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Slåtsveen RE, Wibe T, Halvorsrud L, Lund A. Balancing between dual belongings when organised into interdisciplinary teams, with the trust model as the context: A qualitative study. BMC PRIMARY CARE 2024; 25:314. [PMID: 39182020 PMCID: PMC11344355 DOI: 10.1186/s12875-024-02554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/31/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Home-based healthcare services are facing challenges and pressures of increasing needs due to an ageing population, rising workload for an overburdened workforce, and limited financial resources. The trust model is an approach to address the challenges, by organizing the home-based healthcare services into smaller, autonomous interdisciplinary teams. The aim is to involve users and next of kin in decision-making and trusting frontline workers' professional judgement, thus making the services more flexible and individually tailored. This study explores frontline workers' practices and experiences of working within interdisciplinary teams according to the trust model's goals. METHODS Observations, individual-, and focus groups interviews were conducted within home-based healthcare service in a Norwegian municipality. The participants were leaders and frontline workers at different levels of the home-based healthcare services, including registered nurses, auxiliary nurses, occupational therapists, physiotherapists, and other unskilled healthcare personnel. Data was analysed thematically. RESULTS The results are presented in terms of themes: 'We all want the best for service users', 'Belonging to an interdisciplinary team' and 'Maintaining belonging to those with similar work tasks and responsibilities'. The results show a diversity among the participants' experiences of working within interdisciplinary teams. It demonstrates a dilemma between creating belonging to and forming identities within the interdisciplinary team, and at the same time, the importance of maintaining belonging and identity with those in the same profession or with the same tasks and responsibilities. CONCLUSION This study suggests that the frontline workers need for dual belonging seems to be underestimated within the trust model, and by acknowledging this, organisations and policymakers can create environments that support both. Which in turn can enhance the possibility to deliver flexible and individually tailored services for service users.
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Affiliation(s)
| | - Torunn Wibe
- Centre for Development of Institutional and Home Care Services in Oslo, Oslo, Norway
| | | | - Anne Lund
- OsloMet- Oslo Metropolitan University, Oslo, Norway
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Donaghy E, Huang H, Henderson D, Wang HH, Guthrie B, Mercer SW. Primary care transformation in Scotland: a qualitative study of GPs' and multidisciplinary team members' views. Br J Gen Pract 2024; 74:e1-e8. [PMID: 38154939 PMCID: PMC10756001 DOI: 10.3399/bjgp.2023.0086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/05/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND The Scottish Government's vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018. AIM To explore practitioners' views on the expansion of MDT working in Scotland. DESIGN AND SETTING Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland. METHOD In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify commonalities and divergences in the interviews. RESULTS Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance. External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale. Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased). In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue. Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems. CONCLUSION Although there has been substantial expansion of the primary care MDT, which most GPs welcome, many challenges to effective implementation remain that must be addressed if transformation of primary care in Scotland is to become a reality.
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Affiliation(s)
- Eddie Donaghy
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Huayi Huang
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - David Henderson
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Harry Hx Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Bruce Guthrie
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Stewart W Mercer
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Henderson DAG, Donaghy E, Dozier M, Guthrie B, Huang H, Pickersgill M, Stewart E, Thompson A, Wang HHX, Mercer SW. Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China. BMC Med 2023; 21:319. [PMID: 37620865 PMCID: PMC10463288 DOI: 10.1186/s12916-023-03033-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation. METHODS We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed. RESULTS A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes. CONCLUSIONS Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.
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Affiliation(s)
- D A G Henderson
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Donaghy
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - M Dozier
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - B Guthrie
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - H Huang
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - M Pickersgill
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Stewart
- School of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
| | - A Thompson
- School of Social and Political Sciences, University of Edinburgh, Edinburgh, UK
| | - H H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - S W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.
