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Introduction: Implementation evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines a detailed protocol of an implementation evaluation embedded in a stepped-wedge cluster randomised controlled trial of a model of care, Strengthening Care for Children (SC4C), that integrates paediatric care in general practice. The purpose of this manuscript is to describe the pragmatic methods that will be used to capture implementation evaluation process and outcome data within this trial., Methods and Analysis: Our implementation evaluation will use a mixed methods design, with data collected in the intervention arm of the SC4C trial guided by a logic model developed using the Consolidated Framework for Implementation Research (CFIR) and Proctor and colleague's taxonomy of implementation outcomes. Data collection will be via questionnaires and semistructured interviews with general practitioners, paediatricians, general practice administrative staff and children and families. Each of the 21 general practices recruited into the study will be described in terms of staffing, patient throughput and location, in addition to the nuanced inner and outer contexts, use of the intervention and its acceptability. We will quantify implementation effectiveness in each general practice clinic using the CFIR validated scoring system. Importantly, we have embedded data collection post intervention to enable assessment of the sustainable adoption of the intervention. An inductive approach to the analysis of qualitative data will identify additional emerging themes that may not be covered by the formal frameworks underpinning our analysis., Ethics and Dissemination: Ethical approval was granted by the Royal Children's Hospital Ethics Committee in August 2020 (HREC: 65955). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences., Trial Registration Number: Australia New Zealand Clinical Trials Registry 12620001299998 on 1 December 2020., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective The aim of this study was to assess the acceptability of a novel, integrated general practitioner (GP)-paediatrician model of care, aiming to reduce referrals to hospitals and improve primary care quality. Methods A pre-post study was conducted with five general practice clinics in north-west Melbourne. Over 12 months, 49 GPs and 896 families participated in the intervention that included weekly to fortnightly paediatrician-GP co-consultation sessions at the general practice, monthly case discussions and telephone or email clinical support for GPs. GPs and families completed surveys or interviews at three time points (before the intervention, after running the model for 4 months and at the end of the implementation). Non-identifiable consultation data were extracted from general practice medical records. Results All GPs found the model acceptable. Although not significant, there was a trend towards a lower proportion of referrals to private paediatricians after the intervention (from 34% to 20%) and emergency departments (from 19% to 12%). Outpatient clinic referrals remained steady, and then increased as the paediatrician left the clinics (31% vs 47% before and after the intervention respectively). Unnecessary prescribing of acid suppression medications decreased by 20% (from 29% to 9%). GPs reported improved confidence in paediatric care (88% vs 100% before and after the intervention respectively). Families reported increased confidence in GP care (78% vs 94% before and after the intervention respectively). Model cost estimates were A$172 above usual care per child seen in the co-consultations. Conclusions This novel model of care is acceptable to GPs and families and may improve access and quality of paediatric care. What is known about the topic? A GP-paediatrician integrated model of care appears effective in reducing hospital burden in England, but has not been implemented in Australia. What does this paper add? This pilot, an Australian first, found that a GP-paediatrician integrated model of care is feasible and acceptable in Australia's primary healthcare system, improves GP confidence and quality of paediatric care, may reduce paediatric referrals to outpatient clinics and emergency departments and improves family confidence in, and preference for, GP care. What are the implications for practitioners? This model may reduce hospital burden and improve quality in GP paediatric care while potentially producing cost savings for families and the healthcare system.

Introduction: Over the past two decades, Australia's child population has grown by 12%, yet fewer children are seen by General Practitioners (GP) (Freed, 2011) and more present to emergency departments (Freed, 2015) and hospital outpatient clinics for relatively simple conditions that could be managed in primary care. We therefore aimed to co-develop and pilot an innovative, integrated GP-paediatrician care model and test its feasibility and acceptability to GPs, families and paediatricians, across 5 Victorian (Australia) general practices. Theory/Methods: GP and paediatrician co-design of an integrated care model comprising: weekly GP-paediatrician co-consulting sessions and monthly hour-long case discussions at each practice led by GPs and facilitated by a paediatrician, and email/telephone support to GPs by paediatricians. Paediatricians recorded data on numbers of children and types of cases seen in co-consults and number and topics and number of attendees in the case discussions. We extracted data on quality of GP care for common conditions and pre/post referral patterns of GPs via GHRANITE electronic medical record data extraction software. GP and paediatrician satisfaction with model of care and family satisfaction with GP care for their child were collected via surveys. Results: After 9 months of implementation, 447 children were seen in co-consults and 27 case discussion sessions were conducted with 206 attendees. GPs report high satisfaction with the model and changes in their knowledge and confidence with paediatric care. GPs referred 9% fewer children to hospital and families reported improved confidence in thier GP's care (complete confidence from 78% to 94%) and increased first preference for followup care with a GP (65.4% to 82.8%). Discussion: A novel, integrated model of care between GPs, paediatricians and families is feasible and acceptable to GPs, general practice staff, paediatricians and families. Challenges include ensuring accurate and complete data on GP referral patterns, payment for the co-consulting sessions, and clear communication to practice staff and parents about the role of the paediatrician as a co-consultant with the GP rather than a stand-alone specialist care provider. Conclusions: Developing and embedding a GP-paediatrician model of integrated care in Australia 's primary health care system is feasible and acceptable. Pilot data suggest that the model improves GP confidence to manage paediatric care, streamlines specialist care for child developmental/behavioural problems and may reduce referrals to hospital outpatient clinics and emergency departments. Lessons learned: Intervention design must involve paediatricians, GPs, practice managers and practice administrative staff from the outset. Mutual expectations and clear roles and responsibilities of GPs and paediatricians in co-consultations must be established. Careful attention to messaging to families about the nature of co-consultations will avoid families seeking a paediatrician without a GP. Limitations: pilot study Future research: controlled trial to test the costs and effectiveness of this model in improving GP quality of care for common paediatric health conditions, reducing referrals to outpatient specialist clinics and emergency departments, improving GP confidence in paediatric care, and family satisfaction with primary care for their child. [ABSTRACT FROM AUTHOR]