Ehrlich C, Kendall E, Muenchberger H. (2011) Practice-based chronic condition care coordination: challenges and opportunities., Australian Journal of Primary Health, 17(1), 72-78.no

Interviewer: Michael Bouwman (MB)

Interviewee: Carolyn Ehrlich (CE)

MB: Introducing Dr Carolyn Ehrlich, Research Fellow, Centre for Population and Community Health, School of Human Services and Social Work, Griffith University, Australia. I’m speaking with Carolyn about her article co-authored with Elizabeth Kendall and Heidi Muenchberger entitled, ‘Practice-based Chronic Condition Care Coordination: Challenges and Opportunities’, published in Australian Journal of Primary Health. Welcome.

CE: Thank you.

MB: Your paper explores issues related to the types of support that practice nurses; PNs, require to engage in care coordination for people with chronic conditions. Could you set the context for the discussion by defining coordinated care in relation to chronic conditions and outline the demands on general practitioners and consequently, the role of practice nurses in relation to this coordinated care?

CE: There are 3 components and those components were the coordination and management of health care services for an individual client, coordination of service providers in a way that facilitates teamwork and shared knowledge and finally, service delivery organisations needed to be coordinated in a way that created an integrated network. So that was the background of care coordination that we were coming from. I guess then that we argued that we’re witnessing an increase in chronic diseases which is combined with an ageing population, workforce shortages and rising costs and that’s not unique to Australia. That’s certainly throughout the developed world that common responses to the issue of an increase in chronic diseases are either through disease management programs or care coordination or maybe a mixture of both, that general practice is a pivotal access point for health care services, so especially in Australia general practice acts as a gatekeeper to the remainder of the health care system.

MB: Yes, the first port of call.

CE: Yeah absolutely and because of that GPs are then responsible for monitoring long term health status and care coordination so they’ve had to take on that responsibility. But the problem with the complex care needs that people have and the complex situations that people live in, it’s the demands and the workload that are created because of their chronic diseases means it’s often unmanageable in general practice unless there’s a team of health care providers that are involved, so a single general practitioner is no longer able to respond to that very easily.

MB: Right.

CE: I guess when we looked at who was involved in the general practice team that many, many general practices now have practice nurses and practice nurses are ideally placed to assist with care coordination. Nurses are also able to bring a wellness approach to care provision but I think that in general practice the different perspectives and roles of both GPs and RNs means that together they can provide a total package of care, separately they might not be able to do that. So teamwork between the GP and the RN is especially important but teamwork in general practice is often unsupported, that’s what we were arguing in that paper.

MB: Could you talk about these findings in relation to your 4 main themes on the importance of a developmental and well supported implementation process?

CE: The 4 main themes that we found out of that was that there was a need for cultural change within general practices, that practice nurses and indeed the general practitioners as well relied on trusted and tested partnerships, there was also quite a bit of discussion around the financial models of care provision within the business context of general practice, so these general practices do operate as businesses even though they’re providing health care which is not necessarily always thought of as a being a business I guess.

MB: Yeah.

CE: And there are some altruistic things around health care that aren’t always consistent with business models, I think is what I’m saying there.

MB: Sure.

CE: But also that registered nurses or practice nurses, their roles needed to be defined so they needed professional definition, they needed professional development and they needed recognition of the work that they could do towards care coordination. In terms of the confusion and the lack of clarity about the work, I think that rather than just being nurses that were being confused there were entire general practice teams that were confused about the meaning of care coordination. Indeed it was general practitioners in the study that said, ‘don’t understand this, what does care coordination mean? Surely this is just usual good quality care that we’re already doing’.

MB: Yes.

