Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial

BACKGROUND

Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs.

METHODS

The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered 'clusters' each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels.

RESULTS

Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed.

CONCLUSIONS

While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured.

TRIAL REGISTRATION

The OPEN ARCH study received ethical approval from the Far North Queensland Human Research Ethics Committee, HREC/17/QCH/104-1174 and is registered on the Australian and New Zealand Trials Registry, ACTRN12617000198325p .

OPEN ARCH: integrated care at the primary-secondary interface for the community-dwelling older person with complex needs

Optimal care of community-dwelling older Australians with complex needs is a national imperative. Suboptimal care that is reactive, episodic and fragmented, is costly to the health system, can be life threatening to the older person and produces unsustainable carer demands. Health outcomes would be improved if services (health and social) are aligned towards community-based, comprehensive and preventative care. Integrated care is person-focussed in outlook and defies a condition-centric approach to healthcare delivery. Integration is a means to support primary care, with the volume and complexity of patient needs arising from an ageing population. Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) is a targeted model of care that improves access to specialist assessment and comprehensive care for older persons at risk of functional decline, hospitalisation or institutionalised care. OPEN ARCH was developed with primary care as the central integrating function and is built on four values of quality care: preventative health care provided closer to home; alignment of specialist and generalist care; care coordination and enablement; and primary care capacity building. Through vertical integration at the primary-secondary interface, OPEN ARCH cannot only improve the quality of care for clients, but improves the capacity of primary care to meet the needs of this population.

Integrated care for community dwelling older Australians

Purpose

Integrated care is gaining popularity in Australian public policy as an acceptable means to address the needs of the unwell aged. The purpose of this paper is to investigate contemporary models of integrated care for community dwelling older persons in Australia and discuss how public policy has been interpreted at the service delivery level to improve the quality of care for the older person.

Design/methodology/approach

A scoping review was conducted for peer-reviewed and grey literature on integrated care for the older person in Australia. Publications from 2007 to present that described community-based enablement models were included.

Findings

Care co-ordination is popular in assisting the older person to bridge the gap between existing, disparate health and social care services. The role of primary care is respected but communication with the general practitioner and introduction of new roles into an existing system is challenging. Older persons value the role of the care co-ordinator and while robust model evaluation is rare, there is evidence of integrated care reducing emergency department presentations and stabilising quality of life of participants. Technology is an underutilised facilitator of integration in Australia. Innovative funding solutions and a long-term commitment to health system redesign is required for integrated care to extend beyond care co-ordination.

Originality/value

This scoping review summarises the contemporary evidence base for integrated care for the community dwelling older person in Australia and proposes the barriers and enablers for consideration of implementation of any such model within this health system.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Connecting Care in the Community: what works and what doesn't

As the burden of chronic and complex disease grows, there is an emphasis on programs that enhance the quality of care within primary care. The Connecting Care in the Community (CCC) program is an example of the implementation of care integration. This qualitative study sought to explore the experiences general practice staff face in managing clients with chronic and complex care issues, and their perceptions of the contribution of the CCC program to this care. Seventeen general practice staff from 11 practices throughout the Illawarra/Shoalhaven region participated in semistructured interviews. Five main themes emerged: (1) awareness of the CCC program; (2) varying program exposure and value placed on the program; (3) practice 'busyness' and role confusion; (4) communication and information sharing; and (5) the need for staff education and knowledge of local resources. If policymakers and healthcare organisations can gain a better understanding of the experiences of general practice staff, they will be able to design and implement programs that best meet the needs of the providers that they are attempting to integrate.

Practice change in chronic conditions care: an appraisal of theories

Background

Management of chronic conditions can be complex and burdensome for patients and complex and costly for health systems. Outcomes could be improved and costs reduced if proven clinical interventions were better implemented, but the complexity of chronic care services appears to make clinical change particularly challenging. Explicit use of theories may improve the success of clinical change in this area of care provision. Whilst theories to support implementation of practice change are apparent in the broad healthcare arena, the most applicable theories for the complexities of practice change in chronic care have not yet been identified.

Methods

We developed criteria to review the usefulness of change implementation theories for informing chronic care management and applied them to an existing list of theories used more widely in healthcare.

Results

Criteria related to the following characteristics of chronic care: breadth of the field; multi-disciplinarity; micro, meso and macro program levels; need for field-specific research on implementation requirements; and need for measurement. Six theories met the criteria to the greatest extent: the Consolidate Framework for Implementation Research; Normalization Process Theory and its extension General Theory of Implementation; two versions of the Promoting Action on Research Implementation in Health Services framework and Sticky Knowledge. None fully met all criteria. Involvement of several care provision organizations and groups, involvement of patients and carers, and policy level change are not well covered by most theories. However, adaptation may be possible to include multiple groups including patients and carers, and separate theories may be needed on policy change. Ways of qualitatively assessing theory constructs are available but quantitative measures are currently partial and under development for all theories.

