Evaluating partnership working: lessons for palliative care

Complexity in partnerships: A qualitative examination of collaborative depression care in primary care clinics and community-based organisations in California, United States

Partnering across health clinics and community organisations, while worthwhile for improving health and well-being, is challenging and time consuming. Even partnerships that have essential elements for success in place face inevitable challenges. To better understand how cross-organisational partnerships work in practice, this paper examines collaborations between six primary care clinics and community-based organisations in the United States that were part of an initiative to address late-life depression using an enhanced collaborative care model (Archstone Foundation Care Partners Project). As part of an evaluation of the Care Partners Project, 54 key informant interviews and 10 focus groups were conducted from 2015 to 2017. Additionally, more than 80 project-related documents were reviewed. Qualitative thematic analysis was used to code the transcripts and identify prominent themes in the data. Examining clinic and community organisation partnerships in practice highlighted their inherent complexity. The partnerships were fluid and constantly evolving, shaped by a multiplicity of perspectives and values, and vulnerable to unpredictability. Care Partners sites negotiated the complexity of their partnerships drawing upon three main strategies: adaptation (allowing for flexibility and rapid change); integration (providing opportunities for multi-level partnerships within and across organisations) and cultivation (fostering a commitment to the partnership and its value). These strategies provided opportunities for Care Partners collaborators to work with the inherent complexity of partnering. Intentionally acknowledging and embracing such complexity rather than trying to reduce or avoid it, may allow clinic and community collaborators to strengthen and sustain their partnerships.

Development of a tool for the evaluation of obesity prevention partnerships

ISSUE ADDRESSED

Working in partnership is advocated as a necessary process to achieve shared goals in complex policy areas, yet little effort is dedicated to evaluating how well partnerships are functioning. This study describes the development and psychometric properties of a partnership assessment tool and illustrates its use in an obesity prevention partnership.

METHODS

A literature scoping review was conducted on existing partnership assessment tools and used to develop a new tool, which was tested using the ACT whole-of-government Healthy Weight Initiative at two timepoints. The psychometric properties of the tool were evaluated using principal component analysis and Cronbach's alpha for internal consistency of domain subscales.

RESULTS

The review identified 11 partnership assessment tools, from which we identified five domains of partnership to develop the new tool. Factor analysis showed each domain yielded a single subscale. Cronbach's alpha for each of the domain subscales ranged between 0.88 and 0.94 at Timepoint 1 and 0.90 and 0.95 at Timepoint 2 demonstrating very high internal consistency. All subscales demonstrated high correlation with an overall partnership rating, good internal consistency and concordance with issues raised in open-ended questions.

CONCLUSION

This paper describes the development and implementation of a tool to evaluate partnership functioning, which was found to have high internal consistency and reliability. SO WHAT?: With increasing emphasis on working in partnership, using partnership assessment tools can provide useful evidence to assess whether partnerships are a successful strategy in complex programs evaluation.

General practice and specialist palliative care teams: an exploration of their working relationship from the perspective of clinical staff working in New Zealand

With the future focus on palliative and end-of-life care provision in the community, the role of the general practice team and their relationship with specialist palliative care providers is key to responding effectively to the projected increase in palliative care need. Studies have highlighted the potential to improve co-ordination and minimise fragmentation of care for people living with palliative care need through a partnership between generalist services and specialist palliative care. However, to date, the exact nature of this partnership approach has not been well defined and debate exists about how to make such partnerships work successfully. The aim of this study was to explore how general practice and specialist palliative care team (SPCT) members view their relationship in terms of partnership working. Five focus group discussions with general practices and SPCT members (n = 35) were conducted in 2012 in two different regions of New Zealand and analysed using a general inductive approach. The findings indicate that participants' understanding of partnership working was informed by their identity as a generalist or specialist, their existing rules of engagement and the approach they took towards sustaining the partnership. Considerable commitment to partnership working was shown by all participating teams. However, their working relationship was based primarily on trust and personal liaison, with limited formal systems in place to enable partnership working. Tensions between the cultures of 'generalism' and 'specialism' also provided challenges for those endeavouring to meet palliative care need collaboratively in the community. Further research is required to better understand the factors associated with successful partnership working between general practices and specialist palliative care in order to develop robust strategies to support a more sustainable model of community palliative care.

