Critical Success Factors for Intersectoral Collaboration: Homelessness and COVID-19 - Case Studies and Learnings from an Australian City.

Introduction: The COVID-19 pandemic disproportionally impacted people experiencing homelessness, including people sleeping rough, people in temporary accommodation and those living in boarding houses. This paper reports on intersectoral responses across six health and social care agencies in Inner Sydney, New South Wales, Australia. Prior to the pandemic the six agencies had established an Intersectoral Homelessness Health Strategy (IHHS), in recognition of the need for intersectoral collaboration to address the complex health needs of people experiencing homelessness. Description: The governance structure of the IHHS provided a platform for several innovative intersectoral responses to the pandemic. A realist informed framework was used to select, describe, and analyse case studies of intersectoral collaboration. Discussion: The resultant six critical success factors (trust, shared ways of working, agile collaboration, communication mechanisms, authorising environment, and sustained momentum), align with the existing literature that explores effective intersectoral collaboration in complex health or social care settings. This paper goes further by describing intersectoral collaboration 'in action', setting a strong foundation for future collaborative initiatives. Conclusion: While there is no single right approach to undertaking intersectoral collaboration, which is highly context specific, the six critical success factors identified could be applied to other health issues where dynamic collaboration and integration of healthcare is needed.

Screening patients in general practice for advanced chronic liver disease using an innovative IT solution: The Liver Toolkit.

BACKGROUND: Identifying patients with undiagnosed advanced chronic liver disease (ACLD) is a public health challenge. Patients with advanced fibrosis or compensated cirrhosis have much better outcomes than those with decompensated disease and may be eligible for interventions to prevent disease progression. METHODS: A cloud-based software solution ("the Liver Toolkit") was developed to access primary care practice software to identify patients at risk of ACLD. Clinical history and laboratory results were extracted to calculate aspartate aminotransferase-to-platelet ratio index and fibrosis 4 scores. Patients identified were recalled for assessment, including Liver Stiffness Measurement (LSM) via transient elastography. Those with an existing diagnosis of cirrhosis were excluded. RESULTS: Existing laboratory results of more than 32,000 adults across nine general practices were assessed to identify 703 patients at increased risk of ACLD (2.2% of the cohort). One hundred seventy-nine patients (26%) were successfully recalled, and 23/179 (13%) were identified to have ACLD (LSM ≥10.0 kPa) (10% found at indeterminate risk [LSM 8.0-9.9 kPa] and 77% low risk of fibrosis [LSM <8.0 kPa]). In most cases, the diagnosis of liver disease was new, with the most common etiology being metabolic dysfunction-associated steatotic liver disease (n=20, 83%). Aspartate aminotransferase-to-platelet ratio index ≥1.0 and fibrosis 4 ≥3.25 had a positive predictive value for detecting ACLD of 19% and 24%, respectively. Patients who did not attend recall had markers of more severe disease with a higher median aspartate aminotransferase-to-platelet ratio index score (0.57 vs. 0.46, p=0.041). CONCLUSIONS: This novel information technology system successfully screened a large primary care cohort using existing laboratory results to identify patients at increased risk ACLD. More than 1 in 5 patients recalled were found to have liver disease requiring specialist follow-up.

Diverse and vulnerable: experiences of private allied health practices managing through the coronavirus (COVID-19) pandemic. Implications for the financial viability of Australian primary care.

Background The majority of allied health services are delivered by small, private practices in the primary care setting with limited government funding. During the coronavirus disease 2019 (COVID-19) lockdowns these practices were subject to the same health orders as any other private business with only 'essential services' permitted to remain open. Research aim We set out to understand the impact of the COVID-19 pandemic, and associated public health measures, on the financial viability of private allied health practices. Methods Thirteen semi-structured interviews were conducted with primary care allied health practice owners and managers in Sydney. Data were analysed thematically. Findings All of the interviewees reported experiencing the stress of balancing precarious finances caused by reduced and/or fluctuating patient demand. Patients' reluctance to seek care was compounded by ambiguity around whether allied health services were 'essential'. Manual therapies were particularly vulnerable to financial stress because their capacity to transition to telehealth and access to government funding were limited. Conversely, psychologists reported demand for their services exceeded what they could provide. Study implications The findings are indicative of primary care allied health's peripheral status in Australia's primary care landscape. Greater priority to the funding and integration of primary care allied health is needed in primary care policy.

Determinants of well-being and their interconnections in Australian general practitioners: a qualitative study.

