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Shared Care Model between GP and non-GP specialists for complex chronic conditions


Last updated 17 July 2023

1.   Position

Increasingly patients are living with multiple chronic diseases. General Practitioners (GPs), as expert generalists in the health system, provide holistic management and play a vital role in care coordination. When patients are referred for specialist care there can sometimes be a disconnect with the GP. The Shared Care Model aims to ensure that the management of co-morbidities and preventive activities remain prioritised. The Shared Care Model also allows patients to benefit from interim review between scheduled specialist visits. Shared care already happens in some settings but is not yet normalised in the management of serious or complex conditions. In this position statement specialist care is defined as care provided by non-GP specialists on referral.

The RACGP:

  • believes all people benefit from having regular contact with a GP, especially people with complex needs who also access non-GP specialist medical care.
  • supports Shared Care pathways, such as protocols between GPs and non-GP specialists, which should be established and embedded in practice to improve care for people with complex chronic conditions.
  • proposes that funding for information technology (IT) infrastructure and care coordination services, to better support a system of Shared Care for complex conditions, is required.

2.   Definition

Shared Care Model is where there is joint responsibility for planned care that is agreed between healthcare providers, the patient and any carers they would like to engage. 1 The Model provides improved quality and continuity between services by clearly delineating roles and responsibilities for the multidisciplinary team; having structured management plans; providing clear communication channels for access to prompt help; is informed by an enhanced information exchange and advice between healthcare providers and patients; and has access to unscheduled review by specialist teams when the need arises. 2-5

The Shared Care Model presents an opportunity for people to receive the benefits of specialist intervention combined with continuity of care and management of comorbidity provided by generalists, who maintain responsibility for all aspects of the patient’s health care beyond the specified chronic disease. 6 Benefits of the Shared Care Model include reductions in hospital admissions related to specific conditions which drives cost savings to the health system;5-6 improved patient health outcomes; higher levels of follow-up care and patient adherence to treatment.7 The model aligns with the RACGP Vision of patient centred medical homes.

Appendix A provides an example of a Shared Care arrangement between a GP and non-GP specialist for a person who has developed Schizophrenia.

3.   Background

Traditional primary care encompasses a whole-person approach to care including preventive health, management of acute medical needs, assessment and management of chronic diseases and multimorbidity. 8-10 People who develop complex, chronic conditions are often referred to one or more non-GP specialist teams to support their care. The healthcare providers responsible for different aspects of care are often unclear to the patient at this point, so there is a risk of care fragmentation. There is a missed opportunity to share and coordinate the monitoring and management of complex conditions between the GP and non-GP specialist.

Effective and efficient long-term management of complex, chronic diseases is one of the greatest health-related challenges facing patients and health professionals.9 In 2018-2019, the disease groups that caused the most burden on health were cancer, musculoskeletal conditions, cardiovascular diseases and mental & substance use disorders. They accounted for 35% ($47 billion) of the total national health expenditure ($133.9 billion).11

Evidence from Lumos 12 data in NSW demonstrates the benefits of GP access to reduce hospital readmissions and in the management of chronic diseases. The data showed that a GP visit within the first week of hospital discharge was followed by 7% fewer readmissions within 28 days, while a visit in the first four weeks was followed by 13% fewer readmissions over the following 1–3 months. Unplanned readmissions are estimated to cost Australia in the order of $1.5 billion annually. Reducing avoidable hospital readmissions supports better health outcomes, improves patient safety and leads to greater efficiency in the health system. 13

Integration of health care using the Shared Care Model has been suggested as an effective option to efficiently coordinate and support continuity of care across different services. 14 Shared Care Models are patient centred and establish collaborative goals with the patient and health providers. Clinical handover between health providers is crucial for the success of the model. 13-15 Well-coordinated care will result in cost savings by reducing duplication of scarce health resources and reducing potentially preventable hospital admissions. 5-6

4.   Key Principles

General practice at the centre of Shared Care

Shared care arrangements are not new in Australia. They are in place in aspects of healthcare where non-GP specialists and GPs need to work together and where patient or consumer engagement is recognised as essential to good healthcare and health outcomes. Some examples of existing Shared Care Models include antenatal shared care, cancer, and diabetes. 1, 6, 16,17 In these models GPs and non-GP specialists have developed tailored protocols that usually include a schedule of visits with defined roles for each provider. GPs are at the centre of these models so that patients have continuity of care across the different settings, and co-morbidities for their complex chronic conditions can be monitored and managed with non-GP specialist support. Evidence shows ongoing patient care with a local GP has higher levels of follow-up 18 and adherence to treatment such as medications 2, supports patients’ independence 19-21 and reduces barriers to care in rural Australia where access to non-GPs is limited. 22 It is important that patients, GPs and other providers are both aware of Shared Care arrangements and agree to be involved.

