Finding common ground? Evaluating an intervention to improve teamwork among primary health-care professionals

International Journal for Quality in Health Care 2010; Volume 22, Number 6: pp. 519 524 Advance Access Publication: 17 October 2010 10.1093/intqhc/mzq057 Finding common ground? Evaluating an intervention to improve teamwork among primary health-care professionals BIBIANA C. CHAN 1, DAVID PERKINS 2,QINGWAN 1, NICK ZWAR 3, CHRIS DANIEL 4, PATRICK CROOKES 5 AND MARK F. HARRIS 1 * ON BEHALF OF THE TEAM-LINK PROJECT TEAM 1 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia, 2 Broken Hill University Department of Rural Health, University of Sydney, Broken Hill, New South Wales, Australia, 3 School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia, 4 Chronic Disease Management, Central Sydney GP Network, Sydney, New South Wales, Australia, and 5 Faculty of Health and Behavioural Sciences, School of Nursing, Midwifery and Indigenous Health, University of Wollongong, Wollongong, New South Wales, Australia *Address reprint requests to: Mark F. Harris, Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia. Tel: þ612-9385-8384; Fax: þ612-9385-8404; E-mail: m.f.harris@unsw.edu.au Accepted for publication 13 September 2010 Abstract Objective. Multidisciplinary care has been shown as the most effective option for chronic disease. The aim of the Team-link study was to assess the effectiveness of an intervention to improve teamwork among general practitioners (GPs), practice staff and allied health professionals (AHPs). This paper describes changes to teamwork using qualitative data collected in the study. Design. Qualitative data about changes in internal and external professional collaboration were collected from facilitators observations, GPs reports and responses to a survey of AHPs assessing multidisciplinary teamwork. Setting. Multidisciplinary teams within general practices and external collaborations with AHPs including dietitians, diabetic educators, exercise physiologists, podiatrists, psychologists and physiotherapists. Participants. GPs, practice nurses, practice staff, AHPs. Intervention. A 6-month intervention consisting of an educational workshop and structured facilitation using specially designed materials, backed up by informal telephone support, was delivered to 26 practices. Main Outcome Measure. Data were analysed thematically using an approach based on identifying actors and associated collaborative actions. Results. New and enhanced communication pathways were observed between GPs, practice staff, patients and AHPs following the intervention. The enhanced information sharing expedited communication and improved interprofessional collaboration within general practices and with AHPs. There was evidence of increased patient participation and empowerment in the care process and improved collaboration by practice staff and allied health providers. Conclusion. The Team-link intervention improved professional collaboration among GPs, practice staff, AHPs and patients, increasing understanding and trust and enhancing multidisciplinary teamwork for chronic disease care in primary care settings. Keywords: quality improvement, qualitative methods, public health, care pathways/disease management, shared decisionmaking Introduction Chronic illnesses such as diabetes and ischaemic heart disease are complex and multifaceted, and best evidence suggests that a multidisciplinary and comprehensive care approach is required to support people suffering from them [1]. Past studies indicate that only 40 60% of patients with chronic illness receive optimal quality care in International Journal for Quality in Health Care vol. 22 no. 6 # The Author 2010. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved 519

Chan et al. Australian general practice and an even smaller proportion receive multidisciplinary care [2]. A high percentage of patients referred to allied health professionals (AHPs) fail to attend and there is often poor communication between general practitioners (GPs) and AHPs [3]. Stewart s Patient-Centred Care Model [4] suggests that GPs need a clear understanding of the roles played by different AHPs and strong trusting relationships with them before they can negotiate shared patient care. It has been argued that teamwork can bring benefits for organisations, teams, patients and clinicians, including reduced hospitalisations, improved care coordination, better health outcomes and job satisfaction [5]. In a qualitative study conducted in the first phase of our project, we identified bilateral dissatisfaction with the referral and the shared-care process between general practice and AHPs [6]. Boon et al. [7] described multidisciplinary care as team care coordinated by a leader who takes responsibility for overall patient care. Members contribute views and recommendations according to their particular expertise, which may be integrated by the leader. This interdisciplinary collaboration enhances communication and builds consensus. The model emphasises the importance of the patients involvement in, and responsibility for, health-care decisions, but not all patients want the same degree of participation in their care [7]. Patients should therefore be treated as members of the team and their contribution respected. Multidisciplinary teamwork has implications