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Burgmann S, Paier-Abuzahra M, Sprenger M, Avian A, Siebenhofer A. Identifying key policy objectives for strong primary care: a cross-sectional study. Prim Health Care Res Dev 2023; 24:e52. [PMID: 37577950 PMCID: PMC10466205 DOI: 10.1017/s1463423623000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 08/15/2023] Open
Abstract
AIM The aim of this study was to identify key policy objectives by investigating the perception of important stakeholders and affected professionals concerning relevance and feasibility of a successful primary care (PC) reform. BACKGROUND Since 2013, the Austrian PC system has been undergoing a reform process to establish multiprofessional primary care units. The reforms have various defined objectives and lack clear priorities. METHODS After the definition and consensus-based selection of 12 policy objectives, a cross-sectional online survey on their relevance and feasibility was distributed via email and social media to PC and public health networks. The survey was conducted in the period from January to February 2020. Results were analyzed descriptively, and further, Pearson Chi-Square Test or Fisher's Exact Test was performed for group comparison regarding respondents' characteristics. Open-ended responses were analyzed using qualitative content analysis. FINDINGS In total, 169 questionnaires were completed. A total of 46.3% of the responders had more than 20 years of professional experience (female: 60.5%). A mandatory internship in general practice, vocational training for general practice, and a modern remuneration system were the three top-rated policy objectives regarding relevance. A mandatory internship in general practice, specialization in general practice, and coding of services and diagnosis were assessed as the most feasible objectives. The group comparisons regarding working field, years of professional experience, age, and sex did not show any meaningful results in the evaluation of relevance and feasibility. DISCUSSION In the view of the study participants, easily obtainable objectives include adapting the duration and setting of internships for medical students, as well as mandatory vocational training for GP trainees. Further efforts are necessary to achieve complex objectives such as the adoption of a modern remuneration scheme and a comprehensive quality assurance program. Building capacity and creating team-oriented environments are also important aspects of a successful PC reform.
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Affiliation(s)
- Sarah Burgmann
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Neue Stiftingtalstraße 6, Graz8010, Austria
| | - Muna Paier-Abuzahra
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Neue Stiftingtalstraße 6, Graz8010, Austria
| | - Martin Sprenger
- Institute of Social Medicine and Epidemiology, Medical University of Graz, Neue Stiftingtalstraße 6, Graz8010, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Neue Stiftingtalstraße 6, Graz8010, Austria
| | - Andrea Siebenhofer
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Neue Stiftingtalstraße 6, Graz8010, Austria
- Institute of General Practice, Johann Wolfgang Goethe University Frankfurt, Frankfurt60590, Germany
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Gillespie P, Hobbins A, O’Toole L, Connolly D, Boland F, Smith SM. Cost-effectiveness of an occupational therapy-led self-management support programme for multimorbidity in primary care. Fam Pract 2022; 39:826-833. [PMID: 35137039 PMCID: PMC9508868 DOI: 10.1093/fampra/cmac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Multimorbidity is a major public health concern. Complex interventions, incorporating individualized care plans, may be appropriate for patients with multimorbidity given their individualized and variable needs. There is a dearth of evidence on the cost-effectiveness of complex multimorbidity interventions. OBJECTIVE This study examines the cost-effectiveness of a 6-week occupational therapy-led self-management support programme (OPTIMAL) for adults with multimorbidity. METHODS Economic evaluation, from a healthcare perspective, was conducted alongside a randomized controlled trial of 149 adults with multimorbidity. Intervention was the OPTIMAL programme with a comparison of usual primary care. Incremental costs, quality-adjusted life years (QALYs) gained, and expected cost-effectiveness were estimated at 6 months and uncertainty was explored using cost-effectiveness acceptability curves. RESULTS The intervention was associated with a mean improvement in QALYs gained of 0.031 per patient (P-value: 0.063; 95% confidence intervals [CIs]: -0.002 to 0.063) and a mean reduction in total costs of €2,548 (P-value: 0.114; 95% CIs: -5,606 to 509) per patient. At cost-effectiveness threshold values of €20,000 and €45,000 per QALY, the probability of the intervention being cost-effective was estimated to be 0.951 and 0.958, respectively. The results remained consistent across all subgroups examined. CONCLUSIONS This study adds to the limited evidence base on the cost-effectiveness of complex interventions for multimorbidity, and highlights the potential for the OPTIMAL programme to be cost-effective. Further studies are warranted to explore the clinical and cost-effectiveness of complex interventions for the multimorbidity patient population, and for subgroups within it. TRIAL REGISTRATION Trial number: ISRCTN67235963.
