Improving screening and management of latent tuberculosis infection: development and evaluation of latent tuberculosis infection primary care model.

BACKGROUND: In Australia, demand for specialist infectious diseases services exceeds capacity to provide timely management of latent tuberculosis infection (LTBI) in areas of high refugee and asylum seeker settlement. A model for treating LTBI patients in primary care has been developed and piloted in a refugee-focused primary health service (Monash Health Refugee Health and Wellbeing [MHRHW]) and a universal primary care clinic. This study reports on the development and evaluation of the model, focusing on the model feasibility, and barriers and enablers to its success. METHODS: A convergent mix-methods design was used to evaluate the model for treating LTBI patients in primary care, where a prospective cohort study of patients commencing treatment either at MHRHW or the universal primary care clinic determined the model feasibility, while focus groups with clinicians directly involved in treating these patients explored barriers and enablers to sustainability and success of the model. RESULTS: From January 2017 to April 2018, 65 patients with confirmed LTBI presented at participating clinics. Treatment was accepted by 31 (48%) patients, of whom 15(48%) were treated at MHRHW and 16 (52%) at the universal primary care clinic. The 6-months' treatment completion rate was higher at MHRHW compared to the universal primary care clinic (14 (93%) compared to 9 (56%) respectively, p = 0.0373). Reasons for non-completion included adverse reaction, opting out and relocation. At the completion of the pilot, 15 clinicians participated in two focus groups. Clinicians identified barriers and enablers for successful LTBI management at patient, provider, organisational and clinical levels. While barriers for treatment completion and adherence were consistent across the two pilot sites, enablers, such as resources to facilitate patient education and follow-up, were available only at MHRHW. CONCLUSION: Screening and management of LTBI patients can be achieved within the primary care setting, considerate of barriers and enablers at patient, provider, organisational and clinical levels. Upscaling of a primary care response to the management of LTBI will require supporting primary care clinics with resources to employ dedicated clinical staff for patient education, follow-up communication and monitoring medication adherence.

The association of migration experiences on the self-rated health status among adult humanitarian refugees to Australia: an analysis of a longitudinal cohort study.

BACKGROUND: Refugees are potentially at an increased risk for health problems due to their past and current migration experiences. How migration factors shape refugee health is not well understood. We examined the association between migration factors and the self-rated general health of adult humanitarian refugees living in Australia. METHODS: We analyzed the first three waves of data from the 'Building A New Life In Australia' longitudinal survey of 2399 humanitarian refugees resettled in Australia. The study outcome was self-rated health measured by the 36-Item Short Form Health Survey. Predictors were migration process and resettlement factors. We used generalized linear mixed models to investigate the relationship between predictor and outcome variables. RESULTS: Poor general health persisted among this refugee population at high levels throughout the three-year follow-up. At baseline, 35.7% (95% CI: 33.8-37.7%) of the study population reported poorer general health. Female gender, increasing age and post-migration financial stressors were positively associated with poorer general health. Having a university degree and absence of chronic health conditions were seemingly protective against declining general health (OR: 0.50; 95% CI: 0.65-1.81 and OR: 0.15, 95% CI: 0.09-1.04, respectively). CONCLUSION: Our results show that there is persisting high prevalence of poorer general health among adult refugees across the initial years of resettlement in Australia. This finding suggests unmet health needs which may be compounded by the challenges of resettlement in a new society, highlighting the need for increased clinical awareness of this sustained health burden to help inform and prepare refugee health care and settlement service providers.

An investigation into the association of pre- and post-migration experiences on the self-rated health status among new resettled adult humanitarian refugees to Australia: a protocol for a mixed methods study.