for service costs, provider incentives, fees and payments to clinicians. Multidisciplinary care is characterised by collaboration which, according to D Amour et al. [8], has five elements: sharing, partnership, interdependence, power and collaborative process. Sharing includes the sharing of responsibilities, decisions, values, data, planning and treatment goals. Partnership implies deliberate purposeful activity that is open and respectful. Interdependence is characterised by mutual dependence and patient-centredness, and is understood to be synergistic. Power is based on expertise, not position, and empowers team members and patients. Finally, collaboration is a process that requires joint planning and negotiation and appropriate supporting infrastructure such as information and communication systems and financial incentives. This approach focuses on the actions of those (actors) who are collaborating put simply: who collaborates with whom and how? It also explicitly includes patients. The Australian government introduced Medicare payments for Team Care Arrangements (TCAs) in 2005 as an incentive to increase the provision of multidisciplinary team care. These payments encourage GPs to refer patients with a complex chronic illness to AHPs for up to five subsidized services per patient per annum. TCAs also provide incentives for GPs to coordinate the care of a patient with a chronic condition with at least two other care providers. This TCA payment system influences how and whether primary healthcare providers collaborate in the care of patients with chronic diseases. Within TCAs, GPs are given the role of coordinator and negotiate with AHPs and patients about treatment goals and the most appropriate care. Despite the introduction of TCAs in 2005, progress towards best practice collaborative care has been slow [3]. There are two obvious barriers to multidisciplinary care: (i) GPs and allied health providers are seldom co-located, and (ii) practices have little capacity to coordinate care with other services [9]. Despite these barriers, there is evidence that multidisciplinary, collaborative care can be effective when it is achieved. An audit of medical records of patients with type 2 diabetes with multidisciplinary care plans found an association with higher allied health attendances and improved metabolic control [10]. We described the development and feasibility of an intervention to enhance teamwork between general practice staff and allied health providers, The Team-link Project in an earlier paper [11]. The current paper describes the changes in inter-professional collaboration, communication and patient empowerment using qualitative data from the study. Methods Recruitment and study population Recruitment of practices and AHPs was undertaken by four Divisions of General Practice to ensure an arm s length and voluntary recruitment process. Twenty-six general practices participated with 35 GPs and 39 allied health providers, mainly in private practice but including some public diabetes educators at community health-care centres, who had had a current referral relationship with the participating practices. Intervention The intervention consisted of one evening workshop for GPs, practice staff and AHPs (including podiatrists, optometrists, diabetes educators, dietitians, cardiac rehabilitation workers, exercise physiologists and psychologists) involved in chronic disease care. Eight identical workshops were held; two for participants from each Division, to achieve 100% attendance by GPs. At the workshop the intervention was described and principles of teamwork were discussed. This was followed by a case study using a role-played phone conversation for a prospective referral involving a GP, a patient and an AHP. During the subsequent 6 months, an intervention facilitator based at a local Division of General Practice made three visits to each practice, where staff were introduced to the intervention resources. These resources consisted of a referral directory, referral forms, referral criteria, care plan templates, patient education materials and billing systems for TCAs. Intervention activities were tailored to the needs of each practice. The facilitator also provided ongoing support to the practices through informal visits or by phone between planned visits, which included addressing problems and reviewing progress. The intervention facilitators liaised with the allied health services in person or by telephone to facilitate referral and support direct communication. 520

Finding common ground? Table 1 Collaboration between GPs, practice staff, AHPs and patients Baseline practice Enhanced practice following... intervention Practice perspective AHP perspective Practice, AHPs and patients... 