Integrated careWhat do we have to gain?

Prof Andrew BonneyMBBS (Hons) MFM (Clin) PhD DRANZCOG FRACGP MAICD

Roberta Williams Chair of General Practice

Graduate School of Medicine

Principles of primary care• General practice is the core provider of primary care

in Australia and thus is the foundation upon which our health system is based

• Approximately 85% of Australians consult a general practitioner (GP) each year (AIHW 2008)

White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. Nov 2 1961;265:885-892.

Principles of primary care• Primary care is defined by a number of key principles

that describe its function and also determine its effectiveness (Starfield, Shi et al. 2005)

Principles of primary care

These principles are:• First contact access for each new need• Long-term person- (not disease-) focused care• Comprehensive care for most health needs• Co-ordinated care when it must be sought elsewhere

Principles of primary care• Consistent and robust

international data demonstrate that jurisdictions with strong primary care systems (as measured by the strengths of each of the core principles) have better health outcomes and reduced health related costs compared with jurisdictions with weaker primary care systems (Starfield 1998; Starfield and Shi 2002)

The role of primary care in the health care of communities

• 126.8 million items of service claimed by GPs through Medicare 2012-2013 (Britt et al, 2013)

• An average of 4.93 services per person for 2006-2007 (AIHW 2008)

Mathers CD, Vos ET, Stevenson CE, Begg SJ. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust. Jun 19 2000;172(12):592-596.

The role of primary care in chronic disease management

• In those aged 60 years or more, 69% of patients presenting to a general practice report having at least one chronic or complex medical condition (Bonney et al 2010, 2012)

• Overall, 42% of GP consultations address at least one chronic problem (Britt et al 2013)

The role of primary care in chronic disease management• Patients aged 65 years and over represent

13.2% of the population, but 29.7% of time spent in GP clinical care (Britt and Miller 2009)

• By 2020 a 45% increase in GPs will be required due to population ageing (Harrison and Britt 2011)

• The proportion of the population aged 65 years and over is expected to double by 2051 (AIHW 2000)

The role of primary care in chronic disease management

• Older patients have a higher preference for interpersonal continuity with a single doctor (Kearley & Freeman, 2001; Nutting et al, 2003)

• In patients aged 60 years or more, nearly all (89.8%) express a requirement for a regular doctor who knows them and their medical problems well (Bonney et al 2012)

• Chronic illness significantly increases the likelihood of requiring interpersonal continuity of care (Bonney et al 2014)

The role of primary care in chronic disease managementReduced continuity is associated with poorer

outcomes in older patients:• Associated with increased Emergency

Department presentations (Ionescu-Ittu et al, 2007)

• Associated with increased hospitalisation rates and mortality in diabetic patients (Worrall & Knight, 2011)

Towards integrated careStructured disease

management is associated with:

• Improved care for coronary artery disease, cardiac failure, diabetes and asthma (Fireman et.al.)

A medical home that co-ordinates care is associated with:

• More responsive, efficient care and fewer medical errors (Schoen et. al. 2007)

Sustainable primary care?

• Ageing population• Increasing chronic disease

rates• Increasing requirement for

continuity of care• Demands on medical

workforce outstripping supply

What do we need in future models of chronic disease management?

• Efficient use of human resources• Maintenance of continuity of care• Maintenance of comprehensiveness of care• A ‘whole of system’ approach that balances

practice activity across the determinants of effective primary care

Integrated care – what do we stand to gain?

If we get the model right, we should gain:• Optimal use of appropriate multidisciplinary

care (Harris et al 2007, NHHRC 2009)• Appropriate task distribution (Laurant et al

2004, Scott 2009)• Reduced reliance on GP consultations• Improved efficiency/productivity (Scott 2009)• Sustainability of the positive population

health impact of primary care

References• AIHW. 2008. Incidence and prevalence of chronic diseases [Online]. Canberra: Australian Government. Available:

http://www.aihw.gov.au/cdarf/data_pages/incidence_prevalence/index.cfm [Accessed 26th May 2010. • AIHW. 2000. Disability and ageing Australian population patterns and implications [Online]. Canberra: Australian Government. Available:

http://www.aihw.gov.au/publication-detail/?id=6442467211• [Accessed 26th May 2010.• BONNEY, A., MAGEE, C. & PEARSON, R. 2012. Cross-sectional survey of older patients’ views regarding multidisciplinary care for chronic conditions in

general practice. Australian Journal of Primary Health [Online]. Available: http://dx.doi.org/10.1071/PY12101.• BONNEY, A., JONES, S. C. & IVERSON, D. 2012. The older patient, the general practitioner and the trainee: patients' attitudes and implications for training.