BACKGROUND: Refugees are one of the most vulnerable groups in our society. They are at risk of poor physical and mental health outcomes, much of this attributed to traumatic events prior to migration and the additional risk factors refugees face in the host nations. However, how migration factors shape the health of resettling refugees is not well understood. This study uses a mixed methods approach to examine how pre- and post-migration factors shape the self-rated health of resettling adult refugees in an effort to address the current knowledge gap. METHODS: This study will use a sequential explanatory mixed method study design. We begin by analyzing resettlement and health data from the 'Building a New Life In Australia' longitudinal study of humanitarian refugees resettled in Australia to identify significant associations between migration factors and refugee health. Then, a series of semi-structured interviews with resettled refugees will further explore the lived experiences of refugees with respect to the relationship between migration and refugee health. Finally, we will integrate both sets of findings to develop a detailed understanding of how and why migratory factors contribute to refugee health during resettlement. DISCUSSION: There is a paucity of studies that examine the multidimensional nature of refugee health during resettlement and as a result, little is understood about their resettlement health needs. This information is required to inform existing or new resettlement interventions to help promote or improve refugee health. To overcome these limitations in the research knowledge, this study will use a mixture of study methods to illustrate the complex and multifaceted determinants of refugee health during resettlement in Australia.

What proportion of paediatric specialist referrals originates from general practitioners?

AIM: To determine (i) the proportion of different referral sources for new referrals to paediatric specialist outpatient clinics and (ii) any association of referral source with utilisation of additional health services. METHODS: Survey of parents presenting with their child at five paediatric specialist outpatient clinics at two Melbourne public hospitals. RESULTS: Just over half (52%) of the respondents were referred by a general practitioner (GP). The remainder were referred by a paediatrician (27%) at hospital discharge (16%) or from the ED (6%). Most respondents (71%) reported that their child also has a referral to see another specialist for the same health concern but had not yet had the consultation; 44% had consulted another doctor for the same health concern between receiving the referral and the appointment. Paediatrician referrals were more likely to see another specialist for the same health concern compared to other referral sources (P = 0.032). CONCLUSION: Only half of the referrals of new patients to paediatric specialist outpatient clinics come from GPs. Future research should investigate whether multiple referral sources have a negative impact on the co-ordination and cost of paediatric health care.

Children referred for specialty care: Parental perspectives and preferences on referral, follow-up and primary care.

AIM: Over the last decade, there has been a dramatic increase in the number of referrals for paediatric subspecialty care and in overall appointments (new and review) to these doctors. We sought to determine the perspective of parents regarding their role in the initiation of referrals, their preferences for follow-up and the role of general practitioners (GPs) in care co-ordination. METHODS: Self-completed survey in outpatient paediatric clinics (general paediatrics and four subspecialties) at two children's hospitals in Victoria. Recruitment targets were 100 parents in each of the general paediatrics clinics and 50 parents in each subspecialty clinic, equally divided between new and review visits (total n = 600). RESULTS: A total of 606 parents provided responses, with a decline rate of 9%. Many (52%) new patients were referred by a GP with the remainder from a variety of other sources. With specific regard to providing general care to their child, only 45% were completely confident in a GP. Most (76%) agreed with the statement that a GP would give their child a referral to see a paediatrician whenever they ask. Approximately, a third of parents reported that a GP rarely or never co-ordinates the care of their child with other doctors. CONCLUSIONS: Parents play an important role in both the initiation of paediatric specialty referrals and the patterns of follow-up care provided. Parent perspectives, preferences and motivations on both the referral process and the patterns for ongoing care are essential to develop policies that provide the best and most efficient care for children.

Paediatrician perceptions of patient referral and discharge.

