Trials should inform structures and processes needed for tailoring int
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《英国医生杂志》
1 Department of Health Systems and Policies, School of Public Health, Université Libre de Bruxelles, CP 597, Route de Lennik 808, 1070 Brussels, Belgium jmacq@ulb.ac.be
Coordinating care for people with multiple needs is inherently complex as it relies strongly on social dynamics at various levels of the health systems. Designing fruitful regulation policies to make care efficient requires a proper systems analysis for tailoring the care model to the context. The SA HealthPlus trial was original for its ambition to test one coordinated care model for people with multiple needs across different chronic conditions and local healthcare systems in South Australia, and it seems to have been tailored realistically to local services and needs.1 The key elements—targeting patients who need coordinated care, the general practitioner's role as a care coordinator, and a tool for patient self management—have to be tested further in the Southern Australian context. As for similar programmes tested for one chronic condition,2 results regarding cost and effectiveness are mixed: the overall implementation of the SA HealthPlus model did not reduce costs, but it improved people's health outcomes.
The paper is only a summary, and refers to numerous other papers describing and discussing the trial's outcomes and implications. The main policy lessons that could be learnt from the trial are complex. International readers interested in policy would want to learn more about how the coordinated care framework was tailored to local conditions and how this process could generate knowledge for future analysis, before and during development of coordinated care in other contexts. Such analysis needs an understanding of three intertwined types of structure and process, which have been partly documented for another trial of coordinated care in Australia.3
Firstly, analysing at baseline the interaction between care providers and their roles towards people with multiple needs should help to identify structures within the healthcare system that might hamper properly coordinated care. For instance, the difficulty healthcare professionals have in working as a multidisciplinary team could create problems when one type of healthcare professional coordinates services and another coordinates care for individual patients, as they did in South Australia.
Secondly, monitoring the interactions between stakeholders while the coordinated care model is being implemented can highlight the social structure patterns needed to tailor coordinated care programmes. The framework proposed by Cretin et al for evaluating collaborative interventions to improve chronic illness care in the United States includes issues such as the characteristics of the organisation, environment, healthcare team and patient.4 The SA trials identified patients' capacity for self management as important for targeting those who would benefit from coordinated care—but the variety of local contexts in which the trial was implemented and the apparent variety in the outcomes of the various trials were not analysed to identify patterns of care providers.
Thirdly, a better understanding of national regulatory processes in South Australia and their relation to the health system's structure and culture might inform systems analysis in other settings and countries. One example is the comparison of developments in English and Dutch integrated care.5
Competing interests: None declared.
References
Battersby MW, SA HealthPlus Team. Health reform through coordinated care: SA HealthPlus. BMJ 2005;330: 662-5.
Singh D. Transforming chronic care: evidence about improving care for people with long term conditions. Birmingham: University of Birmingham Health Services Management Centre, 2005.
Segal L, Dunt D, Day S. Introducing coordinated care. 2: evaluation of design features and implementation processes implications for a preferred health system reform model. Health Policy 2004;69: 215-28.
Cretin S, Shortell SM, Keeler E. An evaluation of collaborative interventions to improve chronic illness care: framework and study design. Evaluation Review 2004;28: 28-51.
Kumpers S, Van Raak A, Hardy B, Mur I. The influence of institutions and culture on health policies: different approaches to integrated care in England and in the Netherlands. Public Administration 2002;80: 339-58.(Jean Macq, researcher1)
Coordinating care for people with multiple needs is inherently complex as it relies strongly on social dynamics at various levels of the health systems. Designing fruitful regulation policies to make care efficient requires a proper systems analysis for tailoring the care model to the context. The SA HealthPlus trial was original for its ambition to test one coordinated care model for people with multiple needs across different chronic conditions and local healthcare systems in South Australia, and it seems to have been tailored realistically to local services and needs.1 The key elements—targeting patients who need coordinated care, the general practitioner's role as a care coordinator, and a tool for patient self management—have to be tested further in the Southern Australian context. As for similar programmes tested for one chronic condition,2 results regarding cost and effectiveness are mixed: the overall implementation of the SA HealthPlus model did not reduce costs, but it improved people's health outcomes.
The paper is only a summary, and refers to numerous other papers describing and discussing the trial's outcomes and implications. The main policy lessons that could be learnt from the trial are complex. International readers interested in policy would want to learn more about how the coordinated care framework was tailored to local conditions and how this process could generate knowledge for future analysis, before and during development of coordinated care in other contexts. Such analysis needs an understanding of three intertwined types of structure and process, which have been partly documented for another trial of coordinated care in Australia.3
Firstly, analysing at baseline the interaction between care providers and their roles towards people with multiple needs should help to identify structures within the healthcare system that might hamper properly coordinated care. For instance, the difficulty healthcare professionals have in working as a multidisciplinary team could create problems when one type of healthcare professional coordinates services and another coordinates care for individual patients, as they did in South Australia.
Secondly, monitoring the interactions between stakeholders while the coordinated care model is being implemented can highlight the social structure patterns needed to tailor coordinated care programmes. The framework proposed by Cretin et al for evaluating collaborative interventions to improve chronic illness care in the United States includes issues such as the characteristics of the organisation, environment, healthcare team and patient.4 The SA trials identified patients' capacity for self management as important for targeting those who would benefit from coordinated care—but the variety of local contexts in which the trial was implemented and the apparent variety in the outcomes of the various trials were not analysed to identify patterns of care providers.
Thirdly, a better understanding of national regulatory processes in South Australia and their relation to the health system's structure and culture might inform systems analysis in other settings and countries. One example is the comparison of developments in English and Dutch integrated care.5
Competing interests: None declared.
References
Battersby MW, SA HealthPlus Team. Health reform through coordinated care: SA HealthPlus. BMJ 2005;330: 662-5.
Singh D. Transforming chronic care: evidence about improving care for people with long term conditions. Birmingham: University of Birmingham Health Services Management Centre, 2005.
Segal L, Dunt D, Day S. Introducing coordinated care. 2: evaluation of design features and implementation processes implications for a preferred health system reform model. Health Policy 2004;69: 215-28.
Cretin S, Shortell SM, Keeler E. An evaluation of collaborative interventions to improve chronic illness care: framework and study design. Evaluation Review 2004;28: 28-51.
Kumpers S, Van Raak A, Hardy B, Mur I. The influence of institutions and culture on health policies: different approaches to integrated care in England and in the Netherlands. Public Administration 2002;80: 339-58.(Jean Macq, researcher1)