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Introduction: The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods: A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results: A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion: The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in healthrelated quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program. [ABSTRACT FROM AUTHOR]

Introduction: The Australian Gold Coast Integrated Care programme trialled an innovative model of care to proactively manage high risk patients with complex and chronic conditions in collaboration with general practitioners. The objective was to enhance coordination and continuity of care across primary and secondary health services from a single point-of-entry multidisciplinary coordination centre. This case study, embedded in the broader trial, analysed the perceptions of patients, healthcare staff and general practitioners on the adequacy, comprehensiveness, timeliness and acceptability of the new model of care to help inform the decision by the health service whether to adopt it beyond the trial. Methods: This mixed method embedded, explanatory case study design included surveys of general practice staff and focus groups with patients, carers and coordination centre staff. Qualitative data were thematically analysed and findings merged with survey data in a narrative explanatory case report. Discussion: Staff, patients, general practitioners and practice nurses were generally satisfied with services, coordination of care and information sharing but general practice staff satisfaction ratings declined over time. Conclusion: The programme enhanced care and coordination of services and was valued by patients and healthcare providers. Study results provide a rationale for adopting the model for those with chronic and complex conditions. [ABSTRACT FROM AUTHOR]

This article outlines the development of the Australian Gold Coast Integrated Care Model based on the elements identified in contemporary research literature as essential for successful integration of care between primary care, and acute hospital services. The objectives of the model are to proactively manage high risk patients with complex and chronic conditions in collaboration with General Practitioners to ultimately reduce presentations to the health service emergency department, improve the capacity of specialist outpatients, and decrease planned and unplanned admission rates. Central to the model is a shared care record which is maintained and accessed by staff in the Coordination Centre. We provide a process map outlining the care protocols from initial assessment to care of the patient presenting for emergency care. The model is being evaluated over a pilot three year proof of concept phase to determine economic and process perspectives. If found to be cost-effective, acceptable to patients and professionals and as good as or better than usual care in terms of outcomes, the strategic intent is to scale the programme beyond the local health service. [ABSTRACT FROM AUTHOR]

A primary health care approach is essential to contemporary nursing roles such as practice nursing.This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage.They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs.The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health. [ABSTRACT FROM AUTHOR]

Introduction: The Gold Coast Integrated Care (GCIC) Programme is aimed at maintaining safe, high quality and readily accessible transitions between care settings for people with complex and co-morbid conditions. We have found that the programme goal of optimising care transitions between primary and secondary services can be partially achieved through service coordination; however many patients require assistance in navigating services in a way that ensures timely, effective, adequate and patient-centred care. Practice Change: The GCIC programme incorporates a unique and innovative nurse navigator role to achieve successful patient navigation through care transitions. Aim and Theory of Change: The nurse navigator role aims to bridge the service gap between primary and secondary services by positioning a nurse in each of the general practices involved in the GCIC programme. The nurses undertake holistic patient assessments; risk management strategies; rapid response to patient needs identified through primary or secondary care service providers, multidisciplinary team members in the GCIC Coordination Centre or patients themselves; maintenance of patient information systems including a shared care record and disease registers accessible to all caregivers; coordination, liaison and patient-centred decision making; health promotion for patient health literacy and self-care, and ensuring the adequacy of collaborative structures and processes through referrals and brokerage services. Using the Transtheoretical Stages of Change Model the research team is tracking the evolution and actions of the nurse navigator role from precontemplation (preparation for the role), contemplation (collaboration between the nurses and general practitioners), preparation for change (tailoring their services to practice needs and the integration programme), actions to achieve integration (as described above) and maintenance (issues involved in sustaining the role.) Targeted Population and Stakeholders: patients with complex and co-morbid conditions, general practitioners, hospital and health service providers. Timeline: The initial 12 month evaluation of the nurse navigator role. Highlights: (innovation, impact and outcomes). The role is an innovation of the GCIC programme and as such, evaluative data is being analysed annually to demonstrate patterns of nurse navigator responses to patient need, changes to referral pathways directly related to the role, the use and efficacy of information systems, and the usefulness of risk management strategies in optimising patient transitions. Sustainability and Transferability: Evaluation data will indicate the extent to which this innovation can be transferred beyond the initial program and setting to regional and national services. [ABSTRACT FROM AUTHOR]