Objective The aim of the present study was to determine the factors involved in the decision of paediatric specialists to discharge patients back to their primary care provider following referral. Return of patients to primary care, when medically appropriate, is essential to provide efficient care to children given the limited workforce of paediatric subspecialists in Australia. Methods Data were compiled from a self-completed mail survey of all paediatricians in five specialties at two children's hospitals in Melbourne (n=81). Analysis involved frequency distributions and descriptive analyses, followed by bivariate analyses to determine the differences, if any, among respondents based on the demographic variables collected. Results The response rate was 91%. Most paediatricians (73%) believed that at least sometimes referrals were for a condition general practitioners (GPs) should be able to manage themselves. However, only 36% reported that they frequently or almost always provided the referring GP with information on how to care for the particular condition without a referral. Concerns regarding whether a patient would receive required care following discharge were felt to be important by most paediatricians. Further, many paediatricians reported that their discharge decision is affected by concerns it would be too complicated to arrange for a GP to take over the care of a patient. Conclusions Understanding the factors involved in the referral process and the decision to discharge patients from speciality care clinics to primary care is essential to develop strategies to address long waiting times. Ensuring appropriate referral of children involves the participation of GPs, parents and specialists. What is known about the topic? Most paediatric subspecialists practice in paediatric hospitals, where there is a sufficient volume of patients requiring their services. There have been reports across Australia of increased referrals to general and subspecialist paediatricians, with subsequent increases in waiting times and difficulties accessing timely care for children. There are anecdotal reports of inappropriate referrals to paediatric subspecialty clinics. What does this paper add? There is broad sentiment among paediatric specialists that they receive many referrals from GPs without either a clear rationale for the referral and/or sufficient information regarding the clinical history of the patient. Few paediatricians report contacting the referring GP to obtain additional information. Paediatricians believe parents are a frequent driver of both necessary and unnecessary referrals. What are the implications for practitioners? Understanding the factors involved in the referral process and the decision to discharge patients from speciality care clinics to primary care is essential to develop strategies to address long waiting times.

Private general paediatric care availability in Melbourne.

Objective The aims of the present study were to determine the actual availability of private general paediatric appointments in the Melbourne metropolitan region for children with non-urgent chronic illnesses and the cost of such care. Methods A 'secret shopper' method was used. Telephone calls were made to a random sample of 47 private paediatric clinics. A trained research assistant posed as a parent, requesting the first available appointment with a specific paediatrician. Data regarding appointment availability, total potential charges and net charges after the Medicare rebate were collected. Results Appointments were available in 79% (n=37) of clinics, with 72% (n=34) able to offer an appointment with the requested general paediatrician. The number of days until available appointments varied from same day appointments to a wait of 124 days, with an average wait of 33 days. Of practices that provided information about the appointment cost (n=42), five bulk-billed for the consultation, whereas the remainder (n=37) were fee-paying clinics. The potential maximum charge for an initial consultation in the fee-paying clinics ranged from A$177 to A$430, with an average cost of A$279. The potential maximum out-of-pocket cost for patients ranged from A$40 to A$222, with an average out-of-pocket cost of A$128. Conclusions Private paediatric care in the Melbourne metropolitan region is generally available. The out-of-pocket cost of private paediatric out-patient care may present a potential economic barrier for some families. What is known about the topic? In Australia, out-of-pocket expenses for private specialist care are not covered by private health insurance. There are no data available on the actual cost of private paediatric consultations that are based on real-time assessments. Data collected in 1998 suggested that the average waiting time for a first standard consultation with a general paediatrician in a private room was 14.1 days. There are no recent empirical data on appointment availability and waiting time for appointments with general paediatricians in Australia. What does this paper add? There is high availability of paediatric consultations in the private sector. Waiting times for an appointment vary considerably from same day appointments to a wait of 124 days, with an average wait of 33 days. The cost of a private paediatric consultation in Australia to the patient is considerable, with an average potential maximum up-front charge for an initial consultation of A$279 and an average potential maximum out-of-pocket cost of A$128. What are the implications for practitioners? Data on the availability and cost of private paediatric consultations are imperative to formulate evidence-informed policy and better understand variations in the availability of public and private care.

Parental preferences for paediatric specialty follow-up care.