Developing Organizational Guidelines for the Prevention and Management of Suicide in Clients and Carers Receiving Palliative Care in Australia

This article describes the process of developing a suicide guideline in palliative care. Little literature was available, but utilizing the partnership model, a working party consulted with each discipline regarding specific requirements. The working party experienced significant challenges in creating policy that would adequately cover the diverse needs of all members of the palliative care team, as it was recognized that all staff needed guidance. The final guideline incorporated specific action plans for each discipline; mandatory training for all staff was endorsed through a recognized suicide alertness training program; advanced training in suicide intervention skills for key clinical staff will be required; and a “Rapid Plan Team” was recommended. This policy development has required significant work and the combined expertise of many disciplines.

PaTz groups for primary palliative care: reinventing cooperation between general practitioners and district nurses in palliative care: an evaluation study combining data from focus groups and a questionnaire

BACKGROUND

PaTz (an acronym for 'PAlliatieve Thuis Zorg'; palliative care at home) is an intervention to improve palliative care provision and strengthen the generalist knowledge of palliative care. In PaTz general practitioners and district nurses meet on a regular basis to identify patients with palliative care needs and to discuss care for these patients. This study explores experiences with regard to collaboration between general practitioners and district nurses, and perceived benefits of and barriers for implementation of PaTz.

METHODS

This study is conducted within the primary care setting. Participants were 24 general practitioners who filled in a questionnaire, and seven general practitioners, five district nurses and two palliative care consultants who attended one of two focus groups.

RESULTS

PaTz led to improved collaboration. Participants felt informational and emotional support from other PaTz participants. Also they felt that continuity of care was enhanced by PaTz. Practical recommendations for implementation were: meetings every 6 to 8 weeks, regular attendance from both general practitioners and district nurses, presence of a palliative care consultant, and a strong chairman.

CONCLUSIONS

PaTz is successful in enhancing collaboration in primary palliative care and easy to implement. Participants felt it improved continuity of care and knowledge on palliative care. Further research is needed to investigate whether patient and carer outcomes improve.

Palliative care case management in primary care settings: a nationwide survey

BACKGROUND

In case management an individual or small team is responsible for navigating the patient through complex care. Characteristics of case management within and throughout different target groups and settings vary widely. Case management is relatively new in palliative care. Insight into the content of care and organisational characteristics of case management in palliative care is needed.

OBJECTIVES

To investigate how many case management initiatives for palliative care there are in the Netherlands for patients living at home; to describe the characteristics of these initiatives with regard to content and organisation of care.

SETTING

Primary care.

DESIGN AND PARTICIPANTS

A nationwide survey of all 50 coordinators of networks in palliative care in the Netherlands was conducted. Additional respondents were found through snowball sampling. We looked at 33 possible initiatives using interviews (n=33) and questionnaires (n=30).

RESULTS

We identified 20 initiatives for case management. All stated that case management is supplemental to other care. In all initiatives the case managers are registered nurses and most possess higher vocational education and/or further training. All initiatives seek to identify the multidimensional care needs of the patients and the relatives and friends who care for them. Almost all provide information and support and refer patients who need care. Differences are found between the organisations offering the case management, their target groups, the names of the initiatives and whether direct patient care is provided by the case manager.

CONCLUSIONS

In the Netherlands, case management in palliative care is new. Several models of delivery were identified. Research is needed to gain insight into the best way to deliver case management. By describing characteristics of case management in palliative care, an important first step is made in identifying effective elements of case management.

