We conducted 125 interviews with a total of 83 participants in two rounds between March and September 2016, and from November 2016 to March 2017 (Table 2). There were 59 interviewees in the first and 66 in the second round. These included 12 WSICP enrolled patients, seven of whom were interviewed in both rounds, and 11 carers. We interviewed 29 healthcare providers from WSLHD including medical specialists, registrars, nurses, allied healthcare providers and WSICP care facilitators, and most of these (n = 20) participated in both rounds. We also interviewed 21 GPs and practice staff from different practices across western Sydney with eight of them interviewed twice. Ten managers and clinicians on the Evaluation Advisory Committee participated, with seven participating in both interview rounds. We sampled participants across the three chronic disease areas and in the catchment areas of both Westmead and Blacktown hospitals.
We identified three overarching themes in our thematic analysis. These related to the set-up and operationalising of WSICP; challenges encountered; and the added value of the program. The full analysis table is available as “Additional file 3”.
Setting up of WSICP
Interviews highlighted a range of subthemes related to managing the program in the early stages; initiation and promotion of the program; access to WSICP; understandings of integrated care; and relationships with other unrelated programs, activities and processes.
The first round of interviews highlighted the effort and time involved in setting up WSICP with lengthy delays perceived to be related to WSLHD bureaucracy. Hospital clinicians commented: “That’s been quite stressful …it’s a lot of hours put in of our own time and private time too to get this up and running (Hospital Specialist 11, Round 1), and “…hospital processes held up the Integrated Care Program a lot…has been frustrating…that has slowed things down a lot” (Hospital Specialist 1/Manager 7, Round 1). There were also delays initially in engaging GPs: “it’s not having enough GPs at the start that have been enrolled in the actual program, so we were getting many of our referrals from inpatients” (Hospital Specialist 5, Round 1).
Understanding of policies and processes as well as provision of staff orientation appeared to improve over time. Compared to care facilitators recruited early in the program, later care facilitators received full orientation and mentoring: “New care facilitators coming on board have a different route to orientation to the way I was brought in, quite more substantial orientation than I received 12 months ago” (Care Facilitator 2, Round 2).
Concerns about restrictions to WSICP access continued over time, with many who were perceived as likely to benefit excluded: “I've got patients who have diabetes and a heart problem as well but the patient was not included, because the patient had non-Hodgkin's lymphoma” (GP 13, Round 2). Access even for those who were eligible for WSICP was also a concern and patients were reported as missing appointments for reasons including illness, disability, limited English proficiency and financial barriers: “Some of them I know feel that they’re too sick to come, some of them it’s too much effort to get back to the hospital, some of them forget, some of them misplace the timing, and [difficulties accessing] interpreters-ugh (Hospital Specialist 2/Manager 9, Round 1). Poor physical access to hospital clinics and inadequate parking were also described as barriers: “They miss their rehab sessions, miss therapy appointments, they ring and say, ‘I drove around for an hour and couldn’t get a car park, that’s why I didn’t come to my appointment today’” (Allied Health 5, Round 1).
Rapid Access and Stabilisation clinics addressed some of these difficulties by adapting care to patient needs: “We’ve changed to walk-in appointments to try and get them in with the 24–48 hour, even five-day time frame (Hospital Nurse 2, Round 1). Patients felt valued and important:
…rapid access was magic, it was gold, treated like special rather than waiting in emergency for hours and hours feeling unwell, here I was being seen by people who met me at the door with a wheelchair and took me places to assess me (Patient 2, Round 1)
However, it was difficult engaging patients who seemed disinterested in an integrated, team based approach: “…having extra things to do or more people involved was actually a barrier. He wasn't interested in signing up because the last thing he wanted was more phone calls or more appointments” (GP 6, Round 2).