Education for Primary Care, 23, 186-195.• BONNEY, A., JONES, S. C., IVERSON, D. & MAGEE, C. 2014. Trust, continuity and agency: Keys to understanding older patients' attitudes to general

practice trainees. Education for Health, 27, 39-46.• BRITT, H., MILLER, G. C., CHARLES, J., HENDERSON, J., BAYRAM, C., PAN, Y., VALENTI, L., HARRISON, C., FAHRIDIN, S. & O’HALLORAN, J. 2009.

General practice activity in Australia 1999-00 to 2008-09: 10 year data tables. General practice series no. 26. Cat. no. GEP 26. Canberra: AIHW.• BRITT, H., MILLER, G. C., HENDERSON, J., BAYRAM, C., VALENTI, L., HARRISON, C., CHARLES, J., PAN, Y., ZHANG, C., POLLACK, A. J. &

O’HALLORAN, J. 2013. General practice activity in Australia 2012-13. General practice series no. 33. Sydney: Sydney Univeristy Press.• Fireman B, Bartlett J, Selby J. Can Disease Management Reduce Health Care Costs By Improving Quality? Health Affairs. November 1, 2004 2004;23(6):63-

75.• HARRIS, M. F. & ZWAR, N. A. 2007. Care of patients with chronic disease: the challenge for general practice. Med J Aust, 187, 104-7. • HARRISON, C. & BRITT, H. 2011. General practice - workforce gaps now and in 2020. Aust Fam Physician, 40, 12-5.• IONESCU-ITTU, R., MCCUSKER, J., CIAMPI, A., VADEBONCOEUR, A. M., ROBERGE, D., LAROUCHE, D., VERDON, J. & PINEAULT, R. 2007. Continuity

of primary care and emergency department utilization among elderly people. CMAJ, 177, 1362-8.• JEON, Y.-H., JOWSEY, T., YEN, L., GLASGOW, N. J., ESSUE, B., KLJAKOVIC, M., PEARCE-BROWN, C., MIRZAEI, M., USHERWOOD, T., JAN, S.,

KRAUS, S. G. & ASPIN, C. 2010. Achieving a balanced life in the face of chronic illness. Australian Journal of Primary Health, 16, 66-74.• KEARLEY, K. E., FREEMAN, G. K. & HEATH, A. 2001. An exploration of the value of the personal doctor-patient relationship in general practice. Br J Gen

Pract, 51, 712-8.• LAURANT, M., REEVES, D., HERMENS, R., BRASPENNING, J., GROL, R. & SIBBALD, B. 2004. Substitution of doctors by nurses in primary care. Cochrane

Database of Systematic Reviews.• NHHRC. 2009. A Healthier future for all Australians - final report of the National Health and Hospitals Reform Commission - June 2009 [Online]. Canberra:

Commonwealth of Australia. Available: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report [Accessed 28.09.2010]. • NUTTING, P. A., GOODWIN, M. A., FLOCKE, S. A., ZYZANSKI, S. J. & STANGE, K. C. 2003. Continuity of primary care: to whom does it matter and when?

Ann Fam Med, 1, 149-55.• SCOTT, I. A. 2009. Health care workforce crisis in Australia: too few or too disabled? Med J Aust, 190, 689-92.• STARFIELD, B. & SHI, L. 2002. Policy relevant determinants of health: an international perspective. Health Policy, 60, 201-218.• STARFIELD, B., SHI, L. & MACINKO, J. 2005. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 83, 457-502.• Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven

Countries, 2007. Health Affairs. November 1, 2007 2007;26(6):w717-w734.• WHITE, K. L., WILLIAMS, F. & GREENBERG, B. G. 1961. The ecology of medical care.• WORRALL, G. & KNIGHT, J. 2011. Continuity of care is good for elderly people with diabetes: retrospective cohort study of mortality and hospitalization. Can

Fam Physician, 57, e16-20.