Carolyn Elsie Ehrlich

Self-managing versus self-management: reinvigorating the socio-political dimensions of self-management

In Australia, self-management predominantly refers to education programmes that, theoretically, equip people with chronic disease with the necessary information and skills to manage their own healthcare, maintain optimal health, and minimize the consequences of their condition. These programmes are designed, and often delivered, by practitioners. Our research has demonstrated that for consumers, self-management involves navigating and responding to a myriad of information sources and experiences, many of which originate in their own lived bodily experiences and personal knowledge. In contrast to this organic and dynamic version of self-managing that is naturally practised by consumers, common practitioner and policy representations of self-management tend to discount consumer agency and overlook the daily ways in which people manage their own body, experiences and health choices. We argue that if the self-management movement is to tackle health inequalities (rather than creating new ones), health professionals and policy-makers must examine the potentially damaging assumptions that are inherent in contemporary self-management discourse.

Coordinated care: what does that really mean?

The healthcare system in Australia is struggling to meet the healthcare needs of the ageing population. The pressure on health systems to solve these complex problems can create a sense of urgency to find a panacea in concepts such as coordinated care. A common understanding of coordinated care is often assumed when, in reality, the concept is neither clearly defined nor completely understood. The purpose of this review was to examine and identify the attributes of coordinated care to facilitate a shared definition of this concept within the primary care context. The study was a conceptual review of the literature relating to coordinated care in chronic disease. Two key electronic databases (MEDLINE and CINAHL) were searched using terms generated by a panel of primary healthcare practitioners and researchers. Following the application of inclusion and exclusion criteria, 20 studies were selected from an initial pool of 128. Several key attributes of coordinated care were identified together with a definitional statement. Coordinated care in the primary healthcare setting can be broadly defined as the delivery of systematic, responsive and supportive care to people with complex chronic care needs. It relies heavily on complicated concepts such as partnerships, networking, collaboration, knowledge transfer, person-centred practice and self-management support. The expression of these concepts in the literature was relatively superficial, with little discussion of the actual practices that might be implemented in order to enact them. This paper provides a framework of coordinated care within the primary care setting that can guide future work around implementation and evaluation.

Consensus building to improve the physical health of people with severe mental illness: a qualitative outcome mapping study

BackgroundThe poor physical health of people with severe mental illness (SMI) is often attributed to lifestyle, disease-related medication side effects and disparate provision of healthcare. The complexity and inexact nature of this issue prohibits the identification of a clear and concise causal pathway, which in turn leads to uncertainty and imprecision about the most appropriate action to address the problem. One proposed solution is to integrate care across multiple organisations and sectors through collaborative processes. The objective of this study was to identify collective pathways of action that were consensually developed and which could be initiated by clinicians to improve the physical health of people with severe mental illness.MethodsEighteen participants from a service catchment area in Australia were involved in a consensus-building workshop. This resulted in participants identifying and committing to a range of collaborative actions and processes to improve the physical health of people with severe mental illness. Consensus building was combined with an outcome mapping process, which has previously been used to facilitate health system integration. Data from the consensus-building workshop were thematically analysed and used to create an outcome map.ResultsParticipants identified that accessible, continuous, holistic, consumer-driven, recovery-oriented care was required if improved physical health of people with SMI were to be achieved. However, this all-encompassing care was dependant on a wide-ranging philosophical shift in two areas, namely societal stigma and the dominance of pharmacological approaches to care. Participants believed that this shift was contingent on the attitude and behaviours of healthcare professionals and would require an inclusive, networked approach to care delivery and maximal utilization of existing funding.ConclusionsRarely do multiple stakeholders from different sectors within the healthcare system have the opportunity to come together and create a collective vision for improving the health of a specific population in a defined area. We used a consensus building approach to generate solutions, actions and goal statements, which were then used to create a visual map that provided a purpose and signposts for action, thereby maximising the potential for cohesive action across sectors.

Spanning boundaries and creating strong patient relationships to coordinate care are strategies used by experienced chronic condition care coordinators

People with complex chronic conditions frequently need to navigate their own way through and around a fragmented and siloed health care system. Care coordination is a defining principle of primary care and is frequently proposed as a solution to this problem. However, care coordination requires more time and effort than primary care physicians alone have the capacity to deliver. Although registered nurses (RNs) are skilled team members who can be included in the delivery of coordinated patient care, any model of care coordination that involves RNs needs to fit within the existing health care delivery system. In this study, which used qualitative techniques based on grounded theory and included face-to-face interviews and open coding and theoretical sampling until data saturation was achieved, and which was one component of a larger action research study, we aimed to gain an understanding of the difference between usual chronic condition care and the work of chronic condition care coordination. The researchers interviewed general practitioners and RNs from various general practice sites who were actively coordinating care. Four unique processes were found to define care coordination implementation, namely: (1) moving beyond usual practice by spanning boundaries; (2) relationship-based care; (3) agreed roles and routines among relevant parties; and (4) committing to chronic condition care coordination. The findings suggested that existing professional and organisational cultures required negotiation before care coordination could be integrated into existing contexts. The challenge, however, seems to be in acknowledging and overcoming professional practice boundaries that define existing care through reflective practice and shared resourcing.

Responding to health care complexity: suggestions for integrated and interprofessional workplace learning.

