Is the co-location of GPs in primary care centres associated with a higher patient satisfaction? Evidence from a population survey in Italy

Pharmacists Colocated With Primary Care Physicians: Understanding Delivery of Interprofessional Primary Care

BACKGROUND

While evidence supports interprofessional primary care models that include pharmacists, the extent to which pharmacists are working in primary care and the factors associated with colocation is unknown.

OBJECTIVES

This study aimed to analyze the physical colocation of pharmacists with primary care providers (PCPs) and examine predictors associated with colocation.

RESEARCH DESIGN

This is a retrospective cross-sectional study of pharmacists and PCPs with individual National Provider Identifiers in the National Plan and Provider Enumeration System's database. Pharmacist and PCP practice addresses of the health care professionals were geocoded, and distances less than 0.1 miles were considered physically colocated.

SUBJECTS

In all, 502,373 physicians and 221,534 pharmacists were included.

RESULTS

When excluding hospital-based pharmacists, 1 in 10 (11%) pharmacists were colocated with a PCP. Pharmacists in urban settings were more likely to be colocated than those in rural areas (OR=1.32, CI: 1.26-1.38). Counties with the highest proportion of licensed pharmacists per 100,000 people in the county had higher colocation (OR=1.38, CI: 1.32-1.45). Colocation was significantly higher in states with an expanded scope of practice (OR 1.37, CI: 1.32-1.42) and those that have expanded Medicaid (OR 1.07, CI: 1.03-1.11). Colocated pharmacists more commonly worked in larger physician practices.

CONCLUSION

Although including pharmacists on primary care teams improves clinical outcomes, reduces health care costs, and enhances patient and provider experience, colocation appears to be unevenly dispersed across the United States, with lower rates in rural areas. As the integration of pharmacists in primary care continues to expand, knowing the prevalence and facilitators of growth will be helpful to policymakers, researchers, and clinical administrators.

Perspectives on an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a qualitative study

BACKGROUND

A new Health and Wellbeing pathway was introduced into the Improving Access to Psychological Therapies (IAPT) service in one geographical area of the UK in 2021 to address the wider determinants of mental health problems. It comprised assisted signposting to wider services and physical health promotion. This qualitative study aimed to understand stakeholders' experiences of implementing and receiving this new support and the barriers and facilitators to its delivery.

METHODS

Forty-seven interviews were conducted, with service developers (n = 6), service deliverers (n = 12), service users (n = 22) and community and clinical partners (n = 7), as part of a larger mixed-methods evaluation. Interviews were recorded, transcribed, and analysed using reflexive thematic analysis.

RESULTS

Three themes spanned all participant groups and represented key aspects of the service: (1) identifying suitability, (2) a holistic service, and (3) moving forward. The sub-themes represent the barriers and facilitators to processes working in practice, lending insight into potential service improvements. These included strengthening the quality of communication during referral and assessment, tailoring the support and delivery mode, and increasing transparency around continued care to drive sustained benefits.

LIMITATIONS

Service users may have been selected due to their positive experiences of IAPT and were not demographically representative of the population, although participants' experiences of the service did suggest variation in our sample.

CONCLUSIONS

The Health and Wellbeing pathway was perceived as having a positive impact on mental health and could reduce the burden on therapeutic services. However, service- and individual-level barriers need to be addressed to enhance statutory and community support links, manage service users' expectations, and improve accessibility for certain groups.

A New Treatment Program: Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD)

OBJECTIVE

Bipolar disorder (BD) is complicated by a dynamic, chronic course along with multiple comorbid psychiatric and medical conditions, making it challenging for clinicians to treat and patients to thrive. To efficiently manage the complexity of BD and help patients recover, we developed a Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). The purpose of this paper is to describe how we developed this clinic and the lessons we learned.

METHODS

We developed FITT-BD by integrating strategies from stepped care, collaborative care, and learning health care systems. We describe the rationale, details, and lessons learned in developing FITT-BD.

