred and three articles met the inclusion criteria. After data extraction and thematic synthesis, key themes were identified. Patients with LHL and chronic diseases encounter multiple problems in the care process, which are often related to a lack of person-centeredness. Patient perspectives were categorized into four key themes: (1) Support system; (2) Patient self-management; (3) Capacities of HCPs; (4) Barriers in healthcare systems. "Cultural sensitivity" and "eHealth" were identified as recurring themes. A set of learning outcomes for (future) HCPs was developed based on our findings. The perspectives of patients with LHL provided valuable input for a comprehensive and person-centred educational framework that can enhance the relevance and quality of education for (future) HCPs, and contribute to better person-centred care for patients with LHL.

Heart Failure in Minority Populations - Impediments to Optimal Treatment in Australian Aborigines

Chronic heart failure (CHF) among Aboriginal/Indigenous Australians is endemic. There are also grave concerns for outcomes once acquired. This point is compounded by a lack of prospective and objective studies to plan care. To capture the essence of the presented topic it is essential to broadly understand Indigenous health. Key words such as ‘worsening’, ‘gaps’, ‘need to do more’, ‘poorly studied’, or ‘future studies should inform’ occur frequently in contrast to CHF research for almost all other groups. This narrative styled opinion piece attempts to discuss future directions for CHF care for Indigenous Australians. We provide a synopsis of the problem, highlight the treatment gaps, and define the impediments that present hurdles in optimising CHF care for Indigenous Australians.

Interface, interaction and integration: how people with chronic disease in Australia manage CAM and conventional medical services

OBJECTIVES

To understand the extent to which conventional and complementary health care are integrated for CAM users with chronic conditions.

METHODS

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

Many participants reported regular, frequent and long-term use of CAM therapies to maintain their health or assist in the management of their chronic condition. They generally managed the interface between convention and complementary health care on their own, as the perceived or expressed negative attitudes of some doctors, or the belief that the doctor did not need to know, were barriers to the disclosure of CAM use. For a smaller group, there was interaction between conventional and CAM providers, which limited the extent of uncertainty and conflicting information being (mis)interpreted by consumers.

CONCLUSIONS

Greater interaction between CAM and medical providers would be beneficial to consumers. Structural barriers, related to financing and service organization, need to be addressed. Attitudinal shifts of some health-care practitioners also need to be addressed, in the context of workforce development.

Room for improvement: complementary therapy users and the Australian health system

CONTEXT

People with chronic conditions who are often in contact with the health-care system are well placed to reflect on how services meet their needs. Some research characterizes people who use complementary and alternative medicines (CAMs) as a distinct group who opt out of the mainstream health system. However, many CAM users are people with chronic or terminal health conditions who concurrently use mainstream health-care services. The difference in perspectives between people with chronic conditions who do or do not use CAM has received little attention by researchers.

OBJECTIVE

To explore the views of CAM users with chronic conditions and identify their perspectives on the health system.

DESIGN AND SETTING

In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia.

RESULTS

One in four CAM practitioner users was partly motivated to use CAM as a result of their dissatisfaction with the mainstream health system. In general, their dissatisfaction mirrored the concerns of the general population. This included the perceived lack of a humanistic or person-centred approach, which was central to problems relating to individuals' clinical encounters as well as to health system design.

DISCUSSION AND CONCLUSION

Participants' concerns suggest room for improvement in the Australian health system to better reflect patients' needs. A systems approach is needed to reorient health-care practitioners to modify the organization of care because of the incentives embedded in the structure of the health-care system.

Governance, transparency and alignment in the Council of Australian Governments (COAG) 2011 National Health Reform Agreement

OBJECTIVE This article provides a policy analysis of the Australian government's National Health Reform Agreement (NHRA) by bringing to the foreground the governance arrangements underpinning the two arms of the national reforms, to primary health care and hospital services. METHODS The article analyses the NHRA document and mandate, and contextualises the changes introduced vis-à-vis the complex characteristics of the Australian health care system. Specifically, it discusses the coherence of the agreement and its underlying objectives, and the consistency and logic of the governance arrangements introduced. RESULTS The policy analysis highlights the rationalisation of the responsibilities between the Commonwealth and states and territories, the commitment towards a funding arrangement based on uniform measures of performance and the troubled emergence of a more decentralised nation-wide homogenisation of governance arrangements, plus efforts to improve transparency, accountability and statutory support to increase the standards of quality of care and safety. CONCLUSIONS It is suggested that the NHRA falls short of adequately supporting integration between primary, secondary and tertiary health care provision and facilitating greater integration in chronic disease management in primary care. Successfully addressing this will unlock further value from the reforms.

