Multidisciplinary care in general Practice: The Teamwork Study Mark Harris, Centre for Primary Health Care and Equity

UNSW Research Centre for Primary Health Care and Equity Investigators  1.1 Chief Investigators CIAProfessor Mark Harris CIBDr Judy Proudfoot CICProfessor Justin Beilby CIDProfessor Patrick Crookes CIEE/Prof Geoffrey Meredith CIFA/Professor Deborah Black 1.2 Associate Investigators A/Professor Elizabeth Patterson Dr David Perkins Mr Gawaine Powell Davies Mr Matt Hanrahan Dr Barbara Booth

UNSW Research Centre for Primary Health Care and Equity Room to improve Community prevalence General practice prevalence in 2004/5 GP Interventions per encounter Smoking20% smoke daily17.2% smoke daily; 4.1% occas & 27.2% ex-smokers 0.3% smoking cessation advice Nutrition70% low vegetable & 47.5% low fruit -5.5% nutrition or weight counselling Alcohol10% drink at ‘harmful’ levels 26.2% drink at ‘at risk’ levels0.4% involve alcohol advice Physical Activity 54% insufficiently active & 15% sedentary. 65.3% are insufficiently active 2.1% physical activity advice Overweight / obesity 60% overweight & 20.5% obese 54.7% are overweight or obese 5.5% nutrition or weight counselling

UNSW Research Centre for Primary Health Care and Equity Opportunity and gap in performance Community prevalence General practice prevalence GP Interventions Blood Pressure (in 2000) 30% raised blood pressure. Estimates vary from 21% to 30% of people attending GPs. 30% of those diagnosed with hypertension were treated to target. Cholesterol (in 2000) 51% have raised cholesterol (46% with raised LDL 11.9% with reduced HDL, and 20.5% with raised triglycerides. 22% of audit population was diagnosed with lipid disorder. <20% treated to target. 12.7% attending GPs were currently using lipid lowering medications. Both (in 2004/5)-15.2% have both hypertension and lipid disorder 36.7% had either hypertension and/or lipid disorder. Of those with either HT or lipid disorder, 39.9% took 1 medication and 31.3% took 2 medications. 12.2% were not taking any medication.

UNSW Research Centre for Primary Health Care and Equity The need for team care Good evidence that team care:- –Improves patient adherence to management –Helps patient to achieve and sustain lifestyle change especially diet, physical activity, and weight control and monitoring of their chronic condition –Helps to save GP time GAP in current treatment: –Not everyone who needs it is getting multidisciplinary care.

UNSW Research Centre for Primary Health Care and Equity Effective teams have: Small, manageable number of members Appropriate mix of skills and expertise Measurable performance goals and specific tasks Clear roles Suitable leadership (person with most expertise) Good communication structures Collective responsibility for achieving goals Adequate resources – financial, training, admin, technical

UNSW Research Centre for Primary Health Care and Equity Effective teams processes Shared, clear purpose and objectives* Regular communication, problem-solving High level of participation in team Emphasis on quality Support for innovation Clear leadership (incl. lack of conflict about leadership) * Strongest predictor of team effectiveness

UNSW Research Centre for Primary Health Care and Equity Barriers to teamwork GP attitudes/lack of knowledge of benefits Patient attitudes re: nurse care Lack of knowledge/training of individual staff (eg.PN) Lack of time Volume of paperwork Funding structures (i.e. not enough reimbursement to GP or nurse for nurse tasks) Lack of support systems (IT etc) Small business (need for financial viability) Lack of policies & procedures Lack of structured communication systems

UNSW Research Centre for Primary Health Care and Equity Facilitators of teamwork Greater understanding of benefits (patient outcomes) Systemic changes (IT, protocols & processes, communication) Item numbers for CDM (including nurse care) Greater role clarity Clinical benchmarking A designated leader in the practice Different models GP champions & case studies of success Support from Divisions & Colleges Involvement of Divisions with smaller practices (e.g. contract PN) More physical space

UNSW Research Centre for Primary Health Care and Equity Aims NHMRC study Evaluate the impact of a practice-based intervention involving non-GP staff (practice managers, receptionists and nurses) Describe the roles, responsibilities and activities of non-GP practice staff Investigate what practice factors are associated with greater or lesser involvement of non-GP practice staff Calculate the cost of the intervention

UNSW Research Centre for Primary Health Care and Equity Intervention Practice based intervention designed to enhance the role of non-GP staff in chronic disease management. Intervention facilitated by research team. Components –Education session –3 structured practice visits to support practices to put in place systems to create team care –Resources including directories, referral aids, care plan templates, –Telephone support

UNSW Research Centre for Primary Health Care and Equity 3. Evaluation Interviews with GPs and GP staff, and other providers before and after the study Patient information (following patient consent) –Survey at 0 and 12 months including SF12 and PACIC –Data from patient records for the past 2 years (HbA1c; cholesterol – HDL, LDL; blood pressure, body mass index, etc.), as well as any referrals they have received for their condition.

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