Objective The aim of the present study was to examine factors associated with: (1) parental preference to receive follow-up care for their child from a general practitioner (GP); and (2) a decision to seek treatment when there is a slight worsening of their child's condition. Methods Parents presenting with their child at any one of five paediatric out-patient clinics at two public hospitals in Melbourne (Vic., Australia) were surveyed. We performed frequency distributions, bivariate analyses and multivariate logistic regression to evaluate associations with the preference for a GP for follow-up care and treatment in case of a slight worsening. Results In all, 606 parents were recruited to the study, 283 being new presentations and 323 presenting for review. GPs were selected as the preference for follow-up care by 23% (n=142) of respondents, and 26% (n=160) reported they would seek treatment from a GP if the condition of their child were to worsen slightly. There was an increased likelihood to prefer a GP for follow-up care for new patients (odds ratio (OR) 3.10; 95% confidence interval (CI) 1.99-4.83), those attending general paediatrics clinic (OR 1.73; 95% CI 1.11-2.70), and parents with a lower level of education (OR 1.74; 95% CI 1.09-2.78). For review patients, if during the previous visit a paediatrician suggested follow-up with a GP, parents were more likely to prefer a GP as a follow-up provider (OR 6.70; 95% CI 3.42-13.10) and to seek treatment from a GP in case of a slight worsening (OR 1.86; 95% CI 1.03-3.37). Conclusion Most parents attending paediatric out-patient appointments prefer to return for follow-up care; however, a paediatrician's advice may have an important role in return of paediatric patients to primary care. What is known about the topic? In Australia, there has been a growing concern regarding long waiting times for specialist consultations in out-patient clinics and difficulties with access for new patients. This has occurred when the ratio of review attendees to new patients has tipped towards the review attendees. What does this paper add? Most parents of children attending paediatric out-patient clinics value follow-up care with paediatric specialists, even if the referring GP requested a return to their surgery. The advice of the consulting paediatrician in support of follow-up care with a GP contributes significantly to the willingness of parents to return to primary care and to seek treatment from their GP for a slight worsening of their child's condition. What are the implications for practitioners? The findings of the present study have significant implications for the discharge of patients from speciality care: paediatricians can have an important role in the return of paediatric patients to primary care.

Motivators and barriers for paediatricians discharging patients.

The aim of this study was to identify motivators and barriers that paediatricians face when discharging patients from outpatient specialty care. A questionnaire was administered to outpatient care paediatricians in Victoria working in one of five speciality public hospital clinics. Questions focused on how important various motivators and barriers were in respondents' decision to discharge a patient from their clinic. Nearly all (91%, n=74) paediatricians invited to participate provided responses. The factor influencing the greatest proportion of paediatricians in their decision to discharge patients back to primary care was the potential that patients may not receive the required care from a GP. The next most highly rated barrier was that it is too complicated to arrange discharge; rated as a very important influence by one-third of paediatricians (33%, n=24). Improvements to the discharge process may encourage more paediatricians to discharge patients back to their GP, therefore freeing up appointment slots. This in turn could reduce waiting times for paediatric outpatient clinics in Victoria. The concern from paediatricians that patients may not receive the required care from a GP warrants attention and should be further investigated.

Perspectives of Australian general practitioners on shared care for paediatric patients.

Australian general practitioners (GPs) are seeing proportionally fewer paediatric patients. GPs may be increasingly relying on secondary or tertiary care physicians to provide care to children with complex, chronic conditions. Shared-care initiatives may provide a solution to the apparent increasing dependence of GPs on paediatric specialists, although, currently, evidence is lacking about both the prevalence and composition of shared care for children in Australia. We invited 377 GPs in Melbourne, Australia, who had referred at least two children to specialist paediatric outpatient clinics within the 2014 calendar year, to participate in a mailed survey study. Items analysed for the present report included those relating to shared-care arrangements between GPs and paediatric specialists. Responses were received from 254 GPs (response rate 67%). The majority (90%) of GPs in our study have been involved in shared-care arrangements with outpatient paediatricians. We found wide variation in the success of these arrangements, measured through the ability of GPs to establish clear roles with paediatricians. For a national discussion around shared care to be productive, clear definitions and classifications will be crucial. Future research could investigate the reasons for variability in shared care in Australia, and examine optimal shared-care arrangements for children.

General practitioner perspectives on referrals to paediatric public specialty clinics.

BACKGROUND: Changes in the demography of Australia have resulted in changes in patterns of primary care delivery. One of these changes is that the proportion of paediatric visits has decreased. OBJECTIVE: The objectives of the article are to examine patient, practice and personal factors that influence a general practitioner's (GP's) decision to refer patients for paediatric specialty care, and investigate referral goals and experience with shared care. METHODS: A mail survey was sent out to 400 GPs who had referred at least two children to public hospital specialty clinics during 2014. RESULTS: The response rate for the mail survey was 67%. The factors most commonly reported by GPs as 'Somewhat important' or 'Very important' in the decision to refer were whether they had enough knowledge of a specific condition (81%) or did not have experience with similar patients (75%). About one-quarter (26%) of GPs reported that a parental request 'Frequently' or 'Almost always' influenced their referral decision. A similar pro-portion (26%) placed importance on whether they had sufficient time for a specific patient. DISCUSSION: Understanding the perspectives and determinants of GP referrals for paediatric specialty care is important, especially in the context of changing patterns of primary care delivery.