'Working with the team': an exploratory study of improved type 2 diabetes management in a new model of integrated primary/secondary care

This study aimed to explore how a new model of integrated primary/secondary care for type 2 diabetes management, the Brisbane South Complex Diabetes Service (BSCDS), related to improved diabetes management in a selected group of patients. We used a qualitative research design to obtain detailed accounts from the BSCDS via semi-structured interviews with 10 patients. The interviews were fully transcribed and systematically coded using a form of thematic analysis. Participants' responses were grouped in relation to: (1) Patient-centred care; (2) Effective multiprofessional teamwork; and (3) Empowering patients. The key features of this integrated primary/secondary care model were accessibility and its delivery within a positive health care environment, clear and supportive interpersonal communication between patients and health care providers, and patients seeing themselves as being part of the team-based care. The BSCDS delivered patient-centred care and achieved patient engagement in ways that may have contributed to improved type 2 diabetes management in these participants.

Time's up. descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey

Most Western health systems remain single illness orientated despite the growing prevalence of multi-morbidity. Identifying how much time people with multiple chronic conditions spend managing their health will help policy makers and health service providers make decisions about areas of patient need for support. This article presents findings from an Australian study concerning the time spent on health related activity by older adults (aged 50 years and over), most of whom had multiple chronic conditions. A recall questionnaire was developed, piloted, and adjusted. Sampling was undertaken through three bodies; the Lung Foundation Australia (COPD sub-sample), National Diabetes Services Scheme (Diabetes sub-sample) and National Seniors Australia (Seniors sub-sample). Questionnaires were mailed out during 2011 to 10,600 older adults living in Australia. 2540 survey responses were received and analysed. Descriptive analyses were completed to obtain median values for the hours spent on each activity per month. The mean number of chronic conditions was 3.7 in the COPD sub-sample, 3.4 in the Diabetes sub-sample and 2.0 in the NSA sub-sample. The study identified a clear trend of increased time use associated with increased number of chronic conditions. Median monthly time use was 5-16 hours per month overall for our three sub-samples. For respondents in the top decile with five or more chronic conditions the median time use was equivalent to two to three hours per day, and if exercise is included in the calculations, respondents spent from between five and eight hours per day: an amount similar to full-time work. Multi-morbidity imposes considerable time burdens on patients. Ageing is associated with increasing rates of multi-morbidity. Many older adults are facing high demands on their time to manage their health in the face of decreasing energy and mobility. Their time use must be considered in health service delivery and health system reform.

Theorizing accommodation in supportive home care for older people

This paper examines the issue of what thinking is necessary in order to advance a notion of accommodation in the organization and provision of supportive home care for older people. Accommodation in this context is understood as responsiveness to the singularity of older adults, and we consider how this idea might be used to support opportunities for (independent) living for elders as they age and become frailer. To elaborate the question we draw on examples from our empirical work - ethnographic studies of home care practice undertaken in Canada and Iceland - and consider these examples in light of critical philosophical and social theory, particularly Agamben's (1993) work, The Coming Community. This is a relevant frame through which to consider the potential for the accommodation of the unique needs of older adults in home care because it helps us to problematize the systems through which care is accomplished and the current, dominant terms of relations between individuals and collectives. We argue that giving substance to a notion of accommodation contributes an important dimension to aligned ideas, such as patient-centeredness in care, by working to shift the intentionality of these practices. That is, accommodation, as an orientation to care practices, contests the organizational impulse to carry on in the usual way.

Regarding 'National Health and Hospital Reform Commission final report and patient-centred suggestions for reform' by T. Jowsey, L. Yen, R. Wells and S. Leeder

The recently published article by Jowsey et al. (2011, Australian Journal of Primary Health 17, 162-168) highlighted key inclusions and omissions from the National Health and Hospital Reform Commission final report with respect to patient-centred care for people with chronic illness. However, the author proposes that this study could have further addressed dimensions of equity and patient-centred practice by including participants with chronic mental illness. The author suggests that interventions to improve chronic illness care typically remain disease specific, which fails to address the realities that face consumers or service providers. References to the literature and professional experience are provided to support the inclusion of mental illness within discussion, services and policy concerning chronic illness.