Abstract This report highlights complexity in health care and the relevance of integrated and interprofessional care and learning. It is proposed that appropriate workforce training in response to complexity should be contextually relevant and workplace integrated, and should focus on building interprofessional capability for reflective practice and critical thinking. This training should be interprofessional and foster systems thinking. It is suggested that the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) is a useful integrating framework.

Using avoidable admissions to measure quality of care for cardiometabolic and other physical comorbidities of psychiatric disorders: A population-based, record-linkage analysis

Objective: Quality of care for comorbid physical disorders in psychiatric patients can be assessed by the number of avoidable admissions for ambulatory care sensitive (ACS) conditions. These are admissions for physical conditions that, with appropriate primary care, should not require inpatient treatment. Avoidable admissions for ACS conditions feature prominently in Australias National Health Performance Framework and have been used to assess health care provision for marginalized groups, such as Indigenous patients or those of lower socioeconomic status. They have not been applied to people with mental illness. Methods: A population-based, record-linkage analysis was used to measure ACS admissions for physical disorder in psychiatric patients of state-based facilities in Queensland, Australia, during 5 years. Results: There were 77 435 males (48.0%) and 83 783 females (52%) (total n = 161 218). Among these, 13 219 psychiatric patients (8.2%) had at least 1 ACS admission, the most common being for diabetes (n = 6086) and angina (n = 2620). Age-standardized rates were double those of the general population. Within the psychiatric group, and after adjusting for confounders, those who had ever been psychiatric inpatients experienced the highest rates of ACS admissions, especially for diabetes. Conclusions: In common with other marginalized groups, psychiatric patients have increased ACS admissions. Therefore, this measure could be used as an indicator of difficulties in access to appropriate primary care in Canada, given the availability of similar administrative data.

Practice-based chronic condition care coordination: challenges and opportunities

This paper explores issues related to the types of support that practice nurses require to engage in care coordination for people with chronic conditions. A sample of practice nurses and general practitioners participated in a focus group discussion to identify their perspectives on the role of practice nurses as providers of care coordination, the specific tasks that might be conducted and the types of support that might be required. The data were analysed using thematic analysis. The findings suggested there was considerable confusion about care coordination and a lack of conceptual clarity. Nevertheless, nurses were committed to engaging in activities that would promote care coordination. Four main themes emerged that indicated the importance of a developmental and well-supported implementation process. These themes included the need for cultural change within the whole practice, increased capacity to develop trusted and tested partnerships, appropriate role definition and a full understanding of the financial models that could support care coordination. Practice nurses clearly have a role in care coordination, but models of care coordination need to be localised and contextualised within specific GP practices. Cultural change will, in many instances, be critical to the development of localised programs. Broad supportive structures, including ongoing mentorship and administrative assistance (particularly with financial and procedural aspects of care coordination) will be required when implementing programs that enhance roles for practice nurses.

Rebuilding community: considerations for policy makers in the wake of the 2011 Queensland floods

In 2011, Queensland was inundated by the worst flood since 1974. Over 70 communities were affected by flood waters, 75% of the State was declared a natural disaster area, lives were lost and thousands of homes were destroyed. As a formal Commission of Inquiry gets underway, and these events resonate through the media, we are reminded of the emergency needs of individuals, families and communities around us. However, the slow process of recovery and community rebuilding is now beginning and it is timely to consider the scope of the task.

Social Processes That Can Facilitate and Sustain Individual Self-Management for People with Chronic Conditions

Recent shifts in health policy direction in several countries have, on the whole, translated into self-management initiatives in the hope that this approach will address the growing impact of chronic disease. Dominant approaches to self-management tend to reinforce the current medical model of chronic disease and fail to adequately address the social factors that impact on the lives of people with chronic conditions. As part of a larger study focused on outcomes following a chronic disease, this paper explores the processes by which a chronic disease self-management (CDSM) course impacted on participants. Five focus groups were conducted with participants and peer leaders of the course in both urban and rural regions of Queensland, Australia. The findings suggested that outcomes following CDSM courses depended on the complex interplay of four social factors, namely, social engagement, the development of a collective identity, the process of building collaborative coping capacity, and the establishment of exchange relationships. This study highlights the need for an approach to self-management that actively engages consumers in social relationships and addresses the context within which their lives (and diseases) are enacted. This approach extends beyond the psychoeducational skills-based approach to self-management into a more ecological model for disease prevention.

Health partnerships: perspectives of medical practitioners in general practice, health systems and hospital settings

Thepressureformedicalpractitionerstoworkcollaborativelyhasintensifiedoverthelastfewdecades in most industrialised countries, including Australia. However, many barriers prevent doctors from engaging in macro- level health partnerships. If these partnership initiatives are to succeed, it is essential to understand how and why doctors participate. This paper explored the views of eighteen medical practitioners, including general practitioners (in both small and large practices), division representatives, hospital-based doctors and health system managers. The findings revealed eight key themes, which were dominated by scepticism about partnerships based on previous experiences, but juxtaposed against a strong enthusiasm for the approach. There was a significant cost for medical practitioners to engage in partnerships, either financially or in terms of workload. Their enthusiasm was based on the belief that partnerships could achieve their vision for an ideal service system. They highlighted the importance of ongoing consultation, feedback and monitoring and the need for evidence to balance enthusiasm. Partnership initiatives need to engage local medical champions to increase the profile of this approach and enlist the enthusiasm of the diverse medical community.