Analgesic stewardship in Australian residential aged care facilities: Retrospective audit of a collaborative approach to optimising opioid use.

OBJECTIVE: To evaluate retrospectively an analgesic stewardship role of a non-dispensing pharmacist as part of a general practice team providing primary care services to residential aged care facilities (RACF). METHODS: Our general practice implemented an analgesic stewardship program to optimise and monitor opioid usage for our patients located across 12 RACF in Canberra from March 2019 to September 2020. The primary objective was the development of a multidisciplinary chronic pain care plan to document treatment and monitoring strategies for optimising pain control. The pharmacist reviewed and documented existing pain management strategies in a care plan for each patient and discussed recommendations for optimisation with the general practitioner. The general practitioner implemented accepted recommendations and distributed finalised care plans to the RACF. A retrospective audit of care plans was undertaken to assess the outcomes: mean daily oral morphine equivalence to monitor opioid usage, and pain scores to monitor for any potential harm associated with analgesic stewardship. RESULTS: One hundred and sixty-seven residents received an initial care plan. Residents were scheduled for a follow-up care plan after 6 months, which was achieved for 100 residents (60%). Scope for optimising opioid therapy was identified for 47 residents (28%) at baseline and 23 residents (23%) at follow-up. Mean opioid usage and pain scores were reduced at follow-up; 19.4 mg (SD 40.8) versus 13.4 mg (SD 22.8), and 4.2 (SD 2.3) versus 3.9 (SD 2.0), respectively. CONCLUSIONS: A systematic, multidisciplinary analgesic stewardship approach may optimise pain management plans and reduce opioid usage in RACF residents.

Lessons from the implementation of the Health Care Homes program.

Australia's primary health care system works well for most Australians, but 20% of people live with multimorbidity, often receiving fragmented care in a complex system. Australia's 10-year plan for primary health care recognises that person-centred care is essential to securing universal health coverage, improving health outcomes and achieving an integrated sustainable health system. The Health Care Homes trial tested a new model of person-centred care for people with chronic and complex health conditions. This model demonstrated that change can be achieved with dedicated transformational support and highlighted the importance of enablers and reform streams that are now established in the 10-year plan.

Co-creating education and training programs that build workforce capacity to support the implementation of integrated health care initiatives.

Value co-creation focuses on creating value with and for multiple stakeholders - through purposeful engagement, facilitated processes and enriched experiences - to co-design new products and services. User-centred design enables multidisciplinary teams to design and develop or adapt resources from the end user's perspective. Combining value co-creation and user-centred design offers an effective, efficient, user-friendly and satisfying experience for all participants, and can result in co-created, tailored and fit-for-purpose resources. These resources are more likely to be adopted, be usable, be sustainable and produce outcomes that matter, and thereby create value for all parties. Over the past 6 years, the Education and Innovation Department at Australian General Practice Accreditation Limited has used these methods to co-create education and training programs to build workforce capacity and support implementation of many person-centred integrated care programs. In this article, we present examples of how Australian General Practice Accreditation Limited used value co-creation and user-centred design to develop and deliver education programs in primary health care, and offer insights into how program developers can use these methods to co-create any health care product, service or resource to better address end user needs and preferences. As we strive to strengthen the role of consumers as active partners in care and improve service delivery, patient outcomes and patient experiences in Australia, it is timely to explore how we can use value co-creation and user-centred design at all levels of the system to jointly create better value for all stakeholders.

Building capacity in those who deliver palliative care services to Aboriginal and Torres Strait Islander peoples.

The role of culture in palliative care for Aboriginal and Torres Strait Islander peoples builds on over 60 000 years of history and includes meaningful practices to support a good "finishing up". The Gwandalan National Palliative Care Project aims to build capacity in those who deliver palliative care to embed culturally responsive care in all end-of-life settings. Community consultation, value co-creation and user-centred design ensured that diverse Aboriginal and Torres Strait Islander perspectives informed the Gwandalan curriculum. Emerging communities of practice serve as yarning circles where barriers to and enablers of service delivery can be shared and addressed collaboratively.

Creating person-centred health care value together.

In this article we ask: to what extent is person-centred care truly embedded in our system, and are we making the most of the policy levers that could help? We describe person-centred care, shine a light on deficits in the health system, and point to some policy enablers to support person-centred care. Cultural change and a commitment to value-based health care are required. We highlight the merit in adopting and acting on patient-reported measures as an indicator of what matters to the patient, the need for integrated data systems, and the role of a co-creation approach. Most importantly, we underscore the importance of funding reform and consumer leadership.

Activating people to partner in health and self-care: use of the Patient Activation Measure.