OBJECTIVES: The well-being of doctors is recognised as a major priority in healthcare, yet there is little research on how general practitioners (GPs) keep well. We aimed to address this gap by applying a positive psychology lens, and exploring what determines GPs' well-being, as opposed to burnout and mental ill health, in Australia. DESIGN: Semi-structured qualitative interviews. From March to September 2021, we interviewed GPs working in numerous settings, using snowball and purposive sampling to expand recruitment across Australia. 20 GPs participated individually via Zoom. A semi-structured interview-guide provided a framework to explore well-being from a personal, organisational and systemic perspective. Recordings were transcribed verbatim, and inductive thematic analysis was performed. RESULTS: Eleven female and nine male GPs with diverse experience, from urban and rural settings were interviewed (mean 32 min). Determinants of well-being were underpinned by GPs' sense of identity. This was strongly influenced by GPs seeing themselves as a distinct but often undervalued profession working in small organisations within a broader health system. Both personal finances, and funding structures emerged as important moderators of the interconnections between these themes. Enablers of well-being were mainly identified at a personal and practice level, whereas systemic determinants were consistently seen as barriers to well-being. A complex balancing act between all determinants of well-being was evidenced. CONCLUSIONS: GPs were able to identify targets for individual and practice level interventions to improve well-being, many of which have not been evaluated. However, few systemic aspects were suggested as being able to promote well-being, but rather seen as barriers, limiting how to develop systemic interventions to enhance well-being. Finances need to be a major consideration to prioritise, promote and support GP well-being, and a sustainable primary care workforce.

Frequent users of health services among community-based older Australians: Characteristics and association with mortality.

OBJECTIVES: To investigate characteristics of frequent users of general practice (GP; ≥21 visits in a year), medical specialist (≥10 visits), emergency department (ED; ≥2 presentations) and hospital services (≥2 overnight hospitalisations) and the association with mortality for people aged over 75 years. METHODS: The study included residents from Central and Eastern Sydney, Australia, aged over 75 years who participated in a large community-dwelling cohort study. Demographic, social and health characteristics data were extracted from the 45 and Up Study survey. Health service (GP, medical specialist, ED and hospitalisations) use and mortality data were extracted from linked administrative data. We calculated adjusted prevalence ratios to identify independent characteristics associated with frequent users of services at baseline (approx. 2008) and adjusted hazard ratios to assess the association between frequent users of services and mortality. RESULTS: Frequent users of services (GPs, medical specialists, EDs and hospitals) were more likely to be associated with ever having had heart disease and less likely to be associated with reporting good quality of life. Characteristics varied by service type. Frequent users of services were 1.5-2.0 times more likely to die within 7 years compared to those who were less frequent service users after controlling for all significant factors. CONCLUSIONS: Our analysis found that frequent service users aged over 75 years had poorer quality of life, more complex health conditions and higher mortality and so their health service use was not inappropriate. However, better management of these frequent service users may lead to better health outcomes.

An evaluation of a pilot capacity building initiative for smoking cessation in social and community services: the Smoking Care project.

INTRODUCTION AND AIMS: New strategies are required to reach subpopulations with high smoking rates. This study reports on an evaluation of the Smoking Care intervention-a 2-year organisational capacity building strategy--for social and community service organisations (SCSOs) to provide smoking care to clients. DESIGN AND METHODS: The Smoking Care intervention consisted of: awareness raising seminars (half-day); smoking cessation training (1 day) and; nicotine replacement therapy grants (3 months). Baseline and 3-month follow-up data were collected within participating SCSOs and the primary outcomes measured were: changes in staff attitudes, confidence and practice of smoking cessation care. Changes in client self-reported smoking behaviours, quit attempts and interest in quitting were also measured. RESULTS: Of 600 staff who attended training, 306 (51%) returned pre- and post-intervention surveys. At 3-month follow-up staff reported statistically significant increases in positive attitudes to providing smoking cessation care, increased confidence in providing such care and increases in cessation practice. Of 400 client surveys distributed, 367 (92%) were returned at pre-intervention and 255 (64%) at post-intervention. Fewer clients reported daily smoking at post-intervention, while use of nicotine replacement therapy and group counselling increased significantly. Client interest in quitting and receiving quit support from case workers was high at both pre- and post-intervention. DISCUSSION AND CONCLUSIONS: The intervention had an impact on SCSO staff attitudes, confidence and provision of smoking care. Results show clients were receptive to this support. More rigorous testing of similar interventions in SCSOs is warranted.

The strategic development of the NSW Health Plan for Prevention of Falls and Harm from Falls Among Older People: 2011-2015; translating research into policy and practice.

With our rapidly ageing population there is an urgent imperative to minimise the rate of falls and associated injuries. A key challenge to public health is to better conceptualise and contextualise falls prevention evidence for more effective policy making and practice. This paper describes how NSW Health adopted the Nutbeam and Bauman Stages of Research and Evaluation Model in the strategic development of the NSW Health Plan for Prevention of Falls and Harm from Falls Among Older People: 2011-2015. Research evidence has been comprehensively applied to every stage of the development of the Plan and research and evaluation is a key action area within the new Plan. The Stages of Research and Evaluation Model provides a useful overarching framework for policy makers to contextualise and more effectively apply research evidence throughout the policy making process from problem definition to program monitoring.

Randomised controlled trial of health assessments for older Australian veterans and war widows.

OBJECTIVE: To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death. DESIGN: Randomised controlled trial of the effect of health assessments over 3 years. PARTICIPANTS AND SETTING: 1569 community-living veterans and war widows receiving full benefits from the Department of Veterans' Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942). INTERVENTION: Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner. MAIN OUTCOME MEASURES: Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up. RESULTS: 3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05-1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40-2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01). CONCLUSIONS: Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.