CE: And I guess that also means that as soon as you put the words ‘care coordination’ to a group from general practice they individually interpret what that means. They already have some predefined means of determining what it is and I guess we all do that when we’re given new terms but when they individually interpret care coordination there can be a limited perspective that they’re making about what care coordination means. So it can be limited to ‘well, I coordinate care because I make referrals to specialists and I make referrals to dieticians and allied health professionals and to whatever other health professionals need to be included in the provision of care for this person therefore I’m coordinating care’ but I think that care coordination is somewhat deeper than that and that wasn’t that easily understood and that created the confusion. In terms of that confusion, what that meant with relation to the themes that we found is that with cultural change there certainly needed to be some attitudinal shifts so that required a change in understanding and I’m not sure how do we achieve that change but also there needed to be planning to have nurses involved in care coordination again because general practices are all different, they all have treatment rooms. If there’s only one practice nurse working than the participants would say this, you can’t have a nurse that’s working with coordinating the care for a patient which can be sometimes quite complex and in the middle of an in-depth interview with patients and then be called away to do an ECG which might be important or an immunisation which might be important in the acute care treatment room. So there had to be some planning around the nurse’s role about how this would actually happen in the perspective of what happened in general practice in the daily routines that happened, so there needs to be some significant planning that would happen.

MB: And some clear definitions .

CE: Absolutely, absolutely and so the professional definition was also important as a later theme so it was professional definition but also role definition which is possibly a little bit different. In terms of the trusted and tested partnerships we found that participants from general practice really relied on their personal relationships to develop the care team around themselves, so they would look for processes of how they engaged to people external to the general practice to be involved with providing care with people with chronic conditions. So they were often very pragmatic about how that happens, some of the findings for care coordination required that general practitioners got a response from allied health professionals and if the allied health professionals were unable to provide that response in a timely manner GPs weren’t funded for the work that was done. So often the relationships with external providers was very pragmatic, you know ‘I need you to respond to me in this way and if you don’t then I won’t be able to work with you’. It was also things like consideration of how much the allied health professionals were going to charge for the services given that patients might be experiencing quite significant costs for their health care, so there was an importance of making sure that patients would not be too much out of pocket. Within the general practice team, the general practitioner and the nurse needed to work very closely together, they needed to establish the boundaries around what their individual work was. GPs needed to be able to trust the nurse, so there would be a process of finding out from the GP perspective whether he or she could trust the nurse and I guess some of that comes down to the way that Medicare funding happens because with a lot of the item numbers that are associated with care coordination is that the work is done on behalf of the GP and the GP has to sign off on that. So he or she, being the GP needs to trust that the nurse if the nurse is being responsible for some of this work that they do it in the manner in which the GP is happy to sign off on it.

MB: Okay.

CE: The financial models, it really comes down to viability of the practice and how care coordination is interpreted in the general practice and how viable it is. The last thing that we can afford as a society is for general practices not to be financially viable, we can’t have them being unsuccessful in a business operation. So it was imperative that whatever work they were doing was in a way that was consistent with the business of general practice and even within that then general practices interpreted the funding differently and how it applied and who would do it. So in some general practices the general practitioner would take full responsibility for care coordination, in others practice nurses were able to do some of the work, not all of the work, and the GPs would sign off on it. So they would interpret that finding differently but at the end of the day it had to be financially viable. If it wasn’t financially viable they wouldn’t engage with it at all, they couldn’t. And then the final thing was around the professional definition development and recognition of the nurse’s role. The nurse’s role is not always clear, some nurses recognise that they required skills training and development to be able to work with care coordination in a different way than what they were currently doing, they needed a whole range of skills actually but others thought they already had those skills and they needed to be recognised for the skills they already had. So it was I guess about understanding the different skills of the practice nurses and what they bought to the general practice, what was required I guess doing a gap analysis of what was available and what was needed. But there was also the belief that it required certain personal characteristics to be able to provide care coordination, so there was some indication from practice nurses that there are some nurses that shouldn’t be doing this kind of work because they’re much more treatment room, acute care oriented than what care coordination is and I guess that that’s about professional skills. I mean we all have even with our individual professions we have preference for different types of work so that needed to be understood.

MB: Excellent, well thanks for talking with us for Griffith University’s Research Week and congratulations to you and your colleagues on this practical and insightful look at chronic care coordination.

CE: Thank you, and you’re welcome

This podcast was produced by the International Program of Psycho-Social Health Research (IPP-SHR), Griffith University for the Logan Research Showcase held on 6 September 2011. For further information contact Dr Pam McGrath at [email protected]