Barriers to the Shared Care Model include poor communication and lack of clarity around healthcare provider roles in shared care 13, 15, limited opportunities for information sharing (including radiology and pathology results), a lack of current established pathways for communication or direct referrals,13 a lack of continuous care coordination for patients and practical limitations to case conferencing in general practice.13 Often health professionals are unclear about the capacity of other providers to perform monitoring and patient-management tasks.

Communication and information exchange

Models of shared care have failed because of poor communication and lack of clarity around healthcare provider roles.13, 15 Formalised agreements, such as shared care protocols, should be established to provide evidence-based, safe and efficient patient care. Shared care protocols support communication between GPs, non-GP specialists, the patient and

their carer, define roles and responsibilities and outline the frequency and nature of monitoring or follow-up. These agreed roles will differ according to the local context and capacity of each healthcare provider. There is also a need to avoid shared care protocols leading to duplication of visits and an increase in treatment burden for patients.

Greater use of secure messaging platforms and use of accessible shared care plans are required to ensure GPs and non-GP specialists have timely access to relevant patient information. 15 While My Health Record is a tool that aims to streamline sharing of patient health information, it is not a communication tool for direct communication between healthcare providers.24 Current Medicare Benefits Schedule (MBS) arrangements also fail to adequately support direct communication between members of the healthcare team leading to an over reliance on periodic letters or waiting for MBS-funded consultation visits.

Intercollegiate clinical practice guidelines

Interprofessional collaboration will ensure that evidence based clinical practice guidelines are free from bias and able to be implemented across different health sectors. Interprofessional collaboration is also required to develop protocols for Shared Care Models. 4 The RACGP advocates for investment in the development of intercollegiate clinical practice guidelines to actively integrate and facilitate evidence-based care between GPs and specialist services.

Care coordination

For some people with complex care needs, successful coordination of care is supported by a trusted case manager or nurse coordinator. 2, 25 In all cases there is a need to support the work of care coordination through a combination of funding models, shared clinical records, IT infrastructure and the use of recalls and reminders. Practice nurses are well positioned to assist in these tasks but their services are currently underfunded.

Significant practical limitations exist when case conferencing between GPs and the wider healthcare team is needed. Funding and support for asynchronous case conferencing will enhance the effectiveness of shared care.

Continuity between services

Shared care relies on continuity across health providers therefore, primary health networks (PHNs) and local health and hospital networks and districts (LHN/Ds) have a key role in supporting the structure and delivery of new Shared Care Models. Existing local care pathways (such as Health Pathways) 26 that are supported by these services need to enhance information sharing and communication across linked information platforms.

Conclusion

This position statement outlines proposed solutions to existing barriers in Shared Care so that all people with complex chronic conditions can benefit from GPs working in coordination with non-GP specialist teams to manage their condition. It highlights the importance of shared care pathways, communication and information exchange, the need for intercollegiate clinical practice guidelines, improved care coordination and continuity between services. Health professionals alone cannot bring about sustainable change without health system improvements to support them. By establishing more appropriate funding, IT infrastructure and shared care pathways (such as protocols) for care between GPs and non-GP specialists, patients with complex, chronic conditions will achieve better health outcomes.

