Working towards primary care and aged residential care integration

Abstract

Background Overuse of secondary care services and insufficient access to primary care in aged residential care (ARC) are topical issues. There is limited policy guidance or research evidence promoting effective, efficient and sustainable models of primary care in ARC as part of an integrated healthcare system. Aim This thesis aims to understand and delineate the existing relationship between primary care and ARC in New Zealand (NZ), and to propose a model or models of care designed to improve the capacity for integration between primary care and ARC services. The research specifically investigates the current state of primary care in the ARC sector from a policy and practice perspective, to identify features of a model or models that could offer quality and sustainable improvements in the delivery of primary care in ARC. Methods 1) An integrative review of international research literature was completed to identify primary care models in ARC. 2) A predominantly qualitative mixed methods approach was used to identify and describe NZ models within their relevant policy context. This entailed a narrative review of grey literature, 34 in-depth interviews with purposively sampled key informants, and four case studies with either a practice or a policy focus. 3) Factors for integrated delivery of primary care in ARC were identified, and models of care critiqued and compared using thematic analysis and general inductive principles. Results The research identified well-defined existing issues in the delivery of primary care in ARC. Proposed solutions were seldom found to address underlying causes. Multiple models of care that have an impact on the primary care and ARC interface were identified: eighteen from international literature (including three NZ models) and eleven from key informant interviews. Models often operate in parallel and few represented an integrated approach. The persistent use of historic models by ARC undermines the integrity and sustainability of newer more integrated models. Policy guidance was limited at the interface between primary care and ARC. In NZ separate national contracts for the delivery of primary care in ARC has contributed to a lack of integration at the primary care and ARC interface. The research identified common factors that support integration at the primary care and ARC interface. These factors are policy guidance, infrastructure for information sharing, workforce development, secondary care support and clinical governance. Several integrated models that could improve primary care services in ARC and the quality of resident care were identified. Each model was dependent on the context in which they operate. Policy promoting an integrated systems view is needed to inform practice. Conclusion This thesis has national and international relevance as it contributes to our understanding of the issues at the primary care – ARC interface, and the need to adopt more integrated models. Current models of care are context specific and thus no single model of primary care in ARC can be recommended. Common factors and models of integration identified will add to the existing evidence base, and allow potential solutions to be considered and developed.