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Affiliation(s)
- Paddy Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), Institute for Lifecourse & Society (ILAS), CURAM, SFI Research Centre for Medical Devices, NUI Galway, University Road, Galway H91 TK33, Ireland
| | - Anna Hobbins
- Health Economics and Policy Analysis Centre (HEPAC), CURAM, SFI Research Centre for Medical Devices, NUI Galway, University Road, Galway H91 TK33, Ireland
| | - Lynn O’Toole
- Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences, St. James’s Hospital, James’s Street, Dublin 8, D08 NHY1, Ireland
| | - Deirdre Connolly
- Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin, St. James’s Hospital, James’s Street, Dublin 8, D08 NHY1, Ireland
| | - Fiona Boland
- Data Science Centre and HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Mercer Building, Mercer Street Lower, Dublin 2, D02 YN77, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Mercer Building, Mercer Street Lower, Dublin 2, D02 YN77, Ireland
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Varhol RJ, Randall S, Boyd JH, Robinson S. Australian general practitioner perceptions to sharing clinical data for secondary use: a mixed method approach. BMC PRIMARY CARE 2022; 23:167. [PMID: 35773626 PMCID: PMC9247967 DOI: 10.1186/s12875-022-01759-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The potential for data collected in general practice to be linked and used to address health system challenges of maintaining quality care, accessibility and safety, including pandemic support, has led to an increased interest in public acceptability of data sharing, however practitioners have rarely been asked to share their opinions on the topic. This paper attempts to gain an understanding of general practitioner's perceptions on sharing routinely collected data for the purposes of healthcare planning and research. It also compares findings with data sharing perceptions in an international context. MATERIALS AND METHODS: A mixed methods approach combining an initial online survey followed by face-to-face interviews (before and during COVID-19), designed to identify the barriers and facilitators to sharing data, were conducted on a cross sectional convenience sample of general practitioners across Western Australia (WA). RESULTS Eighty online surveys and ten face-to-face interviews with general practitioners were conducted from November 2020 - May 2021. Although respondents overwhelmingly identified the importance of population health research, their willingness to participate in data sharing programs was determined by a perception of trust associated with the organisation collecting and analysing shared data; a clearly defined purpose and process of collected data; including a governance structure providing confidence in the data sharing initiative simultaneously enabling a process of data sovereignty and autonomy. DISCUSSION Results indicate strong agreement around the importance of sharing patient's medical data for population and health research and planning. Concerns pertaining to lack of trust, governance and secondary use of data continue to be a setback to data sharing with implications for primary care business models being raised. CONCLUSION To further increase general practitioner's confidence in sharing their clinical data, efforts should be directed towards implementing a robust data governance structure with an emphasis on transparency and representative stakeholder inclusion as well as identifying the role of government and government funded organisations, as well as building trust with the entities collecting and analysing the data.
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Affiliation(s)
- Richard J Varhol
- School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia.
| | - Sean Randall
- School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - James H Boyd
- Department of Public Health, School of Psychology and Public Health, College of Science, La Trobe University, Health & Engineering, Melbourne, Australia
| | - Suzanne Robinson
- School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
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7
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Advances in knowledge of screening practices and their use in clinical practice to prevent malnutrition. Proc Nutr Soc 2022; 81:41-48. [DOI: 10.1017/s0029665121003670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Malnutrition is common among older adults and is associated with a progressive decline in overall health and increased mortality. With a rapidly ageing population, the detection, prevention and management of malnutrition require urgent attention within health service planning and delivery. Routine screening for malnutrition among older adults in community settings, which addresses aetiological as well as phenotypic factors, is considered an important step for prevention and early intervention. The aim of this review is to summarise current malnutrition screening literature and highlight research that seeks to understand and address community-based approaches to malnutrition screening and management. Key healthcare professionals (HCPs) that encounter community-dwelling older adults include general practitioners (GPs), community-based nurses, community pharmacists and a range of other health and social care professionals including dietitians, physiotherapists, speech and language therapists, and occupational therapists. The key barriers to implementing screening in primary care include lack of knowledge about malnutrition among non-dietetic HCPs, lack of resources allocated to managing malnutrition, lack of access to dietetic services, and poor GP knowledge about oral nutritional supplement prescribing. In addition, older adults have poor insight into the clinical condition and the associated negative health implications. Investment in education among HCPs and public awareness is required, as well as accompanying resources to successfully implement malnutrition screening programmes for community-dwelling older adults.
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Sourial N, Hacker Teper M, Arsenault-Lapierre G, Mehta K, Kay K, Vedel I. Interprofessional primary care: indispensable for family physicians yet invisible to older patients. J Interprof Care 2022; 36:786-792. [PMID: 35191765 DOI: 10.1080/13561820.2022.2037529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.