Patient activation is a behavioural concept and is at the heart of personalised care. It is defined as an individual's knowledge, skill and confidence for managing their health and health care. Evidence indicates that patient activation scores can predict health behaviour and are closely linked to various clinical outcomes: reduced unnecessary emergency department visits, hospital admissions and re-admissions. Patients with lower activation levels (25-40% of the population) are less likely to adopt healthy behaviour, and more likely to have poorer clinical outcomes and higher rates of hospitalisation. Effective interventions can improve a patient's activation level, and positive change in activation equates to positive change in self-care behaviour. But to improve patient activation, we must first measure it using a robust evidence-based tool such as the Patient Activation Measure (PAM) survey. Armed with the patient's PAM score, providers can tailor their care and help patients achieve better self-care, which can improve outcomes of care and reduce unnecessary health care utilisation. The PAM is also useful for population segmentation and risk stratification - to target interventions and health strategies to meet the needs of patients who are at different points along the activation continuum, to measure the performance of health care systems, and to evaluate the effectiveness of health care interventions. The role of patient activation requires further serious consideration if we are to improve the long-term health and wellbeing of all Australians. The PAM tool is a feasible and cost-effective solution for achieving the Quadruple Aim - improving population health, the cost-efficiency of the health system, and patient and provider experience.

Value-based primary care in Australia: how far have we travelled?

In this article, we discuss how the value-based health care concept has matured across recent years, and consider how it can be achieved in the primary health care sector. We provide illustrations of related initiatives across the four domains of value-based health care, highlight the need for cultural transformation and reorientation of the system, and call for a national framework and agreed plan of action.

Funding pharmacists in general practice: A feasibility study to inform the design of future economic evaluations.

BACKGROUND: Funding is a significant barrier to employing general practice pharmacists. OBJECTIVE(S): To explore the feasibility of determining the cost-benefit of pharmacists in Australian general practice. METHODS: Two part-time pharmacists were employed by general practices in Canberra, Australia. Diaries of the pharmacists were analysed to determine time worked and participation in income-generating activities, including Government-funded programs: Asthma Cycle of Care, Home Medicine Reviews, and Health Care Assessments. Scenarios using different practice and business models were entered into value-cost models to determine the income generated by the pharmacists relative to their salary. RESULTS: Over 19 weeks, pharmacists A and B supported 47 and 23 Asthma Cycle of Care activities, generating income to the general practice of AU$4,700 and AU$2,300, respectively. The pharmacists spent 36.4 and 24.1 hours on activities usually conducted by general practitioners (GPs), allowing additional time for GP-patient consultations. Value-cost models determined AU$0.61 - AU$1.20 income generation by pharmacists per AU$1 salary. CONCLUSIONS: It was feasible to determine the value-cost ratios of employing pharmacists in general practice using these methods. Future work should focus on developing a robust business model that includes health care system savings resulting from practice pharmacist interventions, determined from randomised controlled trials.

Canaries in the coalmine: Stakeholder perspectives of medication management reviews for residents with dementia.

BACKGROUND: Residential medication management reviews (RMMRs) are the primary strategy enabling collaborative and individualised medication reviews in Australian residential aged care homes (RACHs). Residents with dementia often have complex health needs and care goals, which makes them a useful benchmark of health service efficacy. OBJECTIVE: To analyse perspectives of pharmacists, general practitioners (GPs) and nurses on the suitability and delivery of the current RMMR model for residents with dementia; and to identify scope for improvement in medication review service delivery. METHODS: Electronic surveys were distributed to the included health professions via professional agencies. Descriptive statistics and non-parametric tests were used to summarise quantitative variables. Qualitative data obtained from open-text responses underwent iterative thematic analysis. Two researchers independently conducted the thematic categorisation; data within responses was inductively coded, then codes were linked to identify emergent themes that described the data content. In a triangulated exploratory mixed method approach, the qualitative findings were used to explain the quantitative findings. RESULTS: None of the participants agreed that the current program recommendation of a single RMMR every 24 months was suitable for the residents' needs. Participants were more likely to use written, rather than verbal, means of communication during RMMRs. RMMRs were perceived to have minimal benefit if there was minimal face-to-face interaction between stakeholders. Individualised medicine management in relation to resident goals of care was the key benefit of RMMRs. Insufficient remuneration was the primary barrier to effective face-to-face collaboration and delivery of individualised resident care. CONCLUSIONS: Increasing support for stakeholder participation in face-to-face interactions during medication reviews may enable delivery of a more patient-centred service for residents with dementia and improve health professional satisfaction and engagement.

Small Data and Its Visualization for Diabetes Self-Management: Qualitative Study.

