The impact on patients of the tertiary-primary healthcare interface in kidney failure: a qualitative study.

BACKGROUND: Clinicians and patients have reported fragmentation in the primary and tertiary healthcare interface. However, perspectives of service navigation and the impacts of fragmentation are not well defined, particularly for patients transitioning to dialysis. This study aimed to define patient perspectives of the functioning of the health service interface and impacts on healthcare experiences and engagement, informing patient-centred and outcomes-focused service models. METHODS: A qualitative study was conducted through semi-structured interviews with 25 dialysis patients (16 males) aged 34-78 receiving dialysis across a multi-site tertiary service. Transcripts were analysed thematically. RESULTS: Three main themes were identified: (1) The Changing Nature of General Practitioner (GP) Patient Relationships; (2) Ownership and Leadership in Kidney Care; and (3) The Importance of Nephrologist-GP Communications. Patients perceived an unreliable primary-tertiary service interface which lacked coordinated care and created challenges for primary care continuity. These impacted perceptions of healthcare provider expertise and confidence in healthcare systems. Patients subsequently increased the healthcare sought from tertiary kidney clinicians. The fractured interface led some to coordinate communication between health sectors, to support care quality, but this caused additional stress. CONCLUSIONS: A fragmented primary-tertiary healthcare interface creates challenges for patient service navigation and can negatively impact patient experiences, leading to primary care disengagement, reduced confidence in health care quality and increased stress. Future studies are imperative for assessing initiatives facilitating health system integration, including communication technologies, healthcare provider training, patient empowerment, and specific outcomes in health, economic and patient experience measures, for patients transitioning to dialysis.

Building chronic disease management capacity in General Practice: The South Australian GP Plus Practice Nurse Initiative.

AIM: This paper draws on the implementation experience of the South Australian GP Plus Practice Nurse Initiative in order to establish what is needed to support the development of the chronic disease management role of practice nurses. BACKGROUND: The Initiative was delivered between 2007 and 2010 to recruit, train and place 157 nurses across 147 General Practices in Adelaide. The purpose was to improve chronic disease management in General Practice, by equipping nurses to work as practice nurses who would coordinate care and establish chronic disease management systems. METHOD: Secondary analysis of qualitative data contained in the Initiative evaluation report, specifically drawing on quarterly project records and four focus groups conducted with practice nurses, practice nurse coordinators and practice nurse mentors. FINDINGS: As evidenced by the need to increase the amount of support provided during the implementation of the Initiative, nurses new to General Practice faced challenges in their new role. Nurses described a big learning curve as they dealt with role transition to a new work environment and learning a range of new skills while developing chronic disease management systems. Informants valued the skills development and support offered by the Initiative, however the ongoing difficulties in implementing the role suggested that change is also needed at the level of the Practice. While just over a half of the placement positions were retained, practice nurses expressed concern with having to negotiate the conditions of their employment. CONCLUSION: In order to advance the role of practice nurses as managers of chronic disease support is needed at two levels. At one level support is needed to assist practice nurses to build their own skills. At the level of the Practice, and in the wider health workforce system, support is also needed to ensure that Practices are organisationally ready to include the practice nurse within the practice team.

Improving communication between health-care professionals and patients with limited English proficiency in the general practice setting.

Quality service provision and patient safety and satisfaction in encounters with health-care professionals relies on effective communication between the practitioner and patient. This study aimed to identify effective practices for improving communication between clinical staff in general practice and patients with limited English proficiency, and to promote their implementation in general practice. Effective interventions and strategies were identified from a review of international research. Experiences with their use in practice were explored via focus group discussions with general practitioners and practice nurses. The results suggest that, wherever possible, communication in the patient's primary language is preferable; use of a qualified medical interpreter should be promoted, and practices should have a standardised and documented procedure for accessing interpreter services. General practice staff must increase their awareness about services that are available to facilitate communication with patients with limited English proficiency, and also develop attitudes, both individual and organisational, that will maximise the effectiveness of these strategies. These findings were used to develop brief, evidence-based practice guidelines that were disseminated to focus group participants for evaluation of utility and general feedback. This evidence-based guidance is now available to assist clinical and administrative general practice staff across regional and metropolitan South Australia.

A focus on health promotion and prevention through the development of the national men's health policy.

ISSUES ADDRESSED: The Australian Government announced its intention to develop a national men's health policy in June 2008. A focus on prevention was identified as a foundation principle that would underpin the development of this policy. This brief report provides a descriptive account of the key discussion points relating to health promotion and prevention during a National Men's Health Roundtable held in Canberra in March 2009. METHODS: Invitations to the Roundtable were extended to peak professional organisations and national health bodies with an interest in men's health. Presentations from the National Preventative Health Taskforce, the National Primary Health Care External Reference Group and National Men's Health Ambassadors were used to provoke discussion relating to men's health. RESULTS: The most salient issues that were raised at the Roundtable and that were specific to health promotion and prevention contexts included the need to clearly define key terms that relate to health promotion and prevention (to support a joined-up and health-in-all-policies approach); acknowledge that gender intersects with other social determinants of health; recognise that men's engagement though health promotion and primary healthcare services can be improved by using settings-based approaches more widely; a greater focus on men's health literacy; a universal funding system to support men's health promotion; clarity about the roles and responsibilities that various health professionals play in improving the status of men's health; and the need to build health equity between and within specific populations of men through action on the social determinants of health. CONCLUSION: Recognising the place of health promotion and illness prevention in a national men's health policy will provide the necessary platform to build critical health literacy among men, promote equitable access to primary healthcare services and better support men's engagement within the health system.

Introduction of electronic prescribing in an aged care facility.

Residents of aged care facilities are at high risk of adverse drug events. Electronic prescribing may reduce some of these risks. This article reports on the introduction of electronic prescribing software to a residential aged care facility with the aim of improved medication safety.