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Affiliation(s)
- Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Quebec, Canada
| | | | | | - Kavita Mehta
- Association of Family Health Teams of Ontario, Vice- The Change Foundation, Ontario, Canada
| | - Kelly Kay
- Provincial Geriatrics Leadership Office, Ontario, Canada
| | - Isabelle Vedel
- Department of Family Medicine, McGill University, Quebec, Canada
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Browne S, Kelly L, Geraghty AA, Reynolds CM, McBean L, McCallum K, Clyne B, Bury G, Perrotta C, Kennelly S, Bradley C, McCullagh L, Finnigan K, Clarke S, Bardon LA, Murrin C, Gibney ER, Dominguez Castro P, Corish CA. Healthcare professionals' perceptions of malnutrition management and oral nutritional supplement prescribing in the community: A qualitative study. Clin Nutr ESPEN 2021; 44:415-423. [PMID: 34330499 DOI: 10.1016/j.clnesp.2021.04.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/21/2021] [Accepted: 04/25/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIM Protein-energy malnutrition is under-recognised in the community despite being common in older adults due to physiological and social changes which are often compounded by chronic disease. This qualitative study aimed to explore the opinions of healthcare professionals (HCPs) working in the primary care and community settings about the management of malnutrition and the prescription of oral nutritional supplements (ONS), often included in the treatment of malnutrition. METHODS Twelve healthcare professional (HCP) focus groups with 75 participants were conducted: community dietitians (n = 17), registered dietitians working in industry (n = 5), community and residential care nurses (n = 22), physiotherapists (n = 12), pharmacists (n = 9), occupational therapists (n = 6) and speech and language therapists (n = 4). Focus group discussions were audio-recorded and transcribed verbatim. The data were coded and analysed using thematic analysis and key themes with illustrative quotes extracted are presented. RESULTS Similar views on malnutrition management existed across professions. 'Gaps in Primary Care Management' was the first key theme wherein HCPs identified limitations in malnutrition management in the community. Barriers included limited or no dietetic services available in primary care and poor communication between general practitioners and wider primary care team members which resulted in inappropriate or delayed treatment. The second key theme, 'Challenges with ONS use in the Community', encapsulated several issues HCPs experienced with ONS usage including inappropriate prescribing and lack of monitoring of treatment goals. Conflicts of interest regarding dietitians working in industry assessing and treating older adults in residential care settings was highlighted by participants. CONCLUSIONS This study highlights that more emphasis is needed to identify patients when they are at risk of malnutrition to avoid advanced or severe malnutrition presentations currently seen. Community dietitians for older people are required to address many of the issues raised including the need for awareness, education and training, resources, and malnutrition care pathway structures.
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Affiliation(s)
- Sarah Browne
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Lucy Kelly
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland
| | - Aisling A Geraghty
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Ciara Me Reynolds
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Laura McBean
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Kimberley McCallum
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Gerard Bury
- School of Medicine, University College Dublin, Belfield, Dublin 4, Republic of Ireland
| | - Carla Perrotta
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland
| | - Sharon Kennelly
- National Primary Care Division, Community Funded Schemes Service Improvement, Mountmellick Primary Care Building, Co. Laois, Republic of Ireland
| | - Catriona Bradley
- Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Laura McCullagh
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Republic of Ireland
| | - Karen Finnigan
- HSE Medicines Management Programme, Health Service Executive, St James's Hospital, Dublin 8, Republic of Ireland
| | - Sarah Clarke
- HSE Medicines Management Programme, Health Service Executive, St James's Hospital, Dublin 8, Republic of Ireland
| | - Laura A Bardon
- UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland; School of Agriculture and Food Science, University College Dublin, Dublin, Republic of Ireland
| | - Celine Murrin
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Eileen R Gibney
- UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland; School of Agriculture and Food Science, University College Dublin, Dublin, Republic of Ireland
| | - Patricia Dominguez Castro
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland
| | - Clare A Corish
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Republic of Ireland; UCD Institute of Food and Health, University College Dublin, Dublin, Republic of Ireland.