RESULTS

By integrating stepped care, collaborative care, and a learning health care system approach, FITT-BD aims to reduce barriers to care, leverage the expertise of a multidisciplinary treatment team, ensure patient-centeredness, and use assessments to inform and continuously improve outcomes in real time. We learned that there are challenges in the creation of a web-based application that tracks the treatment of patients within a network of hospitals.

CONCLUSIONS

The success of FITT-BD will be determined by the degree to which it can increase treatment access, improve treatment adherence, and help individuals with BD achieve their treatment goals. We expect that FITT-BD will improve outcomes in the context of ongoing clinical care.

PUBLIC HEALTH SIGNIFICANCE

The treatment of BD is challenging and complex. We propose a new treatment model for BD: FITT-BD. We expect that this program will be a patient-centered approach that improves outcomes in the context of ongoing clinical care for patients with BD.

Defining a threshold above which an adult can be considered to frequently use ambulance services: a retrospective cross-sectional study of emergency calls to an ambulance service in England

Objective

There is no empirical definition of adult frequent use of ambulance services. This study aimed to define a threshold, and utilise this to explore characteristics of people frequently using services.

Methods

This was a retrospective cross-sectional study in a single ambulance service in England. Routinely collected, pseudo-anonymised call- and patient-level data were collected for two months (January and June 2019). Incidents, defined as independent episodes of care, were analysed using a zero-truncated Poisson regression model to determine a suitable frequent-use threshold, with comparisons subsequently made between frequent and non-frequent users.

Results

A total of 101,356 incidents involving 83,994 patients were included in the analysis. Two potentially appropriate thresholds were identified: five incidents per month (A); and six incidents per month (B). Threshold A produced 3137 incidents from 205 patients, with five patients likely false-positive identifications. Threshold B produced 2217 incidents from 95 patients, with no false-positive identifications but 100 false-negatives compared to threshold A. Regardless of threshold, frequent users compared to non-frequent users had relatively reduced service use between 08:00 and 15:00, were younger and were more likely to receive lower-priority responses (all p < 0.001). We identified several chief complaints indicative of increased frequent use, including chest pain, psychiatric/suicide attempt and abdominal pains/problems.

Conclusions

We suggest a threshold of five incidents per month, with recognition that a small number of patients may be incorrectly identified as using ambulance services frequently. The rationale for this choice is discussed. This threshold may be applicable in wider UK settings and could be used for the routine automated identification of people using ambulance services frequently. The identified characteristics can help inform interventions. Future research should examine applicability of this threshold in other UK ambulance services and countries where patterns and determinants of frequent ambulance use may differ.

Demographic, practice and clinical management characteristics of osteopaths referring to podiatrists: secondary analysis of a nationally representative sample of Australian osteopaths

Background

Interprofessional care is paramount in contemporary healthcare practice. How different professions interact, and the characteristics of those practitioners who practice in an interprofessional way are rarely described in the literature. The aim of the current work was to identify the demographic, practice and clinical management characteristics of Australian osteopaths who report referring to podiatrists.

Methods

The study was a secondary analysis of data from the Osteopathy Research and Innovation Network (ORION). Inferential statistics were generated to identify statistically significant demographic, practice and clinical management characteristics associated with referrals to podiatrists by Australian osteopaths.

Results

Nine-hundred and ninety-two Australian osteopaths responded to the questionnaire. Sending referrals to a podiatrist was reported by 651 participants (65.6%). Female Australian osteopaths were less likely to report referring to podiatrists compared to male osteopaths (OR 0.76, 95%CI 0.59–0.99). Australian osteopaths who reported referring to podiatrists were more likely to report receiving referrals from podiatrists (OR 9.75, 95%CI 6.98–13.61), use orthopaedic testing in patient assessment (OR 7.62, 95%CI 2.82–20.60), and often treat patients with postural disorders (OR 1.71, 95%CI 1.03–2.26), compared to osteopaths who do not refer to podiatrists.