Patients, carers and providers demonstrated a good understanding of integrated care describing this in terms of a focus on patient centred care that was integrated across hospital, specialist, GP and community settings: “In a nutshell I believe what integrated care is about - integrating three different groups of people, which is hospital, GP, the patient carer or a different family member” (Carer 17, Round 2). Informational continuity was often part of their description with care facilitation and team based approaches frequently considered to be aspects of integrated care. Comments included: “there's continuity…healthcare plans are uploaded so other health professionals involved in their care can have an idea of what's going on with what other people are doing (GP 12, Round 2), and “Shared-care, basically. So, we’re looking at a group of people to look after the one patient” (Practice Nurse 5, Round 2).
The need for all to work together for the benefit of the patient was identified as paramount. Typical responses included: “Somebody communicating with all the various specialities that take care of a patient. So, there’s one person overlooking it all and making sure everything is working well together” (Practice Nurse 7, Round 2), and “So many of the patients are shared anyway, you know, they sort of bounce back and forth from the normal heart failure program, integrated care, when they have deteriorations, so we work as a team” (Hospital Nurse 4, Round 1).
Good communications and upskilling of community healthcare providers were noted as key facilitators: “We want to empower the GP … we want them [patients] to look after themselves of course, and to work on themselves, but through the GP” (Hospital Specialist 10, Round 1).
The two hospitals implemented aspects of the program differently and interviewees sometimes confused pre-existing or related programs with newly introduced WSICP strategies:
At Blacktown it’s set up differently; at Westmead we almost use it as a post-discharge clinic-we’ll see patients that aren’t necessarily suited in the program, but at Blacktown they like to recruit GPs first and then see patients through the GP (Allied Health 2, Round 1).
Interviewees identified numerous challenges to implementing integrated care approaches through WSICP. Subthemes described issues around roles and responsibilities of those working on WSICP; inter-organisational challenges; and challenges related to the scale of WSICP and achieving major changes with limited time and funding.
Early challenges included uncertainty about roles especially with new positions like care facilitators, but also difficulties for nursing, allied health and hospital specialist staff in working together on the program.
I think there’s still uneasiness between the teams, in terms of integrated care working, I think we need to do a lot more teambuilding exercises there. I think it’s still very much viewed as an us and them approach (Care Facilitator 2, Round 2)
Broader challenges described by interviewees often related to differences between the hospital culture and that of general practice: “I wonder about…, this disinclination on the LHD [local health district] staff to recognise that community health or other services are of any relevance to this whole exercise” (Manager 3, Round 2), and “…our culture needs to change a bit. I think general practice has been a bit of a silo” (GP 7, Round 1). Interviewees frequently spoke about siloed provision of care which inhibited the sharing of information, even between hospitals. However, this was starting to slowly change as WSICP became more established: “We were working in siloes before, almost didn’t know the other was there” (Hospital Nurse 4, Round 2).
Inefficient IT was a constant source of frustration in its failure to bridge these siloes through better communication, shared records and efficient referral processes.
Another frustration is the whole integration of health records; that’s been hopeless…the other frustration is they said we could get e-referrals. We haven’t got any e-referrals from any of the external practices…we think that GP’s should be able to e-refer; they still can’t e-refer to us at all (Hospital Specialist 1/Manager 7, Round 1)
By the later interviews there was some evidence of health information being shared across sectors, although often as a result of WSPHN staff visiting general practices to build IT capacity, and care facilitators manually updating hospital records.
They managed to link my Mum’s entire medical history with both Blacktown and Westmead, through the GP [via Care Facilitator]. So in emergency situations those places have full access at the touch of a button rather than me having to explain everything or try to remember all the details, or remember all her medications (Carer 17, Round 2)
The WSICP was seen as influencing change through its support of Patient Centred Medical Home models of care, however, the fee-for-service remuneration of general practice was considered a barrier to team based care: “Despite the small volume of incentives that we’ve managed to bring in with this program, the system is still geared to reward high throughput, but not high value” (Manager 3, Round 2).