5.   References

  1. Morgan M, Peters D, Hopwood M, C, Moy C, Fehily C, et al. Being equally well: a national policy roadmap to better physical health care and longer lives for people living with serious mental illness. Mitchell Institute, Victoria University, Melbourne; 2021.
  2. Shaw J, Sethi S, Vaccaro L, Beatty L, Kirsten L, Kissane D, et al. Is care really shared? A systematic review of collaborative care (shared care) interventions for adult cancer patients with depression. BMC health services research. 2019;19(1):120.
  3. Galica J, Zwaal C, Kennedy E, Asmis T, Cho C, Ginty A, et al. Models of Follow-Up Care and Secondary Prevention Measures for Survivors of Colorectal Cancer: Evidence-Based Guidelines and Systematic Review. Current oncology (Toronto, Ont). 2022;29(2):439-54.
  4. Kamath CC, Dobler CC, McCoy RG, Lampman MA, Pajouhi A, Erwin PJ, et al. Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies. Journal of general internal medicine. 2020;35(Suppl 2):849-69.
  5. Smith SM, Cousins G, Clyne B, Allwright S, O'Dowd T. Shared care across the interface between primary and specialty care in management of long term conditions. The Cochrane database of systematic reviews. 2017;2:CD004910.
  6. Jackson C, Tsai J, Brown C, Askew D, Russell GPs with special interests: impacting on complex diabetes care. Australian family physician. 2010;39(12):972-4.
  7. Anderson H, Hardwick Realism and resources: Towards more explanatory economic evaluation. Evaluation. 2016;22(3):323-41.
  8. Royal Australian College of General The role of specialist GPs Melbourne: RACGP; 2020 Available from: https://www.racgp.org.au/advocacy/position-statements/view-all-position-statements/health-systems-and- environmental/the-role-of-specialist-gps.
  9. Australian Bureau of Chronic conditions Canberra: ABS; 2018 [cited 2022 4 August 2022]. Available from: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/chronic-conditions/2017-18.
  10. Australian Institute of Health and Chronic conditions and multimorbidity Canberra: AIHW; 2022 [Available from: https://www.aihw.gov.au/reports/australias-health/chronic-conditions-and-multimorbidity.
  11. Australian Institute of Health and Disease expenditure in Australia 2018-19 Canberra: AIHW; 2019 [Available from: https://www.aihw.gov.au/reports/health-welfare-expenditure/disease-expenditure- australia/contents/australian-burden-of-disease-groups.
  12. NSW Health. Lumos Shining a light on the patient journey in NSW 2021 [cited 2 December 2022]. Available from: https://www.health.nsw.gov.au/lumos/Pages/default.aspx.
  13. Mitchell GK, Young CE, Janamian T, Beaver KM, Johnson JLK, Hannan-Jones C, et al. Factors affecting the embedding of integrated primary–secondary care into a health district. Australian journal of primary health. 2020;26(3):216-21.
  14. Deeble Institute for Health Policy Avoiding hospital readmissions: the models and the role of primary care. 2022.
  15. Trankle SA, Usherwood T, Abbott P, Roberts M, Crampton M, Girgis CM, et Integrating health care in Australia: a qualitative evaluation. BMC health services research. 2019;19(1):954.Henderson J, Wong C, Britt H, Pan Y, Gordon J. Antenatal care in Australian general practice. Australian Journal for General Practitioners. 2016;45(8):538-41.
  16. Henderson J, Wong C, Britt H, Pan Y, Gordon Antenatal care in Australian general practice. Australian Journal for General Practitioners. 2016;45(8):538-41.
  17. Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, et The expanding role of primary care in cancer control. The Lancet Oncology. 2015;16(12):1231-72.
  18. van Heinsbergen M, Maas H, Bessems S, Vogelaar J, Nijhuis P, Keijzer-Bors L, van Liempd A, Janssen-Heijnen
  19. Follow-up after surgical treatment in older patients with colorectal cancer: The evaluation of emerging health problems and quality of life after implementation of a standardized shared-care model. J Geriatr Oncol. 2019 Jan;10(1):126-131.
  20. Jefford M, Koczwara B, Emery J, Thornton-Benko E, Vardy JL. The important role of general practice in the care of cancer survivors. AJGP. 2020; 49(5):289-292.
  21. Emery JD, Shaw K, Williams B, et The role of primary care in early detection and follow-up of cancer. Nat Rev Clin Oncol 2014;11(1):38–48.
  22. Singer S, Kuehni CE, Hohn A, Gianinazzi ME & Michel G (2013).GP-led follow-up after childhood cancer – a systematic review. Pediatric Blood & Cancer. 60(10), 1565–1573.
  23. Street TD, Somoray K, Richards GC, Lacey Continuity of care for patients with chronic conditions from rural or remote Australia: A systematic review. Aust J Rural Health. 2019 Jun;27(3):196-202.
  24. Deeble Institute for Health Policy Perspectives brief: Shared or brokered care: A paradigm shift for clinical governance frameworks. 2022.
  1. Royal Australian College of General RACGP position statement: My Health Record Melbourne: RACGP; 2019 [cited 2022 26 August 2022]. Available from: https://www.racgp.org.au/advocacy/position-statements/view-all-position-statements/clinical-and-practice-management/my-health-record.
  2. Nieuwboer MS, Perry M, van der Sande R, Maassen ITHM, Rikkert MGMO, Marck MAvd, et al. Identification of influencing factors and strategies to improve communication between general practitioners and community nurses: a qualitative focus group study. Family Practice. 2018;35(5):619-25.
  3. Healthpathways Welcome to the HealthPathways Community 2022 [cited 26 August 2022]. Available from: https://www.healthpathwayscommunity.org/.

Author:                  Quality Care

Contact:                qualitycare@racgp.org.au

Review date:         2025

 

Appendix A

Vision for Shared Care - example for a person who develops schizophrenia
Appendix A

 

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