| Project Objectives / Summary:
This project sought to develop and evaluate a model of cooperation between general practices and community health services in two local disadvantaged communities in South West Sydney. This model involves improving the linkage between community health in general practices in disadvantaged areas by co-locating community health in general practices for part of their time and establishing systems for liaison, referral, case management, health promotion and community development. This model contrasts with the existing situation in which GPs and community health services operate more or less independently and with only limited referral and communication.
The two communities chosen are among the most disadvantaged in Australia both in terms of their index of socio-economic disadvantage and with the very real practical problems of poverty, drug abuse, crime, illness and disability that exists within them.
The intervention differed at each site to fit local needs. Community 1 involved full time co-location by one nurse in a general practice and Community 2 involved a part time co-location by two nurses in a general practice.
Project Collaboration:
- Liverpool and Macarthur Health Services
- Liverpool and Macarthur Divisions of General Practice
- Department of General Practice (South West Sydney Area Health Service and UNSW)
Project Outcomes:
Community 1
The four audits of GP records showed an increase in recording of socio-economic factors, risk-factors such as smoking status, and multi-disciplinary and shared care. There was no change in home visits, or the recording of chronic disease or preventative care. The two community nurse audits showed that the vast majority of initial patient visits took place in the home. Most patients referred by the GP were female, English speaking and receiving a pension. There was a high referral rate to other services, most of which were referrals to psycho-social services. The COMCAS data showed a large increase in referrals from GPs to the community nurse during the project and a trend towards the referral of problems related to psycho-social issues. These trends were not observed in the records of other community nurses working in the area. The GP, community nurse and patients interviewed in the area were very positive about the usefulness of the project and the GP and community nurse saw their roles as complementary. The community nurse felt that her views were important and had informed patient care.
Community 2
The GP audits showed an increase in multi-disciplinary care and shared care but no change in the recording of social information. While recording of drug or alcohol use was already high there was a small increase in recording of illicit drug use especially opiates. Most preventive care did not change. The GPs, community nurses and patients interviewed were generally positive about the co-location project but the limited nature of their contact made program development difficult.
Issues:
The findings, not unexpectedly, varied between the two communities. In Community 1, while there were evident positive views held by the various parties, there was some effect on the project due to movement of GPs. In Community 2, the part time access by the community nurse and delays in commencement of the project resulted in slower development of working relationships.
Another issue was that there is no solid data to prove that co-location actually improved patient health outcomes. While opinions were expressed to support this, there is a lack of objective data.
Structural issues affecting the project were:
- a lack of a coherent Primary Health Care focus within the Area Health Service that provides structure, leadership and resourcing for integration at the general practice level;
- different funding structures in community health and general practice;
- deconstruction of community health services to focus on episodic and post acute care;
- undertaking a pilot that other GPs and community health staff see as giving unfair advantage to one group;
- the business demands on general practice that have created some additional pressures (such as the limited amount of time spent at the Community 2 practice by the senior GPs and the selling of the practice in Community 1)
Individual issues included:
- differences in professional cultures and levels of control over their work;
- previous and ongoing poor experiences that result in a lack of trust and suspicion.
Lessons / Assessment:
The project report states it is possible to develop models of co-location between GPs and community nurses but that these need to be facilitated and take into account the wider organisational culture, structure and pressures operating on general practice and Community Health. Co-location has the potential to affect GP practice and referral patterns and there is an important role for community nurses that is different from that of a practice nurse especially in dealing with psychological issues, providing home based care and in linking the practice to other Community Health Services.
Of the two models, the full time model produced greater change. However, this was difficult to sustain both within the context of the demands on Community Health Services and the commercial pressures operating on general practice. Both Community Health Services and general practice are facing increasing pressure to change. This presents both a barrier an a potential opportunity for the development of innovative ways in which these different organisations and structures can work more effectively together. However it is clear that this cannot be achieved without considerable support and commitment, external facilitation by those who are trusted by both sides and enough time to make the changes.
There were significant delays experienced in finalizing this project report. The project did not result in a "model" per se but has provided insights into the wide range of issues and considerations that need to be taken into account.
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