Capacity building for integrated health care at the local level

Aims & Rationale/Objectives
Taking a capacity building approach to research and evaluation within the context of a federally funded national program challenges the traditional paradigms of both research and evaluation. The objective of this approach was to foster attitudes and behaviours of reflection, critical inquiry and collaborative action amongst participants responsible for health care integration activities.

Methods
A series of workshops focusing on different elements of health care integration was conducted. Each workshop offered skill development in research and evaluation methods relevant to the participants' clinical practise. The workshops were multidisciplinary and cross-sectoral in order to promote discussion about shared patient care issues.

Principal Findings
Participatory action research facilitated by external agents can build the capacity of participants to identify and make changes that improve health care integration at local levels. A capacity building approach to research and evaluation can mediate tensions between top-down initiatives and on-the-ground practitioners.

Discussion
A capacity building approach was crucial to the success of this project particularly as the project proposal was developed at the corporate level. The workshops played an important role in engaging the participants and fostering the development of solutions for locally identified clinical issues. The opportunities for discussion with other health care service providers were both readily embraced and appreciated by the participants. The networks formed during the workshops are likely to be vital in sustaining integration efforts.

Implications
Education sessions such as the workshops held within this project ensure that health care integration remains on the agenda of the relevant organisations. These workshops fostered a continuous quality improvement approach whilst focusing on the skills required and the systemic barriers to achieving health care integration. The success of these workshops is evidence that the need and desire for shared education opportunities exists and the interdisciplinary focus is a powerful tool for developing an appreciation of the cultures within disciplines as well as linkages.

Using project evaluation to build capacity for integrated health care at local levels

Capacity-building evaluation featuring multidisciplinary cross-agency workshops fostered continuous quality improvement, while focusing on skills required and systemic barriers to health care integration between GPs and a regional hospital.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background : Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods : Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results : Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion : Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context

Cultural safety has been promoted by its New Zealand proponents as an effective process for managing cultural risk in health care and improving the cultural responsiveness of mainstream health services when delivering care to culturally diverse populations. Its effectiveness in this regard has not, however, been comprehensively investigated. A key purpose of this study was to explore and describe what is known and understood about the notion of cultural safety and its possible application to and in Australian health care domains. Findings from the study indicate that the notion of cultural safety is conceptually problematic, poorly understood, and underresearched and, unless substantially revised, cannot be meaningfully applied to the cultural context of Australia.

What's needed to increase research capacity in rural primary health care

The aim of this study is to identify ways to build research capacity within primary health. A consultation was undertaken in late 2004 using a combination of a one-page survey and a guided meeting format, in a primary health setting in rural NSW. Most (81.3%) of the 134 individuals consulted were part of an Area Health Service, with 12.7% from non-government settings. Most (80.6%) were clinicians, with a third (31.5%) nurses, 8.3% in medicine, and the remainder from a range of allied health professions. Eleven organisations were represented. The main  outcome measures were identification of support needs, processes to enhance research engagement, and barriers and enablers to clinicians’ research  involvement. The results showed that popular delivery modes for research training and support were courses and “one-to- one” advice. Writing topics were generally more popular than others. Common barriers were time and technology issues. A key enabler was a discipline-specific focus. This is one of few rural Australian  consultations on research needs in primary health conducted with a diverse  range of clinicians at the clinician level. It will direct future research capacity  building efforts towards maximising face-to-face discipline specific options and  minimising technology use.

Investigating people management issues in a third sector health care organisation - an inductive approach

Objective : To explain use of inductive convergent interviewing to generate the perceived critical people management issues, as perceived by staff, as a prelude to longitudinal surveys in a third sector health care organisation.

Design : Convergent interviewing is a qualitative technique that addresses research topics that lack theoretical underpinning and is an inductive, flexible, evolving research approach. The key issues converged after six rounds of interviews as well as a further round to ensure that all of the common people management issues had been generated.

Setting : Studies in employee behaviour in the health care industry exist, but there is little in the way of tested models of predictors of such behaviour in third sector organisations in the Australian health care industry. The context is what differentiates this study covering a range of facilities and positions in hospitals and aged care situations within one third sector health care organisation.

Subjects : The study proposed twenty seven extensive interviews over a range of facilities and positions. Twenty one interviewees participated in the final convergent process.

Conclusions : Critical issues included: workload across occupational groups, internal management support, adequate training, the appropriate skill mix in staff, physical risk in work, satisfaction, as well as other issues. These issues confirm the proposition of sector‑ness in health organisations that are multi‑dimensional rather than uni‑dimensional.

To integrate or not to integrate? Future considerations for chronic disease self-management programs in the health care system

Objective: The growing burden of chronic disease and the increasing realisation that the current health system is ill equipped to deal with this trend has resulted in a health policy shift away from the traditional medical model to a more patient centred approach. As such, chronic disease self-management programs (CDSMP) have emerged as a potentially important component within this approach. Policy and program trends at the international level highlight several critical factors that need to be considered by governments and health care providers alike if CDSMP are to be integrated within the broader health system. This study reviewed international and local policy literature and sought perspectives from key stakeholders to determine the value and potential for integrating a generic group-based CDSMP into the care continuum.
Method: Prominent self-management policies were identified through a comprehensive literature search. Interviews were conducted with policy makers across Australia (n=20), health practitioners (n=20) and consumers (n=42) purposefully recruited from metropolitan and rural Victoria, representing key demographics of interest including low socioeconomic areas.
Results: Whilst CDSMP were viewed as having significant potential to be integrated into the health sector it was identified that the delivery and content of CDSMP needs to be flexible in order to address the needs of people across the disease, age and care continuums. Critical issues to be addressed if CDSMP are to be successfully integrated include increasing the profile of self-management; actively engaging and training health practitioners in self-management and overcoming system barriers such as lack of integrated referral pathways and networks.
Discussion: Policy directions at the national level suggest that self-management will be a centrepiece in forthcoming chronic disease initiatives. International evidence has highlighted the requirement for a ‘suite’ of programs to adequately cater to different stages of the disease continuum, age groups, ethnic backgrounds and sociogeographical areas. Furthermore engagement with key stakeholders (particularly GPs) is identified as critical to ensure the successful integration of CDSMP into the health system.
Conclusion: Evidence suggests that CDSMP is an important facet in improving care of people with chronic conditions. Findings from this study suggest that current infrastructure and policy direction, which have been found to be critical factors in facilitating integration of CDSMP into the health sector, are either absent or inadequate in Victoria. CDSMPs are currently lacking a sustainable workforce, referral infrastructure and specific policy. Such factors need to be addressed before the integration of CDSMP can be considered across the healthcare continuum in Victoria.