The size and complexity of the process of the WSICP transformation was a common theme: “You’re rebuilding, changing, you’re realigning the way we’re doing business. We’re trying to turn the Titanic around a little bit and we’re slowly doing that” (Manager 6, Round 1). Although the WSICP was showing promise, concerns were expressed that the limited time and funding for WSICP made it difficult to establish the program, change behaviours, and demonstrate improved health outcomes.
We have to allow the time to get this message out to the GPs, allow time for changing behaviour…we’re not even a year into this and I think we’re trying to change a system that’s been in place for a very, very long time (Hospital Specialist 3, Round 1).
Interviewees emphasised the need for long term commitment noting that retaining staff and maintaining gains already achieved would be difficult if the program ended too quickly: “it’s going into mid next year , that makes it very difficult people are worried about what’s going to happen after that, a lot of turnover of staff– then you have to start again, retrain people and fill jobs” (Hospital Specialist 3, Round 2).
Added Value of Integrated Care
Interviewees identified many improvements to care as a result of WSICP. Subthemes described these as building capacity, education and upskilling of patients and health care providers; changes in practice; valuing WSICP; and suggestions for future practice.
From early in its implementation, healthcare providers, patients and carers valued the benefits provided by WSICP. Healthcare providers described services as more time efficient, and potentially more cost effective.
Initially I thought it was going to create more problems, like take a lot more time. If anything it's actually made it work a lot more efficiently. And care plans are now up to date. Care plans are being followed up properly - I'm definitely seeing that it's helping (GP 9, Round 2)
Patients reported support from multidisciplinary teams to self-manage their care and accessed care in the community that was described as holistic and patient centred, and included services outside the program. Interviewees said: "I’m seeing a lot more improvements, in terms of the patient’s ability to self-manage their condition and making sure they go to their GP before it becomes worse” (Care Facilitator 3, Round 2) and “with the case conference I think it is a good thing, because we can see everyone’s input on it and we can work together as a team to better manage this patient” (Care Facilitator 4, Round 2). When patients needed hospital care, patients and their GPs, knew who to contact and patients valued seeing people who knew them.
Multidisciplinary approaches upskilling and empowering patients (particularly in Rapid Access and Stabilisation clinics) were said to reduce the need for hospital admission: “We’ve slightly decreased the readmission rate, so I suppose that’s something, as in they’re weighing themselves regularly, they’re watching their fluid restriction, they’re taking their medication. Maybe we’ve got some people to stop smoking” (Hospital Nurse 2, Round 1). Another said: “a patient who used to come in once every month, now haven’t seen him for a few months in the hospital because he’s been managed through integrated care” (Hospital Specialist 7, Round 1). Patients learned how to manage their conditions more effectively and were making lifestyle changes: “They’re brilliant, they explained what will happen, and how to deal with it (Patient 14, Round 2).
Healthcare providers and patients appeared to collaborate more. The GP support line connected GPs with hospital specialists, while the patient hotline was regarded as providing a reliable contact point and improved patient access to the hospital: “they get a number to call, they can just pick up the phone and ring the nurse or pick up the phone and ring the doctor… or go to the GP, get the GP to call us. I think that is a big plus” (Hospital Specialist 11, Round 1). Patients and healthcare providers valued working with care facilitators who further helped connect them with others: “I think they appreciate that there is a care facilitator as well - a bit of a one stop kind of shop if they have got questions or problems, help them navigate the system” (GP 6, Round 2).
Healthcare providers discussed upskilling of the multi-disciplinary team. General practice staff described the education they received from care facilitators and also through case conferences, practice visits and evening workshops convened by hospital staff. They particularly valued case based learning approaches commenting “they upskill GPs. I still feel anxious about starting people on insulin but I am able to do that now, whereas before I wouldn’t have felt comfortable doing that” (GP 5, Round 2). Hospital staff also commented on learning about general practice: “Going out to GP practices and doing some teaching has been incredibly eye-opening, I’ve got a much better understanding of what it is my GP colleagues want and need” (Hospital Specialist 2/Manager 9, Round 1).