Conclusion

This study provides initial evidence for the referral relationship between Australian osteopaths and podiatrists. Further work could explore the nature of these referrals, including the complaints resulting in referral and outcomes of care. This information will be useful to those involved in health policy development and the professions advocating for their role in the wider healthcare system.

Resident Experiences With a Place-Based Collaboration to Address Health and Social Inequities: A Survey of Visitors to the East Harlem Neighborhood Health Action Center

In 2016 and 2017, the New York City Department of Health and Mental Hygiene established Neighborhood Health Action Centers (Action Centers) in disinvested communities of color as part of a place-based model to advance health equity. This model includes co-located partners, a referral and linkage system, and community space and programming. In 2018, we surveyed visitors to the East Harlem Action Center to provide a more comprehensive understanding of visitors’ experiences. The survey was administered in English, Spanish, and Mandarin. Respondents were racially diverse and predominantly residents of East Harlem. The majority had been to the East Harlem Action Center previously. Most agreed that the main service provider for their visit made them feel comfortable, treated them with respect, spoke in a way that was easy to understand, and that they received the highest quality of service. A little more than half of returning visitors reported engaging with more than one Action Center program in the last 6 months. Twenty-one percent of respondents reported receiving at least one referral at the Action Center. Two thirds were aware that the Action Center offered a number of programs and services and half were aware that referrals were available. Additional visits to the Action Center were associated with increased likelihood of engaging with more than one program and awareness of the availability of programs and referral services. Findings suggest that most visitors surveyed had positive experiences, and more can be done to promote the Action Center and the variety of services it offers.

Integrated health and social care in the community: A critical integrative review of the experiences and well-being needs of service users and their families

A need for people-centred health and social support systems is acknowledged as a global priority. Most nations face challenges in providing safe, effective, timely, affordable, coordinated care around the needs and preferences of people who access integrated health and social care (IHSC) services. Much of the current research in the field focuses on describing and evaluating specific models for delivering IHSC. Fewer studies focus on person-centred experiences, needs and preferences of people who use these services. However, current international guidance for integrated care sets a precedence of person-centred integrated care that meets the health and well-being needs of people who access IHSC services. This integrative literature review synthesises empirical literature from six databases (CINAHL; MEDLINE; AMED; TRIP; Web of Science and Science Direct; 2007-2019). This review aims to better understand the experiences and health and well-being needs of people who use IHSC services in a community setting. Twenty studies met the inclusion criteria and results were thematically analysed. Three overarching themes were identified, including relationships, promoting health and well-being and difficulty understanding systems. Findings of this review indicate that relationships hold significance in IHSC. People who access IHSC services felt that they were not always involved in planning their care and that there was a lack of clarity in navigating integrated systems; subsequently, this impacted upon their experiences of those services. However, service user and informal carer voices appear to be underrepresented in current literature and studies that included their views were found to be of low quality overall. Collectively, these findings support the need for further research that explores the person-centred experiences and needs of people who access IHSC.

General Practitioners' Experiences During the First Phase of the COVID-19 Pandemic in Italy: A Critical Incident Technique Study