BACKGROUND: As digital healthcare expands to include the use of mobile devices, there are opportunities to integrate these technologies into the self-management of chronic disease. Purpose built apps for diabetes self-management are plentiful and vary in functionality; they offer capability for individuals to record, manage, display, and interpret their own data. The optimal incorporation of mobile tablets into diabetes self-care is little explored in research, and guidelines for use are scant. OBJECTIVE: The purpose of this study was to examine an individual's use of mobile devices and apps in the self-management of type 2 diabetes to establish the potential and value of this ubiquitous technology for chronic healthcare. METHODS: In a 9-month intervention, 28 patients at a large multidisciplinary healthcare center were gifted internet connected Apple iPads with preinstalled apps and given digital support to use them. They were invited to take up predefined activities, which included recording their own biometrics, monitoring their diet, and traditional online information seeking. Four online surveys captured the participants' perceptions and health outcomes throughout the study. This article reports on the qualitative analysis of the open-ended responses in all four surveys. RESULTS: Using apps, participants self-curated small data sets that included their blood glucose level, blood pressure, weight, and dietary intake. The dynamic visualizations of the data in the form of charts and diagrams were created using apps and participants were able to interpret the impact of their choices and behaviors from the diagrammatic form of their small personal data sets. Findings are presented in four themes: (1) recording personal data; (2) modelling and visualizing the data; (3) interpreting the data; and (4) empowering and improving health. CONCLUSIONS: The modelling capability of apps using small personal data sets, collected and curated by individuals, and the resultant graphical information that can be displayed on tablet screens proves a valuable asset for diabetes self-care. Informed by their own data, individuals are well-positioned to make changes in their daily lives that will improve their health.

What can pharmacists do in general practice? A pilot trial.

BACKGROUND AND OBJECTIVES: Non-dispensing pharmacists are being suggested as a useful addition to the workforce in general practice. The aim of this study was to describe the activities of three general practice pharmacists over six months in a pilot trial. METHOD: Three general practices integrated a part-time (15.2-16 hours per week) non-dispensing pharmacist to be employed according to their individual skillset and local workplace needs. Each general practice pharmacist maintained a daily activity diary, which was subsequently analysed. RESULTS: The general practice pharmacists' activities were categorised as quality of practice (37%), administration (34%), medication review (19%) and patient education (11%). Within the quality of practice category, most time was spent conducting clinical audits (47%). Over the course of the six months, time spent on administration decreased, while time communicating with general practitioners (GPs) on clinical issues increased. DISCUSSION: The general practice pharmacists conducted a range of predominantly clinically related activities involving their expertise in the quality use of medications. Involvement in clinical activities to support GPs increased with time working in the practice. Randomised controlled trials are required to collect clinical outcomes and determine which activities conducted by pharmacists are most beneficial to Australian patients and GPs.

Stakeholder perspectives about general practice pharmacists in the Australian Capital Territory: a qualitative pilot study.

Previous studies have found that integrating non-dispensing pharmacists in general practice may improve patient safety, improve patient outcomes, deliver health system efficiencies and generate savings. However, the employment of pharmacists in general practice is not common in Australia. A naturalistic study was conducted in the Australian Capital Territory with three general practices, each employing a part-time pharmacist for 12 months. This study reports on stakeholder perspectives of the benefits, barriers and enablers for integrating pharmacists into general practice. Patients, practice staff and community pharmacists that had interacted with a practice pharmacist were asked to complete a self-administered questionnaire. Patient questionnaire respondents (n=44) reported that a practice pharmacist was beneficial and wanted to see this continue. Practice pharmacists were also perceived beneficial by primary healthcare employees surveyed (n=42). Opinions were further explored by individual semi-structured interviews (n=20). The qualitative data explored five themes: perception of the practice pharmacist, collaboration with doctors, pharmacist roles, sustainability and community pharmacy aspects. Patients welcomed improved understanding about their medication, whereas general practice staff appreciated pharmaceutical advice about patients with chronic conditions. Participants discussed options to fund practice pharmacists longer term, which was identified as the main barrier to widespread roll out.

Experiencing integration: a qualitative pilot study of consumer and provider experiences of integrated primary health care in Australia.

BACKGROUND: The terms integration and integrated care describe the complex, patient-centred strategies to improve coordination of healthcare services. Frameworks exist to conceptualise these terms, but these have been developed from a professional viewpoint. The objective of this study was to explore consumers' and providers' concepts, expectations and experience of integrated care. A key focus was whether frameworks developed from a professional perspective are effective models to explore people's experiences. METHODS: A qualitative pilot study was undertaken at one Australian multidisciplinary primary health care centre. Semi-structured interviews were conducted with consumers (N = 19) and staff (N = 10). Data were analysed using a framework analysis approach. RESULTS: Consumers' experience of integrated care tended to be implicit in their descriptions of primary healthcare experiences more broadly. Experiences related to the typologies involved clinical and functional integration, such as continuity of providers and the usefulness of shared information. Staff focused on clinical level integration, but also talked about a cultural shift that demonstrated normative, professional and functional integration. CONCLUSIONS: Existing frameworks for integration have been heavily influenced by the provider and organisational perspectives. They are useful for conceptualising integration from a professional perspective, but are less relevant for consumers' experiences. Consumers of integrated primary health care may be more focussed on relational aspects of care and outcomes of care.