General practitioners' challenges during the 2009/A/H1N1 vaccination campaigns in Australia, Israel and England: a qualitative study.

BACKGROUND: The 2009/A/H1N1 influenza vaccination campaign was managed mainly by general practitioners (GPs); however, little is known about the challenges GPs encountered during the vaccination campaign. AIM: To analyse the challenges GPs encountered during the 2009/A/H1N1 vaccination campaign. METHODS: In-depth, semi-structured qualitative interviews were conducted with GPs in Australia, Israel and England, and subjected to thematic analysis. RESULTS: GPs experienced different levels of autonomy when organising vaccinations in clinics. Their significant role was the provision of advice about the vaccine to the patients. This role was challenged by the necessity to provide the advice as a response to the anti-vaccination messages in the media and because GPs harboured doubts about mass vaccination policies. DISCUSSION: It is important that GPs accept the rationale behind vaccination campaigns and should be given accurate information about the vaccine before the campaign commences. Trustful, two-way channels for communication between GPs and public health authorities should also be established.

Influenza pandemic 2009/A/H1N1 management policies in primary care: a comparative analysis of three countries.

BACKGROUND: During the influenza pandemic 2009/A/H1N1, the main burden of managing patients fell on primary care physicians (PCP). This provided an excellent opportunity to investigate the implications of pandemic policies for the PCP role. AIM: To examine policies affecting the role of PCP in the pandemic response in Australia (in the state of Victoria), Israel and England. METHODS: Content analysis of the documents published by the health authorities in Australia, Israel and England during the pandemic 2009/A/H1N1. RESULTS: The involvement of PCP in the pandemic response differed among the countries in timing and allocated responsibilities. The Israeli approach during the containment phase was to maximise the protection of PCP at the expense of putting pressure on hospitals where the suspected cases were tested and treated. In Australia and England, PCP managed the suspected patients from the beginning of the pandemic. The work of PCP in England was supported by the introduction of the National Pandemic Flu Service during the mitigation phase, whereas Australian PCP had no additional support structures and their role was constant and intensive throughout the pandemic period. CONCLUSION: Health authorities need to engage with representatives of PCP to evaluate policies for pandemic planning and management. Adequate support and protection for PCP during different stages of pandemic management should be provided. What is known about the topic? During the influenza pandemic 2009/A/H1N1, the main burden of diagnosing and managing the patients fell on PCP. The prominent role of PCP in the 2009/A/H1N1 pandemic presents an excellent opportunity to investigate implications of pandemic policies for primary care and to tackle the possible problems that these policies may impose on the ability of PCP to effectively participate in the public health response. What does this paper add? This paper examines policies that affected the roles of PCP in managing the influenza pandemic 2009/A/H1N1 in three countries: Australia, Israel and England. Although general evaluations of the pandemic response in different countries have previously been reported, this is the first study that focuses on policies for pandemic management at the primary care level. What are the implications for practitioners? Practitioners (PCP and primary care workers in general) would benefit if pandemic preparedness plans were constructed to provide an adequate system of support and protection to primary care workers during different stages of pandemic management. For policy makers, this analysis may help to overhaul the strategies for primary care engagement in the pandemic response.

Providing Care by Telephone to Refugees and Asylum Seekers: An Evaluation of Telephone Mode-of-Care in Monash Health Refugee Health and Wellbeing Clinic in Victoria, Australia.