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Effect of the OPTIMAL programme on self-management of multimorbidity in primary care: a randomised controlled trial. Br J Gen Pract 2021; 71:e303-e311. [PMID: 33685920 PMCID: PMC7959668 DOI: 10.3399/bjgp20x714185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 10/02/2020] [Indexed: 11/19/2022] Open
Abstract
Background Effective primary care interventions for multimorbidity are needed. Aim To evaluate the effectiveness of a group-based, 6-week, occupational therapy-led self-management support programme (OPTIMAL) for patients with multimorbidity. Design and setting A pragmatic parallel randomised controlled trial across eight primary care teams in Eastern Ireland with 149 patients with multimorbidity, from November 2015 to December 2018. Intervention was OPTIMAL with a usual care comparison. Method Primary outcomes were health-related quality of life (EQ-5D-3L) and frequency of activity participation (Frenchay Activities Index [FAI]). Secondary outcomes included independence in activities of daily living, occupational performance and satisfaction, anxiety and depression, self-efficacy, and healthcare utilisation. Complete case linear regression analyses were conducted. Age (<65/≥65 years) and the number of chronic conditions (<4/≥4) were explored further. Results A total of 124 (83.2%) and 121 (81.2%) participants had complete data at immediate and 6-month post-intervention follow-up, respectively. Intervention participants had significant improvement in EQ-VAS (visual analogue scale) at immediate follow-up (adjusted mean difference [aMD] = 7.86; 95% confidence interval [CI] = 0.92 to 14.80) but no difference in index score (aMD = 0.04; 95% CI = −0.06 to 0.13) or FAI (aMD = 1.22; 95% CI = −0.84 to 3.29). At 6-month follow-up there were no differences in primary outcomes and mixed results for secondary outcomes. Pre-planned subgroup analyses suggested participants aged <65 years were more likely to benefit. Conclusion OPTIMAL was found to be ineffective in improving health-related quality of life or activity participation at 6-month follow-up. Existing multimorbidity interventions tend to focus on older adults; preplanned subgroup analyses results in the present study suggest that future research should target younger adults (<65 years) with multimorbidity.
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11
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Tierney E, Hannigan A, Kinneen L, May C, O'Sullivan M, King R, Kennedy N, MacFarlane A. Interdisciplinary team working in the Irish primary healthcare system: Analysis of 'invisible' bottom up innovations using Normalisation Process Theory. Health Policy 2019; 123:1083-1092. [PMID: 31575445 DOI: 10.1016/j.healthpol.2019.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/26/2019] [Accepted: 09/12/2019] [Indexed: 11/15/2022]
Abstract
Interdisciplinary team working in primary care is a key policy goal across healthcare jurisdictions. The National Primary Care Strategy (2001) in Ireland is a top down policy for primary healthcare reform, which prioritised the development and implementation of interdisciplinary Primary Care Teams. The number of Primary Care Teams and features of their clinical meetings have been the key metric in Ireland for appraising progress with the implementation of the strategy. However, these have been challenging to organise in practice. The aim of this paper is to analyse empirical evidence of other forms of interdisciplinary working in Irish primary care, using Normalisation Process Theory. Drawing on data from an on-line survey (71 GPs and 498 other healthcare professionals), and an interview study (37 participants; 8 GPs, 7 practice managers/admin support and 22 health care professionals) in three of the four Health Service Executive (HSE) regions in Ireland, we analyse the nature of these other forms of interdisciplinary working and describe innovations for service delivery that have been developed 'from the ground up' as a result. We examine levers and barriers to the implementation of these bottom up innovations. The levers are that these innovations make sense to professionals, are based on local needs and focus on preventive patient-centred care. They are driven forward by small groups of professionals from different backgrounds with complementary skills. The evaluations show positive impacts of the innovative services for patients, however, many have ceased to operate due to negative effects of the recent economic recession on the Irish healthcare system. These flexible and localised innovations were shaped in part by the reforms set out in the 2001 Primary Care Strategy but also represent unintended effects of that policy because they are the result of bottom up interdisciplinary working that occurs alongside, or instead of, Primary Care Team clinical meetings. Furthermore, as they not captured by existing metrics, the interdisciplinary work and resultant services have been 'invisible' to senior management and policy makers. If appropriately acknowledged and supported, they can shape primary care in the future.
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Affiliation(s)
| | - Ailish Hannigan
- Biomedical Statistics, Graduate Entry Medical School and Health Research Institute, University of Limerick, Ireland.
| | | | - Carl May
- Medical Sociology London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Rachael King
- Graduate Entry Medical School, University of Limerick, Ireland.
| | - Norelee Kennedy
- Department of Clinical Therapies School of Allied Health, University of Limerick, Ireland.
| | - Anne MacFarlane
- Primary Healthcare Research, Graduate Entry Medical School and Health Research Institute University of Limerick, Ireland.