Collaboration and communication between hospitals and community based care providers were said to be improving: “There are actually more GPs contacting the service with regards to referring their patients to our care. There are more doctors being talked to by the care facilitators in regards to how the services are being done” (Hospital Nurse 6, Round 2). General Practitioners reported having better communication from hospitals: “The doctors from the hospital are more into calling us for more information, there’s no hesitancy to ring us if they need help” (GP 8, Round 2). Patients and carers described consistency in the care they received from different care providers. They valued the strong multidisciplinary team based approach of WSICP in both hospital and community, and perceived they had greater control and confidence:
We are on the same track. The psychologists, the doctors, the care plan clarified – hopefully you get to understand drugs, how to manage correctly, so they are good. It’s also, like an assurance for me that I’m doing it right - as a carer (Carer 18, Round 2)
The WSICP was described as keeping people well and treating patients earlier in their illnesses. A hospital specialist said: “We’re picking up changes earlier and keeping on them, it does help them to self-manage a bit better” (Hospital Nurse 4, Round 2). Rapid Access and Stabilisation clinics were central in this preventative approach and hospital staff sometimes provided home visits for patients: “…since he’s come home there’s always someone ringing up or coming out” (Carer 19, Round 2).
Most interviewees described positive outcomes from the holistic focus of WSICP. “...they would see the diet educators and doctors all at once – so you can package the service into a one-hour, two-hour period, rather than, say, an admission or have a patient come back three times to see different parties” (Hospital Specialist 4, Round 1).
Interviewees provided numerous suggestions for improving ongoing implementation of WSICP. Some spoke about extending access to those not currently meeting the inclusion criteria: “it would be good to expand it a bit, it would be probably good to look – well, we’re doing chest pain and heart failure but to link in a hypertension clinic” (Hospital Nurse 2, Round 1). This also included building nursing home capacity:
Why can’t we go to the nursing homes and try and educate the nursing staff? If somebody is short of breath, rather than sending them into the hospital, they actually have qualified personnel there that can try and manage these things (Hospital Nurse 3, Round 1).
Others suggested extending valued WSICP activities such as case conferencing in additional clinical areas and through use of videoconferencing. Greater access to allied healthcare providers was recommended, including provision of group sessions. “A clinical psychologist - there's a role for them. I've done my statistics and in my clinic about 50% of my patients suffer some form of mental illness, whether it’s mild or severe” (Hospital Specialist 7, Round 2).
Promoting WSICP more strongly and continuing learning activities across sites and over time were other recommendations. There’s not a lot of advertisement regarding the program, what we can do. I think you need a full project manager to help with communication, newsletters, you know, establishing who we are (Care Facilitator 2, Round 2).
The biggest source of frustration in both interview rounds related to IT and communications, and interviewees frequently recommended a system enabling shared patient records by connecting hospital and general practice IT programs.
The thing that would make a really big difference would be if we could look at their notes, and they could look, maybe not everything, but if I could actually look and see what's happened. If we had a shared electronic record (GP 7, Round 2)
Interviewees further recommended co-locating integrated care services in the hospital, providing more space for this and improving access for patients to these services. Hospital staff said: “the other frustration is that we don’t have our own team down there. I have an educator with me, I don’t have a dietitian, and I don’t have psychologists” (Hospital Specialist 5, Round 2)
Further investment in general practice was also frequently recommended in comments such as: “I think it needs a little more investment in general practice… we don’t have the manpower or staffing or the funding to employ someone to track these patients and recall them in” (GP 3, Round 1). Additionally, interviewees identified the need to collaborate beyond the health sector for wider systems change: “Urban design, transport, food supply and physical activity, and then identifying people at risk of, say, chronic disease and then working with primary care as they interface with the health system to keep them healthy and keep them well” (Hospital Specialist 8/Manager 7, Round 1).