Since February 2020, when coronavirus disease began to spread in Italy, general practitioners (GPs) were called to manage a growing number of health situations. The challenges experienced by Italian GPs remained unrevealed. This study aimed at exploring Italian GPs' care experiences and practices associated with critical incidents during the first wave of the pandemic. A qualitative study design involving the critical incident technique through an online survey was applied. Sociodemographic data and open-ended responses were collected. While participants' characteristics were analyzed through descriptive statistics, qualitative data were thematically analyzed employing the framework method. 149 GPs responded to the survey and 99 participants completed the survey (dropout rate = 33%). Eight themes emerged indicating factors related to the organization of the healthcare system and factors related to the clinical management of patients, that were perceived as impacting on the GPs' care provision. The analysis revealed difficulties in communicating with other local services. This, together with the lack of coordination among services, was reported as a major challenge. Primary care was perceived as having been undervalued and criticalities in the organization of GP courses, led in a bureaucratic fashion, posed at risk some trainees to be infected. The digital technologies adopted for remote patient consultations were seen as useful tools for daily practice helping the GPs to stay emotionally connected with their patients. Besides, the improvement in the GP–patient relationship in terms of solidarity between patients and doctors and compliance to rules, had a positive impact. Moreover, many respondents addressed the importance of professional collaboration and teamwork, in terms of both support in practical issues (to find PPE, diagnostics and guidelines) and emotional support. At the same time, the lack of resources (e.g., PPE, swabs) and of specific guidelines and protocols impacted on the care provision. Our findings suggest that GPs in Italy are at risk of being left behind within the epidemic management. Communication and coordination among services are essential and should be substantially improved, and primary care research should be initiated to collect the context-specific evidence necessary to enhance the system's preparedness to public health emergencies and the quality of primary care services.

Predictive factors of a prolonged length of stay in a community Nursing-Led unit: A retrospective cohort study

AIMS AND OBJECTIVES

To describe the care provided to patients admitted into a community Nursing-Led inpatient unit and to identify factors predicting a length of stay exceeding an established threshold.

BACKGROUND

Few studies have been conducted to describe the care provided in a Nursing-Led unit. No studies have investigated factors affecting length of stay in these services.

DESIGN

Retrospective cohort study.

METHODS

Consecutive patients admitted to a community Nursing-Led unit between 2009-2015 were enrolled. Sociodemographic, medical and nursing care (diagnoses and activities) variables were collected from electronic health records. Descriptive analysis and a backward stepwise logistic regression model were applied. The study followed the STROBE guidelines.

RESULTS

The study enrolled 904 patients (mean age: 77.7 years). The most frequent nursing diagnoses were bathing self-care deficit and impaired physical mobility. The nursing activities most provided were enteral medication administration and vital signs measurement. Approximately 37% of the patients had a length of stay longer than the established threshold. Nine covariates, including being discharged to home, having an impaired memory nursing diagnosis or being treated for advanced wound care, were found to be independent predictors of prolonged length of stay. Variables related to medical conditions did not affect the length-of-stay threshold.

CONCLUSIONS

The length of stay in the community Nursing-Led unit was mainly predicted by conditions related to sociodemographic factors, nursing complexity and functional status. This result confirms that the medical and nursing needs of a community Nursing-Led unit population substantively differ from those of hospitalised acute patients.

RELEVANCE TO CLINICAL PRACTICE

The nursing complexity and related nursing care to be provided may be adopted as a criterion to establish the appropriate length of stay in the community Nursing-Led unit for each individual patient.

Chronic disease management: Discussing the perspectives of general practitioners in Italy

The aim of this paper is to provide an overview of general practitioners’ perspectives across key criteria for effective chronic disease management. The study setting is the Tuscany Region in Italy that implemented the Chronic Care Model in 2010 with multidisciplinary team to assist chronic patients. We used the results of a web-based survey of general practitioners (N = 1136) conducted in 2015 to compare the experiences and satisfaction of general practitioners involved (group 1) and not involved (group 2) in the Chronic Care Model. The analysis included all general practitioners, and compared the two groups’ perspectives of the different core aspects of Chronic Care Model through conducting an ANOVA analysis and Bonferroni test. General practitioners involved in the Chronic Care Model are found to be more favourably disposed toward measurement and benchmarking, and more satisfied in terms of decision support system. Conversely, no significant differences were found in terms of collaboration with specialists, which remains weak and in terms of community collaboration and involvement. This study provides a detailed investigation of the implementation of Disease Management Programs, by considering the professional point of view.

Chronic disease prevention and management programs in primary care: Realist synthesis of 6 programs in Quebec

OBJECTIVE

To identify the mechanisms associated with success and failure of chronic disease prevention and management (CDPM) programs, as well as their key contexts.