Conclusions

Theoretical bases are available to structure clinical change research in chronic condition care. Theories will however need to be adapted and supplemented to account for the particular features of care in this field, particularly in relation to involvement of multiple organizations and groups, including patients, and in relation to policy influence. Quantitative measurement of theory constructs may present difficulties.

The Complexity of Health Service Integration: A Review of Reviews

BACKGROUND

The aim of health service integration is to provide a sustainable and integrated health system that better meets the needs of the end user. Yet, definitions of health service integration, methods for integrating health services, and expected outcomes are varied. This review was commissioned by Queensland Health, the government department responsible for health service delivery in Queensland, Australia, to inform efforts to integrate their mental health services. This review reports on the characteristics, reported outcomes, and design quality of studies included in systematic reviews of health service integration research.

METHOD

The review was developed by systematically searching nine electronic databases to find peer-reviewed Australian and international systematic reviews with a focus on health service integration. Reviews were included if they were in the English language and published between 2000 and 2015. A standardized assessment tool was used to analyze the study design quality of included reviews. Data relating to the integration types, methods, and reported outcomes of integration were synthesized.

RESULTS

Seventeen publications met the inclusion criteria. Eleven (65%) reviews were published during the past 5 years, which may indicate a trend for increased awareness of the need for service integration. The majority of reviews were published by researchers in the UK (8/47%), USA (3/18%), and Australia (3/18%). Included reviews focused on a variety of integration types, including integrated care pathways, governance models, integration of interventions, collaborative/integrated care models, and integration of different types of health care. Most (53%) of the reviews reported on the cost-effectiveness of service integration, e.g., positive results, no effect, or inconclusive. Only one of the reviews reported on the importance of consumer involvement. The overall design of 70% of the reviews was high, 18% medium, and 12% low.

CONCLUSION

There is no "one size fits all" approach to health service integration. Instead, this literature review highlighted the complexity of service integration, which in most primary studies involved a range of strategies. Rigorous assessments of cost-effectiveness and reporting on consumer involvement are required in future research.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Obstacles to the coordination of delivering integrated prenatal HIV, syphilis and hepatitis B testing services in Guangdong: using a needs assessment approach

Background

Integration of services for Prevention of Mother-To-Child Transmission of HIV (PMTCT) into routine maternal and child health care is promoted as a priority strategy by the WHO to facilitate the implementation of PMTCT. Integration of services emphasizes inter-sectoral coordination in the health systems to provide convenient services for clients. China has been integrating prenatal HIV, syphilis and hepatitis B testing services since 2009. However, as the individual health systems are complex, effective coordination among different health agencies is challenging. Few studies have examined the factors that affect the coordination of such complex systems. The aim of this study is to assess the effectiveness of and examine challenges for integrated service delivery. Findings will provide the basis for strategy development to enhance the effective delivery of integrated services.

Methods

The research was conducted in Guangdong province in 2013 using a needs assessment approach that includes qualitative and quantitative methods. Quantitative data was collected through a survey and from routine monitoring for PMTCT and qualitative data was collected through stakeholder interviews.

Results

Routine monitoring data used to assess key indicators of coordination suggested numerous coordination problems. The rates of prenatal HIV (95%), syphilis (47%) and hepatitis B (47%) test were inconsistent. An average of only 20% of the HIV positive mothers was referred in the health systems. There were no regular meetings among different health agencies and the clients indicated complicated service processes. The major obstacles to the coordination of delivering these integrated services are lack of service resource integration; and lack of a mechanism for coordination of the health systems, with no uniform guidelines, clear roles or consistent evaluation.

Conclusions

The key obstacles that have been identified in this study hinder the coordination of the delivery of integrated services. Our recommendations include: 1) Facilitate integration of the funding and information systems by fully combining the service resources of different health agencies into one unit; 2) Establish regular meetings to facilitate exchange of information and address problems; 3) Establish a client referral network between different health agencies with agreed guidelines, clear roles and consistent evaluation.

Prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility: a cross-sectional prevalence study

BACKGROUND

Australian subacute inpatient rehabilitation facilities face significant challenges from the ageing population and the increasing burden of chronic disease. Foot disease complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute rehabilitation inpatient services, it seems imperative to investigate the prevalence of foot disease and foot disease risk factors in this population. The primary aim of this cross-sectional study was to determine the prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility.