An evaluation of accessibility, appropriateness, acceptability and efficiency of telephone consultations, implemented at Monash Health Refugee Health and Wellbeing (MH RHW) throughout the COVID-19 pandemic, was conducted. A convergent mix-methods design was used, with both patients (n = 50) and clinicians (n = 11) participating in a survey, and two focus groups (n = 14) involving clinicians being conducted. Service utilization data was sourced from the MH RHW database. During May to December 2020, 61% (n = 3012) of the consultations were conducted by telephone, 42% (n = 11) of these required interpreters in a 3-way conversation Most patients were satisfied with telephone as a medium for providing care and with the quality of telephone-based care. Similarly, clinicians considered telephone consultations to be an acceptable mode-of-care for most patients during the pandemic, however, expressed caution in relation to certain patient cohort. Finally, the provision of care by telephone was considered no more efficient than face-to-face service provision, as reflected in the time required for each consultation, with some clinicians reporting adverse workload outcomes. This study highlighted the benefits and challenges of telephone consultations from patient and clinician perspectives. It also highlighted the types of patients that may not be suited to telephone consultations. Overall, this study showed that telephone service delivery is a feasible option in providing care to people of refugee background and should be considered in future decisions as an ongoing Medicare (Australia's universal healthcare insurance scheme) billing item. However, clinical discretion should prevail in determining the most appropriate means of delivering care.

Improving access for the vulnerable: a mixed-methods feasibility study of a pop-up model of care in south-eastern Melbourne, Australia.

Access to appropriate health and social care is challenging for vulnerable populations. We used a 'pop-up' delivery model to bring community-based services in contact with communities with poor access to health and social care. Our aim was to examine whether pop-up events improve access to essential health and social support services for selected vulnerable communities and increase collaboration between community-based health and social services. Set in south-eastern Melbourne, two pop-up events were held, one with people at risk of homelessness attending a community lunch and the other with South Sudanese women helping at-risk youth. Providers represented 20 dental, housing, justice, employment and mental health services. We made structured observations of each event and held semi-structured interviews with consumers and providers. Pre-post surveys of managers assessed acceptability and perceived impact. We reached 100 community participants who had multiple needs, particularly for dentistry. Following the events, participants reported increased knowledge of services and access pathways, community members spoke of increased trust and partnerships between service providers were fostered. The pop-up model can increase provider collaboration and provide new options for vulnerable populations to access needed services. 'Bringing the service to the person' is a compelling alternative to asking consumers to negotiate complex access pathways.

Increased extent of and risk factors for pandemic (H1N1) 2009 and seasonal influenza among children, Israel.

During the pandemic (H1N1) 2009 outbreak in Israel, incidence rates among children were 2× higher than that of the previous 4 influenza seasons; hospitalization rates were 5× higher. Children hospitalized for pandemic (H1N1) 2009 were older and had more underlying chronic diseases than those hospitalized for seasonal influenza.

General practitioners' knowledge and use of an urban Australian hospital General Practice Liaison service: A qualitative study.

BACKGROUND AND OBJECTIVES: Strong integration between primary and secondary healthcare is essential. Health services across Australia have developed General Practice Liaison (GPL) services to improve communication and understanding between general practitioners (GPs) and hospitals. The aim of this study was to explore GPs' experiences of and interaction with a health service's GPL service and capture perspectives concerning future service expansion. METHOD: This descriptive qualitative study used semi-structured interviews with 10 GPs in the catchment area of a large urban health service in Melbourne in 2018. Data were analysed thematically. RESULTS: While GPs accepted the value of a GPL service, few had direct experience. Acknowledging the challenge of negotiating complex healthcare systems, they saw GPL services ideally staffed by a health professional, not necessarily a GP. DISCUSSION: The results provide insight into what GPs want from a GPL service. This can inform development of the GPL role within health services.

Access to care: a qualitative study exploring the primary care needs and experiences of older people needing assistance with daily living.

Older people who live in the community and need assistance with daily activities are a unique group of patients to treat in the primary care (PC) setting. This study aimed to understand access-related PC needs and experiences of community-living people over 65 years of age receiving home-based assistance through the Home and Community Care (HACC) program in Melbourne, Australia. This descriptive qualitative study used thematic analysis of in-depth interviews with HACC program clients and assessment officers. Access-related needs and experiences were examined using the patient-centred access to care framework. Client (n=11) and assessment officer (n=4) interviews showed that community-living older people receiving home-based assistance from social services are able to find a GP according to their preferences; however, some challenges in access to comprehensive care exist. These challenges relate to regularity of PC attendance, out-of-pocket fees for specialist care and maintaining an enduring patient-GP relationship. GPs can play an important role in improving PC access for vulnerable older people. In particular, GPs can contribute to improving PC attendance and facilitating more affordable access to specialist care by improving systems to recall patients more regularly and developing explicit systems for linking vulnerable patients to affordable specialist services.