DESIGN

Realist synthesis.

SETTING

Six primary care CDPM programs funded between 2011 and 2013 in Quebec.

PARTICIPANTS

Patients, health providers, program leaders, and other stakeholders involved in CDPM programs.

METHODS

A collaborative research process was implemented, involving representatives from the executive and advisory committees: researchers, health care providers, decision makers, and patients and families. Leaders were asked to provide all documents related to their programs to the research team. The documents were selected depending on their relevance and rigour. The thematic analysis of each program consisted of identifying the outcomes and mechanisms, as well as the specific contexts associated with these outcomes. Results for each program were validated by its leader before synthesizing the results of all programs together.

MAIN FINDINGS

A total of 108 documents (eg, grant applications, scientific reports) were collected from the programs. Positive and negative outcomes were observed at the patient, health care provider, and health care system levels. Four main mechanism categories were associated with outcomes: patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners. The main contextual factors that influenced the successes of these mechanisms were related to patients (multimorbidity, involvement of family caregivers), to health care providers (professional training, culture of interprofessional collaboration, mobilization of family physician), and to health care organizations (coordination between services, history of collaboration between partners, funding).

CONCLUSION

This study confirms the essential role of patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners when caring for patients with chronic diseases. It constitutes a relevant contribution for stakeholders involved in primary care transformation and should be used to inform the sustainability and scaling up of CDPM programs.

Integrating professionals in French multi-professional health homes: Fostering collaboration beyond the walls

Current evidence of the effectiveness of multi-disciplinary co-location for healthcare integration is mixed. This case study investigates a territorial healthcare project that is implemented across four French rural healthcare practices that co-locate multi-disciplinary healthcare practitioners. Two levels of collaboration were identified: (i) local, intra-team collaboration (i.e., care and prevention) and (ii) territorial, inter-team collaboration (i.e., patient therapeutic education and knowledge sharing). An analysis of 50 interviews with healthcare professionals uncovers important aspects of successful multi-disciplinary collaboration, which is an intermediary between co-location and care integration. By highlighting the social dimension of care integration, with a specific focus on the professional component of interpersonal integration, this study expands the theory of care integration by identifying three antecedents of multi-disciplinary collaboration: (i) prior general practitioner joint-practice experience, (ii) professional impetus (i.e., initiated by practitioners) and (iii) general practitioner peer group membership. Successful multi-disciplinary co-location and, in turn, collaboration offer a range of benefits to both patients and practitioners and advance progress towards promising perspectives, such as local competence transfer and territorial contagion.

A Scoping Review of Facilitators of Multi-Professional Collaboration in Primary Care

INTRODUCTION

Multi-professional collaboration (MPC) is essential for the delivery of effective and comprehensive care services. As in other European countries, primary care in Norway is challenged by altered patient values and the increased expectations of health administrations to participate in team-based care. This scoping review reports on the organisational, processual, relational and contextual facilitators of collaboration between general practitioners (GP) and other healthcare professionals (HCPs) in primary care.

METHODS

A systematic search in specialist and Scandinavian databases retrieved 707 citations. Following the inclusion criteria, nineteen studies were considered eligible and examined according to Arksey and O'Malley's methodological framework for scoping reviews. The retrieved literature was analysed employing a content analysis approach. A group of stakeholders commented on study findings to enhance study validity.

RESULTS

Primary care research into MPC is immature and emerging in Norway. Our analysis showed that introducing common procedures for documentation and handling of patient data, knowledge sharing, and establishing local specialised multi-professional teams, facilitates MPC. The results indicate that advancements in work practices benefit from an initial system-level foundation with focus on local management and MPC leadership. Further, our results show that it is preferable to enhance collaborative skills before introducing new professional teams, roles and responsibilities. Investing in professional relations could build trust, respect and continuity. In this respect, sufficient time must be allocated during the working day for professionals to share reflections and engage in mutual learning.

