What drives primary care providers to adopt innovative care delivery models in New South Wales, Australia?

The Australian health system, like many around the world, is under increasing demands from rising chronic disease and costs of care. Value Based Health Care (VBHC), of which Integrated Care is a key element, combats this by aiming to provide better patient outcomes for less cost. At the heart of this approach is improved chronic disease management through general practice, which may require change to some aspects of how a practice works. This change may be simple, such as switching focus to a condition of interest to the health system, or it may be bigger, such as turning the nature of the practice more towards being pro-active rather than reactive. Many Integrated Care projects fail at the implementation stage. This thesis examines how general practice has engaged with two VBHC initiatives under the Collaborative Commissioning program run by the NSW Ministry of Health, Australia. Cardiology in Community was implemented in Western Sydney, focusing on cardiovascular disease (CVD) with an emphasis on atrial fibrillation (AF), and in Northern Sydney, the Rapid Care for the Elderly and Frail (RCEF) initiative. Specifically, the aims of this thesis were: 1. To explore how uptake of innovative models of care by service providers has been explained and described in previous literature. 2. To identify service provider characteristics that are associated with increased participation in two regionally-designed health pathways at one to two years of implementation of the Collaborative Commissioning initiative. 3. To identify mechanisms of uptake by service providers of specified health pathways, and constraints and enablers to uptake. 4. To develop recommendations for future scale up of regionally-led initiatives to optimise service provider participation. Time-trend analysis was conducted on process of care and quality of care measures for target cohorts using data from GP software in the Lumos database held by the NSW Ministry of Health. Program implementation tracking data kept by program administrators were also analysed. Semi-structured interviews were conducted with general practice staff implementing the models, as well as administrators of the programs. Normalisation process theory was used to help guide the thematic analysis. Uptake varied between and within the two models of care. General practices taking part in CiC increased CVD screening of the target cohort compared to non-CiC practices, as well as showing increased use of GP management plans and team care arrangements for patients with chronic disease. General practices with GPs using the RCEF model showed a slight increase in use of medication reviews but no difference for the other measures analysed from GP software. Program monitoring data showed an uptake of a remote monitoring device for arrythmia in CiC, and a good uptake of use of the geriatrician to GP service in RCEF. The differences in apparent uptake between the two models can at least partly be attributed to some key differences between the models. CiC recruited practices and asked them to carry out assessments on the target cohort as the first step, hence an increase in heart checks shows some uptake, whereas RCEF recruited individual GPs and supplied lists of eligible patients, no large-scale screening necessary. We were only able to look at practice level data in Lumos dataset, so it is quite possible that individual enrolled GPs were making changes that were not seen at the whole practice level. Program monitoring data told a slightly different story to the GP software data which suggests that the data from GP software was too blunt to pick up some the specific changes that general practice made, for example, use of remote monitoring devices and referrals to other elements of the model. The qualitative analysis indicated that the context within which the models were being implemented was one of resource tightening and pragmatism balanced with an eagerness to provide preventive care for patients. Mechanisms found to impact the normalisation of the new models included the perceived value, ease of use, team involvement and organisation, patient response, flexibility and PHN support. This thesis contributes to the essential step of monitoring and evaluating VBHC models to provide evidence for policy makers, administrators, and health care providers when designing such models or planning the scale-up of local successful models, particularly around general practice engagement.

Grantor dc:publisher

UNSW, Sydney

Year dc:date

2025

Author dc:creator

• Mulley, John

• Primary care
• Implementation science
• Behaviour change
• Health system reform
• anzsrc-for: 42 HEALTH SCIENCES
• anzsrc-for: 420312 Implementation science and evaluation

Statement dc:rights

• open access
• CC BY 4.0
• free_to_read

Licence

• https://purl.org/coar/access_right/c_abf2
• https://creativecommons.org/licenses/by/4.0/

Language dc:language

en

Identifier

https://doi.org/10.26190/unsworks/31074

OAI identifier oai:identifier

oai:unsworks.library.unsw.edu.au:1959.4/104768