METHODS

Eligible participants were all adults admitted at least overnight into a large Australian subacute inpatient rehabilitation facility over two different four week periods. Consenting participants underwent a short non-invasive foot examination by a podiatrist utilising the validated Queensland Health High Risk Foot Form to collect data on age, sex, medical co-morbidity history, foot disease risk factor history and clinically diagnosed foot disease complications and foot disease risk factors. Descriptive statistics were used to determine the prevalence of clinically diagnosed foot disease complications, foot disease risk factors and groups of foot disease risk factors. Logistic regression analyses were used to investigate any associations between defined explanatory variables and appropriate foot disease outcome variables.

RESULTS

Overall, 85 (88%) of 97 people admitted to the facility during the study periods consented; mean age 80 (±9) years and 71% were female. The prevalence (95% confidence interval) of participants with active foot disease was 11.8% (6.3 - 20.5), 32.9% (23.9 - 43.5) had multiple foot disease risk factors, and overall, 56.5% (45.9 - 66.5) had at least one foot disease risk factor. A self-reported history of peripheral neuropathy diagnosis was independently associated with having multiple foot disease risk factors (OR 13.504, p = 0.001).

CONCLUSION

This study highlights the potential significance of the burden of foot disease in subacute inpatient rehabilitation facilities. One in eight subacute inpatients were admitted with active foot disease and one in two with at least one foot disease risk factor in this study. It is recommended that further multi-site studies and management guidelines are required to address the foot disease burden in subacute inpatient rehabilitation facilities.

System-level intersectoral linkages between the mental health and non-clinical support sectors: a qualitative systematic review

OBJECTIVES

Concerns about fragmented mental health service delivery persist, particularly for people with severe and persistent mental illness. The objective was to review evidence regarding outcomes attributed to system-level intersectoral linkages involving mental health services and non-clinical support services, and to identify barriers and facilitators to the intersectoral linkage process.

METHODS

A systematic, qualitative review of studies describing attempts to coordinate the activities of multiple service agencies at the policy, program or organisational level was conducted. Electronic databases Medline, PsycINFO and EMBASE were searched via OVID from inception to July 2012.

RESULTS

Of 1593 studies identified, 40 were included in the review - 26 in adult and 14 in vulnerable youth populations. Identified mechanisms to promote positive system-level outcomes included: interagency coordinating committees or intersectoral/interface workers engaged in joint service planning; formalised interagency collaborative agreements; a single care plan in which the responsibilities of all agencies are described; cross-training of staff to ensure staff culture, attitudes, knowledge and skills are complementary; service co-location; and blended funding initiatives to ensure funding aligns with program integration. Identified barriers included: adequacy of funding and technology; ensuring realistic workloads; overcoming 'turf issues' between service providers and disagreements regarding areas of responsibility; ensuring integration strategies are implemented as planned; and maintaining stakeholder enthusiasm.

CONCLUSIONS

System-level intersectoral linkages can be achieved in various ways and are associated with positive clinical and non-clinical outcomes for services and clients. Some linkage mechanisms present greater implementation challenges than others (e.g. major technology upgrades or co-location in geographically remote areas). In some instances (e.g. co-location) alternative options may achieve equivalent benefits. Publication bias could not be discounted, and studies using high-quality research designs are scarce. The limited information base applicable to system-level integration argues strongly for the evaluation of the models that evolve in the rollout of the national Partners in Recovery initiative.

How do general practitioners engage with allied health practitioners to prevent falls in older people? An exploratory qualitative study

AIM

To explore general practitioners' (GPs') perceptions about their use of Chronic Disease Management (CDM) items to access allied health interventions, in particular occupational therapy and physiotherapy, with the purpose of preventing falls, as well as to identify GP support needs with regard to development of partnerships with local allied health practitioners.

METHOD

A qualitative study was conducted in the Sydney metropolitan area through individual semistructured interviews with eight GPs, which were recorded, transcribed and analysed thematically.

RESULTS

Themes included (i) difficulties and opportunities associated with multidisciplinary care; (ii) potential for CDM items to be used to support falls prevention strategies; and (iii) the user-friendliness of the CDM items.

CONCLUSION

Effective coordination of multidisciplinary care between GPs and allied health professionals was desired but difficult to achieve through the CDM system, making translation of falls prevention evidence into clinical practice challenging. Further education on falls prevention and CDM item modification is needed to bridge this gap.

Communication pathways in community aged care: an Australian study

BACKGROUND

Health and social care practitioners collaborate in discharge planning for older people. Difficulties securing timely and quality discharge information and unclear role boundaries can be challenging. There are limited reports in the literature describing community-based practitioners' roles communicating client information.

AIM

To describe the roles of community-based practitioners in communication of older clients' information in an Australian context.

DESIGN

A descriptive and exploratory qualitative research design was applied.

METHODS

Four focus groups were conducted in 2009 with a small sample (n = 16) of district nurses, practice nurses and aged care case managers.