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McKittrick R, McKenzie R. A narrative review and synthesis to inform health workforce preparation for the Health Care Homes model in primary healthcare in Australia. Aust J Prim Health 2018; 24:PY18045. [PMID: 30103852 DOI: 10.1071/py18045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/03/2018] [Indexed: 02/28/2024]
Abstract
The Australian Government Health Care Homes (HCH) model recently implemented in general practice targets people with chronic complex conditions. Identifying how general practitioners (GPs) and practice nurses (PNs) can work within this model is important given existing health workforce challenges. A narrative review and synthesis has been undertaken to develop a preliminary understanding of this, incorporating literature describing health workforce challenges, GP and PN functions, and team-based care; supplemented by interviews with key informants from within the primary healthcare system. Narrative synthesis principles guided literature analysis. Interview data were thematically analysed. A clear rationale for health workforce reform was ascertained and functions for the GP and PN under the HCH model were determined. The model was found to be an opportunity for an enhanced PN role in a team-based approach to care with the GP. Challenges to advancing the PN role and team-based care were identified, including the medical dominance of the health system and the significant culture change required by general practices to fully implement the model. Enablers included strong nursing leadership and improved ongoing education for PNs to unlock their capacity. The HCH model is an opportunity to strengthen primary healthcare, provided concerted action is taken regarding these challenges and enablers.
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 316] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Tierney E, McEvoy R, Hannigan A, MacFarlane AE. Implementing community participation via interdisciplinary teams in primary care: An Irish case study in practice. Health Expect 2018; 21:990-1001. [PMID: 29770551 PMCID: PMC6250861 DOI: 10.1111/hex.12692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 11/30/2022] Open
Abstract
Background Community participation in primary care is enshrined in international and Irish health policy. However, there is a lack of evidence about how stakeholders work collectively to implement community participation within interdisciplinary teams; community perspectives are rarely captured, and a theoretical underpinning for implementation of community participation in primary care is absent. Objective To conduct a theoretically informed, multiperspectival empirical analysis of the implementation of community participation via primary care teams (PCTs) in Ireland. Methods/Design/Participants Participatory learning and action (PLA) focus groups and interviews were held with 39 participants across four case study sites within a nationally funded programme designed to enable disadvantaged communities to participate in primary care. Normalization process theory (NPT) informed data generation and analysis of how diverse stakeholder groups worked together to implement community participation via PCTs. Results The various stakeholders had a shared understanding of the value of community participation on PCTs. Motivations to get involved in this work varied, but were strong overall. Challenges to enacting community participation on PCTs included problems with the functioning of PCTs and a lack of clarity and confidence in the role of community representatives at PCT meetings. Informal appraisals were positive, but formal appraisal was limited. Discussion and Conclusion The implementation and sustainability of community participation on PCTs in Ireland will be limited unless (i) the functioning of PCTs is strong, (ii) there is increased confidence and clarity on community representatives’ roles among all health‐care professionals, and (iii) more sophisticated methods for formal appraisal are used.
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Affiliation(s)
- Edel Tierney
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - Ailish Hannigan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Anne E MacFarlane
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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O’Reilly P, Lee SH, O’Sullivan M, Cullen W, Kennedy C, MacFarlane A. Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review. PLoS One 2017; 12:e0177026. [PMID: 28545038 PMCID: PMC5436644 DOI: 10.1371/journal.pone.0177026] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/24/2017] [Indexed: 11/19/2022] Open
Abstract
Background Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps. Methods and findings An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals. Conclusion A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work. Systematic review registration International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.
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Affiliation(s)
- Pauline O’Reilly
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Republic of Ireland
- * E-mail:
| | - Siew Hwa Lee
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, United Kingdom
| | - Madeleine O’Sullivan
- Graduate Entry Medical School (GEMS), Faculty of Education and Health Sciences & Health Research Institute, University of Limerick, Limerick, Republic of Ireland
| | - Walter Cullen
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Republic of Ireland
| | - Catriona Kennedy
- School of Nursing and Midwifery, Robert Gordon University, Aberdeen, United Kingdom
| | - Anne MacFarlane
- Graduate Entry Medical School (GEMS), Faculty of Education and Health Sciences & Health Research Institute, University of Limerick, Limerick, Republic of Ireland
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