Evaluation of a suicide prevention training program for mental health services staff

Training for health services staff often focuses on improving individual practitioner's knowledge and skills, with less emphasis given to the broader organizational context, in particular those elements that support successful implementation of changes post-training. This paper compares the effectiveness of a standard training model for suicide prevention to an enhanced training model. The training involved the public mental health workforce throughout the State of Queensland, Australia and was developed in collaboration with the State health department and as such took place within a policy and practice context. The standard training involved participation in a one-day training workshop, which provided information on evidence-based suicide prevention strategies. The enhanced model took an organizational development approach and incorporated a focus on creating and strengthening networks to enhance the capacity of mental health service staff to undertake preventive strategies. Findings suggest that multi-component organizational approaches for suicide prevention produces benefits that should now be trialled through experimental approaches.

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

BACKGROUND

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers.

AIM

To explore factors that support partnership working between specialist and generalist palliative care providers.

DESIGN

Systematic review.

METHOD

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

RESULTS

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

CONCLUSION

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.

'That's part of everybody's job': the perspectives of health care staff in England and New Zealand on the meaning and remit of palliative care

BACKGROUND

the right for patients of all diagnoses to be in receipt of palliative care from an early point in the diagnosis of a life-limiting condition is now enshrined in policy in a number of countries and increased emphasis is placed upon the role of generalist palliative care. However, little is known as to how this policy is enacted on the ground.

AIM

to explore understandings of, and perceived roles in relation to, palliative care provision amongst generalist and specialist health care providers in England and New Zealand.

DESIGN

qualitative data were collected via individual interviews and focus groups.

SETTING/PARTICIPANTS

participants comprised generalist and specialist palliative care providers working in a variety of settings in England (n = 58) and New Zealand (n = 80).

RESULTS

the following issues with significant implications for this new phase of development for palliative care were identified: (1) difficulties with terminology and perceived roles/responsibilities; (2) problems of integrating palliative care into a generalist workload; (3) challenges in generalist/specialist partnership working; and (4) the potential negative consequences of specialization.

CONCLUSIONS

these data indicate that, within England and New Zealand, the policy rhetoric of universal palliative care provision is not being straightforwardly translated into service delivery and individual clinical practice. Further research is required to explore and evaluate different models of organization and service provision that empower 'generalists' to provide palliative care, without resulting in deskilling. Finally, definitional clarity at an academic/policy level is also needed.

Community palliative care: role perception

Community nurses play a key part in palliative care for patients and their families, yet there is relatively little research examining how their role is understood by nurses themselves. This paper presents findings from a qualitative study exploring how district nursing teams and community matrons (CMs) understood their own and each other's roles in palliative care. Twenty-four district nurses (DNs), 15 CMs and seven other key stakeholders were interviewed. DNs saw themselves as having a pivotal role, often coordinating other services as well as providing hands-on care. CMs agreed with the importance of the DN role, but had doubts about whether DNs had the capacity or skills to provide genuine case management. Both sets of nurses varied in their views of the CM role in palliative care, from seeing it as negligible to extensive and valuable. Organizational change contributed to the defensiveness of many DNs about their role, and to CMs' experiences of suspicion towards theirs.

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study

BACKGROUND

Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services.

AIM

To explore the influences on referrals within general and specialist community palliative care services.

DESIGN OF STUDY

Qualitative, multiple-case study.

SETTING

Three primary care trusts in the north-west of England.

METHOD

Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals.

RESULTS

Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes.

CONCLUSION

Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.

Integration of palliative care practices into the ongoing care of children with cancer: individualized care planning and coordination

Most parents of children with cancer have dual primary goals: a primary cancer-directed goal of cure and a primary comfort-related goal of lessening suffering. Early introduction of palliative care principles and practices into their child's treatment is respectful and supportive of these goals. The Individualized Care Planning and Coordination Model is designed to integrate palliative care principles and practices into the ongoing care of children with cancer. Application of the model helps clinicians to generate a comprehensive individualized care plan that is implemented through Individualized Care Coordination processes as detailed here. Clinicians' strong desire to provide compassionate, competent, and sensitive care to the seriously ill child and the child's family can be effectively translated into clinical practice through these processes.