Implementing joint training sessions of general practitioners and specialists aimed at improving clinical coordination in Colombia: Contributions from participatory action research

OBJECTIVE

To analyse the contribution of participatory action research (PAR) in designing and implementing joint training sessions as a means to improve clinical coordination in a public health care network in Bogotá, Colombia.

METHODS

A qualitative, descriptive-interpretative study using semi-structured individual interviews and focus groups with 40 professionals (GPs, specialists, members of the local steering committee (LSC) and network middle managers) involved in designing and implementing joint training sessions to improve cross-level clinical coordination. The intervention consisted of two forms of joint training sessions for GPs and specialists, implemented through two PAR cycles.

RESULTS

The PAR approach in designing and implementing joint training sessions led to greater awareness of clinical coordination problems and helped adapting sessions to the local health care context. Study participants highlighted the role of LSC leadership during the PAR process and the importance of ensuring the necessary resources for adopting the intervention. Limited institutional support and differences between joint training sessions affected doctors' participation and reduced the time available to conduct the sessions. The use of a reflexive method was essential in enhancing doctors' participation, along with session duration, the facilitator's role and session content.

CONCLUSIONS

The study provides evidence regarding the contribution of a PAR process to designing and implementing joint training sessions for improving clinical coordination. The findings can inform similar approaches in other health systems.

[Barriers and factors associated with the use of coordination mechanisms between levels of care in Mexico]

The aim was to analyze the level and characterize the use of clinical coordination mechanisms between levels of care, and their associated factors, in two public networks of health services in Mexico. A cross-sectional study was carried out using the COORDENA questionnaire to primary and specialized care physicians in the state of Veracruz. Differences were found between networks and levels of care, according to the mechanism. In both, the referral/counter-referral is mostly used to channel the patient to another level, mainly by primary care physicians. A high reception of referrals by specialists was identified, but few counterreferences in primary care. Being a man and recognizing the primary care physician, as responsible for monitoring the patient in his/her healthcare career, were factors associated with the frequent sending of the counter-referral by specialists. The discharge report is used in both networks to send clinical information to the other level, with more sending by specialist doctors, but with less reception in primary care. In both networks, the follow-up to the recommendations of the mechanisms to standardize clinical care was greater by primary care physicians than specialized ones. The use of coordination mechanisms between levels of care is deficient and limited, with greater use of mechanisms to transfer information than for clinical management. The need to implement strategies that consider the participation of professionals is evident, to favor local adaptation, appropriation and improve their use.

Changes in knowledge and use of clinical coordination mechanisms between care levels in healthcare networks of Colombia

Clinical coordination mechanisms (CCMs) have become key tools in healthcare networks for improving coordination between primary care (PC) and secondary care (SC) and are particularly relevant in health systems with highly fragmented healthcare provision. However, their implementation has been little studied to date in Latin America and particularly in Colombia. This study analyses the level of knowledge and use of CCMs between care levels and their changes between 2015 and 2017 in two public healthcare networks in Bogotá, Colombia. Comparison of two cross-sectional studies based on surveys among PC and SC doctors working in their networks (174 doctors per network/year). The COORDENA questionnaire was used for measuring knowledge concerning CCMs and the frequency of use and difficulties involved in using referral/reply letters (R/RLs) and hospital discharge reports (HDRs). Descriptive bivariate analysis and Poisson regression models with robust variance were used for analysing differences between networks and years. The results for both networks and years revealed greater knowledge and use of information coordination mechanisms than those regarding clinical management coordination (though their knowledge increased in 2017). Although widely known and used, significant problems regarding infrequent and late receipt of RLs and HDRs in PC as well as the poor quality of their contents limits their effective use, which may affect the quality of care. Strategies are required to improve CCMs use.