Should the healthcare compass in Australia point towards value-based primary healthcare?

This paper provides an overview of quality improvement in healthcare in an Australian context. Specifically, the paper considers issues around defining, quantifying, recording and incentivising quality improvement and accountability in primary healthcare. The role of newly emerging Primary Health Networks provides a context for the discussion. The paper draws on international learnings that provide a framework for examining the important elements of quality improvement among reforming primary healthcare organisations in order to support healthcare providers and offer an evidence base for policy makers and peak bodies moving forward.

Can we measure integration of healthcare from administrative and clinical records?

BACKGROUND: A major component of integrated care is shared information. Computer-based clinical and administrative systems, particularly in multidisciplinary environments, provide an opportunity to directly measure the degree of integration. OBJECTIVE: The objective of this article is to explore the viability of automated measurement of integration within a multidisciplinary healthcare centre. METHODS: With the assistance of practice staff, researchers explored the structure and content of selected patient records in two practices to understand the viability of automated measurement. RESULTS: Extracted patient records can be used to understand integration to the degree that communication is recorded, but at significant expense to the practices and researchers. Automated systems are practical to the degree that clinicians complete all relevant identifying fields. DISCUSSION: Computerised clinical systems provide opportunities for exploring integration of care if they include a range of care providers and all relevant fields are always completed. The latter condition will always be difficult to achieve.

Commissioning: perspectives from the ground.

Primary Health Networks (PHNs) have been tasked with two key objectives to be achieved through commissioning. Public value aims can be achieved by developing operational capability in the context of an authorising environment. Public value will need to focus on system level outcomes from multiple perspectives, including a consumer perspective. The authorising environment will require policymakers to allow time for PHNs to mature into their role. It will require an environment of effective collaboration amongst multiple stakeholders including consumers. The operational capability will need to ensure highly competent managers and clinical leadership working in a symbiotic relationship. Although some Medicare Locals demonstrated commissioning capacity and capability, this will need to be scaled up at-pace in the new healthcare landscape in order for PHNs to optimally fulfil their roles.

Time to manage: patient strategies for coping with an absence of care coordination and continuity.

This paper examines how people with chronic illnesses respond to absences of continuity and coordination of care. Little work has been done on how the ill person might mitigate flaws in a less than optimal system. Our qualitative research, carried out among 91 participants in Australia, reveals that people with chronic illnesses create strategies to facilitate the management of their care. These strategies included efforts to improve communication between themselves and their health care practitioners; keeping personal up-to-date medication lists; and generating their own specific management plans. While we do not submit that it is patients' responsibility to attend to gaps in the health system, our data suggests that chronically ill people can, in and through such strategies, exert a measure of agency over their own care; making it effectively more continuous and coordinated. Participants crafted strategies according to the particular social and bodily rhythms that their ongoing illnesses had lent to their lives. Our analysis advances the view that the ill body itself is capable of enfolding the health system into the rhythms of illness - rather than the ill body always fitting into the overarching structural tempo. This entails an agent-centric view of time in illness experience. A Virtual Abstract of this paper can be found at: https://youtu.be/UwbxlEJOTx8.

General practices' perspectives on Medicare Locals' performance are critical lessons for the success of Primary Health Networks.

BACKGROUND: Under a health reform after two decades, Primary Health Organisations (PHOs) in Australia were changed from Divisions of General Practice (DGP) to Medicare Locals (MLs). Following a review of Medicare Locals, in July 2015 Primary Health Networks (PHNs) replaced Medical Locals to potentially improve outcomes through supporting primary care and enhancing integration. AIMS: The aim of this paper was to gather front-line staff's perspectives on MLs and identify any lessons applicable to PHNs. METHODS: A national purposive sample of 22 high-performing general practices representing all Australian states and territories was selected for semi-structured, face-to-face interviews, and a thematic analysis conducted. RESULTS: Fifty-three interviews were conducted: participants comprised 19 general practitioners (GPs), 18 practice managers (PMs), 15 practices nurses (PNs), and one community pharmacist. Most participants reflected on the difference between the DGP and MLs. Themes that emerged included ambiguity, community needs, professional development and education, communication and support, duplication in services and ignoring existing ones, recruitment and retention, and engagement and involvement. CONCLUSION: Those MLs that did well continued in an expanded way the work DGP were doing beforehand and made a seamless transition. PHNs will need to build on the strengths of previous PHOs, and create locality structures and processes that maximise the potential for clinical engagement. They will actively guide the dialogue between related microsystems: to achieve this they will have to be clinically led, change management organisations.