RESULTS

All participants described communication as a core characteristic of their role focused on minimising risks for older people. Participants valued dialogue with other health and social care providers in real time with an emphasis on telephone communication, face-to-face meetings, and case conferences. Telephone communication was considered important where there was an urgent need to problem solve. Written communication was noted as less effective.

CONCLUSIONS

There is an increasing need for stronger models of communication in community-based settings to facilitate safe, efficient and sustainable health and social outcomes for older people.

IMPLICATIONS FOR PRACTICE

There is limited available research with this focus to guide practice. Findings from this exploratory study indicate a number of important areas for further research: (i) to understand how communication feedback systems and pathways between community and inpatient providers could improve information exchange and (ii) to describe community nurses' roles in communication and medication risks for older people.

Multi-professional communication for older people in transitional care: a review of the literature

AIMS AND OBJECTIVES

To synthesise research-reporting literature about multi-professional communication between health and social care professionals within transitional care for older people, with particular attention on outcomes, enabling contextual factors and constraints.

BACKGROUND

Older adults experience high rates of morbidity and health care usage, and frequently transit between health services, and community and social care providers. These transition episodes place elders at increased risk of adverse incidents due to poor communication of information. Integrated multi-professional models of care built on enhanced communication have been widely promoted as a strategy to improve transitional care for older people. However, a range of findings exist in the literature to guide service providers and researchers.

DESIGN

Comprehensive literature search and review strategies were employed to identify, describe and synthesise relevant studies. Ten databases were searched in addition to Google Scholar.

CONCLUSIONS

Specified discharge worker roles, multi-professional care coordination teams, and information technology systems promote better service satisfaction and subjective quality of life for older people when compared with standard hospital discharge. Improved multi-professional communication reduces rates of re-admission and length of stay indicating greater cost effectiveness and efficiency for the health and social care systems. Systems of care emphasizing information exchange, education and negotiation between stakeholders facilitate communication in transitional care contexts for older adults. Conversely, lack of dialogue and lack of understanding of others' roles are barriers to communication in transitional care.

IMPLICATIONS FOR PRACTICE

Enhanced multi-professional communication, transitional pathways, and role clarity are required to improve the quality, sustainability and responsiveness of aged care into the future. Recommendations for further research include: (i) Investigation of pathways promoting person-centred care planning including the older person, their family and relevant practitioners; (ii) Development of interventions aimed at improving multi-professional communication and transitional aged care with marginalised and socially disadvantaged elders on indicators of equity and access; (iii) Investigation of changing roles for practitioners in multi-professional teams with a focus on community-based teams including nurses specialising in aged care and general practice.

Towards an integrated service response to the link between legal and health issues

International research that confirms links between health issues and legal needs and the prevalence of non-legal services as the first port of call for assistance with legal problems has reinvigorated interest in providing integrated legal and health services. This article details research that indicates experiencing ‘justiciable events’ (problems for which there is a potential legal remedy) leads to stress, anxiety and deterioration in physical or mental health problems. Health consequences are identified for those that do not obtain appropriate and timely legal assistance. People often experience clusters of legal and non-legal problems that require a range of responses. For those that seek assistance with their justiciable event, most seek this assistance from non-legal sources. Within the legal aid sector, these research findings are considered compelling reasons to integrate legal, health and welfare services. However, the co-ordination and collocation of legal and non-legal services (particularly for disadvantaged communities) is not a straightforward solution. Drawing on the experience of several examples of integrated approaches in legal, health and welfare service delivery including the longstanding arrangements between the West Heidelberg Community Legal Service, which is collocated with Banyule Community Health, a range of challenges facing those agencies wishing to develop relationships to provide integrated legal, health and welfare services are identified.

Better than nothing? Restrictions and realities of enhanced primary care for allied health practitioners

Participation of allied health professionals (AHP) in the Enhanced Primary Care (EPC) program is increasing. However, access to allied health services is strictly delineated under the EPC program and AHP face unique practice realities in providing care to patients with chronic conditions. This paper examines the discretionary practices adopted by AHP in response to the realities at the policy–practice interface and situates the discussion within a description of their experiences with EPC. Semistructured telephone interviews were conducted with a purposive sample of fifteen AHP. Participants were selected from a larger cohort who responded to a questionnaire about EPC. The EPC program was perceived as a positive start, although some aspects were problematic. Participants reported that the restriction on the number of subsidised sessions was not conducive to providing a good allied health service to patients with complex care needs and remuneration was not commensurate with the nature and scope of treatment required. The AHP in this study spoke of the dilemma of wanting to assist patients but at the same time to operate a financially viable business. Moreover, their experience was that multidisciplinary team care was implied rather than reality. Abbreviated care practices, reasonable solutions for access, and entrepreneurial practices were strategies used to manage the policy–practice tensions.