How general practitioners perceive access needs of vulnerable patients and act to address these needs: a mixed-methods study in south-east Melbourne, Australia.

Objective The aim of this study was to understand primary health care (PHC) access barriers for vulnerable people living in south-east Melbourne from the perspective of general practitioners (GPs) who work in the area and to outline strategies that GPs have used to address these barriers. Methods A convergent mixed-methods design was used. Quantitative surveys were conducted with practice managers and GPs, and semistructured qualitative interviews were undertaken with GPs. Data were analysed using a thematic framework approach. Results Each of the vulnerable groups frequently seen by GPs in south-east Melbourne is thought to encounter access barriers in one or more access domains. GPs reported: (1) improving transparency, outreach and information on available treatments to address limited health literacy; (2) using culturally sensitive and language-speaking staff to overcome cultural stereotypes; (3) making practice-level arrangements to overcome limited mobility and social isolation; (4) bulk billing and helping find affordable services to overcome financial hardship; and (5) building trusting relationships with vulnerable patients to improve their engagement with treatment. Conclusion GPs understand the nature of access barriers for local vulnerable groups and have the potential to improve equitable access to primary health care. GPs need support in the on-going application and further development of strategies to accommodate access needs of vulnerable patients. What is known about the topic? Access to primary health care (PHC) is integral to reducing gaps in health outcomes for vulnerable groups. Vulnerable groups often encounter challenges in accessing PHC, and GPs have the potential to improve PHC access. What does this paper add? GPs thought that the vulnerable patients they frequently treat encounter barriers pertaining to both patient access abilities and service accessibility. They reported addressing these barriers by improving transparency, outreach and information on available treatments; using culturally sensitive and multilingual staff; making practice-level arrangements to overcome limited mobility and social isolation; bulk billing and helping find affordable services; and building trusting relationships with vulnerable patients. What are the implications for practitioners? Understanding the nature of access barriers for local vulnerable groups and information on strategies used by GPs allows for the further development of PHC access strategies.

Improving access to primary healthcare for vulnerable populations in Australia and Canada: protocol for a mixed-method evaluation of six complex interventions.

INTRODUCTION: Access to primary healthcare (PHC) has a fundamental influence on health outcomes, particularly for members of vulnerable populations. Innovative Models Promoting Access-to-Care Transformation (IMPACT) is a 5-year research programme built on community-academic partnerships. IMPACT aims to design, implement and evaluate organisational innovations to improve access to appropriate PHC for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three Australian states (New South Wales, Victoria and South Australia) and three Canadian provinces (Ontario, Quebec and Alberta) used a common approach to implement six different interventions. This paper describes the protocol to evaluate the processes, outcomes and scalability of these organisational innovations. METHODS AND ANALYSIS: The evaluation will use a convergent mixed-methods design involving longitudinal (pre and post) analysis of the six interventions. Study participants include vulnerable populations, PHC practices, their clinicians and administrative staff, service providers in other health or social service organisations, intervention staff and members of the LIP teams. Data were collected prior to and 3-6 months after the interventions and included interviews with members of the LIPs, organisational process data, document analysis and tools collecting the cost of components of the intervention. Assessment of impacts on individuals and organisations will rely on surveys and semistructured interviews (and, in some settings, direct observation) of participating patients, providers and PHC practices. ETHICS AND DISSEMINATION: The IMPACT research programme received initial ethics approval from St Mary's Hospital (Montreal) SMHC #13-30. The interventions received a range of other ethics approvals across the six jurisdictions. Dissemination of the findings should generate a deeper understanding of the ways in which system-level organisational innovations can improve access to PHC for vulnerable populations and new knowledge concerning improvements in PHC delivery in health service utilisation.