CONCLUSION

There is a paucity of research concerning the application and management of MPC in Norwegian primary care. The work practices and relations between professionals, primary care institutions and stakeholders on a macro level is inadequate. Health care is a complex system in which HCPs need managerial support to harvest the untapped benefits of MPC in primary care. As international research demonstrates, local managers must be supported with infrastructure on a macro level to understand the embedding of practice and look at what professionals actually do and how they work.

Reported experience of patients with single or multiple chronic diseases: empirical evidence from Italy

BACKGROUND

More and more countries have been implementing chronic care programs, such as the Chronic Care Model (CCM) to manage non-acute conditions of diseases in a more effective and less expensive way. Often, these programs aim to provide care for single conditions instead of the sum of diseases. This paper analyzes the satisfaction and better management of single and multiple chronic patients with the core elements of chronic care programs in Siena, Italy. In addition, the paper also considers whether the CCM introduced in Siena has any influence on satisfaction and better self-management.

METHODS

Survey data from patients with single chronic (N = 500) and multiple chronic diseases (N = 454), assisted by the Local Health Authority in Siena (Tuscany, Italy), were considered for the analysis. Variables on education, monitoring system, proactivity, relational continuity, model of care (CCM versus no CCM) and patient demographics were used to detect which strategies are associated with a higher patient-reported ability to better self-manage the disease and overall patient satisfaction. Logistic and ordinary logistic models were executed on data related to patients with both single and multiple chronic diseases.

RESULTS

The results showed that monitoring was the sole strategy associated with overall satisfaction and better self-management for both single and multiple chronic patients. Relational continuity also showed a significant positive association with better self-management perception for both patient groups, but had a positive association with patient satisfaction only for single chronic patients. Enrolment in the CCM was not associated with both overall satisfaction and better management for the two patient groups.

CONCLUSIONS

Strategies that are significantly associated with satisfaction and perception of better disease self-management were the same for both single and multiple chronic patients. The delivery of care based on the Siena CCM does not seem to make a difference in the perception of better self-management and overall satisfaction for all the patients. Other concurrent strategies implemented by the regional government in Tuscany on primary care monitoring and health promotion could partially explain why CCM does not have a significant influence.

The benefits of co-location in primary care practices: the perspectives of general practitioners and patients in 34 countries

Background

There is no clear evidence as to whether the co-location of primary care professionals in the same facility positively influences their way of working and the quality of healthcare as perceived by patients. The aim of this study was to identify the relationships between general practitioner (GP) co-location with other GPs and/or other professionals and the GP outcomes and patients’ experiences.

Methods

We wanted to test whether GP co-location is related to a broader range of services provided, the use of clinical governance tools and inter-professional collaboration, and whether the patients of co-located GPs perceive a better quality of care in terms of accessibility, comprehensiveness and continuity of care with their GPs. The source of data was the QUALICOPC study (Quality and Costs of Primary Care in Europe), which involved surveys of GPs and their patients in 34 countries, mostly in Europe. In order to study the relationships between GP co-location and both GPs’ outcomes and patients’ experience, multilevel linear regression analysis was carried out.

Results

The GP questionnaire was filled in by 7183 GPs and the patient experience questionnaire by 61,931 patients. Being co-located with at least one other professional is the most common situation of the GPs involved in the study. Compared with single-handed GP practices, GP co-location are positively associated with the GP outcomes. Considering the patients’ perspective, comprehensiveness of care has the strongest negative relationship of GP co-location of all the dimensions of patient experiences analysed.

Conclusions

The paper highlights that GP mono- and multi-disciplinary co-location is related to positive outcomes at a GP level, such as a broader provision of technical procedures, increased collaboration among different providers and wider coordination with secondary care. However, GP co-location, particularly in a multidisciplinary setting, is related to less positive patient experiences, especially in countries with health systems characterised by a weak primary care structure.