1.1 GP made referrals to AHPs 2.1 AHPs provided clinical advice to patients 1.2 GPs informed patients about reasons for referrals 2.2 AHPs provided reports to GPs and visited practices Data collection Qualitative data were collected throughout the intervention from three sources: (1) Reports (n ¼ 44) were provided by intervention facilitators after visits to practices to track the process of the intervention and record any changes to communication pathways. (2) GPs provided reports at baseline and 6 months (n ¼ 49) in response to practice audits, which took place after the workshop and 6 months later, undertaken by the researchers. These audit reports listed the clinical care measures of each practice compared with the division and national averages. (3) AHPs (n ¼ 39) were surveyed at 6 months to discover their views about referral satisfaction, means of communication, benefits of TCAs and the roles of practice nurses. Data analysis Data from facilitator observations, GP reports and AHP surveys were entered verbatim into a qualitative analysis database [12]. Initial coding was undertaken using the approach of D Amour et al. [8] which focuses on the actor and the action: who collaborated with whom, and the form of that collaboration. Two researchers did the coding. Independent coding of 10% of the data was undertaken to ensure consistency; any differences identified were discussed until agreement was reached. A secondary analysis was undertaken to see how the patterns of collaboration changed during the intervention. This study was approved by the Human Research Ethics Committee of the University of New South Wales, Australia and all participants provided full informed consent. Results 3.1 Patients provided feedback to GPs about their conditions and AHP consultations 3.2. Patients provided feedback about their conditions and about AHP consultations to practice staff who provided support to patients about self-management and contacting 3.3 Three-way communication took place by phone between GPs, patients and AHPs to track progress and negotiate goals for the care plan and discuss patient progress 3.4 Practice team improved communication processes with AHPs Enhanced collaboration emerged to fit the intentions of the TCAs with its emphasis on collaborative care between GPs, AHPs and patients following the intervention. This development is summarised in Table 1. Baseline collaborative actions At baseline the range of collaborative actions was restricted to the traditional approaches of GPs referrals to AHPs and AHPs written reports to GPs. There was evidence at baseline that GPs had a limited understanding of the roles and capabilities of AHPs, which influenced the extent of their collaboration and referral behaviours. This is illustrated in a facilitator s report: At the beginning GP did not entirely trust AHPs [dietitians] to treat the patient as he wanted them treated, so he was doing all the work himself. This lack of trust was attributed to a poor understanding of the role of AHPs, and the fact that GPs and AHPs did not know each other. One GP asked if it was possible for the Division to organise a workshop with a relevant topic where GPs and AHPs could meet and talk to each other in a friendly environment to improve relationships. Getting to know each other on a personal level was seen as helping with better communications. At the outset referral to AHPs was seen to be the GP s responsibility: The GP knows his patients idiosyncrasies and will pick an AHP that deals with the individual needs of his patients. (Facilitator s report) 521

Chan et al. Thus it was considered the GP s role to explain to patients the reasons for the referral. One GP commented: [With] better understanding of Diabetes Clinic and services, I am more confident in educating patients regarding the benefits of these services. AHPs were very conscious that the GP had authority to refer and that they were dependent on GP referrals so that their patients could receive Medicare subsidies. This sometimes meant that patients were referred back to the GP for a care plan so that patients could receive subsidised care: Some AHPs are suggesting patients to get EPC [Enhanced Primary Care] referral to patients who are not eligible [i.e. reverse referrals] She [GP] said they [her patients] were told by AHP or other people to go to the GP and ask for a referral that they were often not eligible for [citing the examples of a 19 year old female patient and another elderly patient with quite a stabilised condition]. (Facilitator s report) These observations suggested scope for improvement in collaboration between GPs and AHPs, so as to move beyond referrals made merely for reasons of meeting criteria for payments. AHPs were very aware of the importance of providing reports to practices and building relationships with GPs. [Writing] Letters back to the GP are essential but they have little time for anything else. Contact with the Division and personal contact would be great but not too many opportunities are available. An AHP raised this issue. Similarly an AHP made the following comment: The more contact with the referring Dr the more they [GPs] realise that AHPs play an integral role in the management of their patients in a positive way. Enhanced collaborative actions associated with the intervention The intervention was associated with a broader involvement of patients in their own care through a series of collaborative actions (see Table 1; 3.1). This included patients providing feedback to GPs about their conditions and AHP consultations: GP stated that he is getting feedback from patients saying they are happy with the AHP they had seen, and this is how he finds out if they have been sent to the right AH person. (Facilitator s report). A facilitator noted the following: The GP stated that the patients feel that their care has improved as the GP is asking [patients] more questions. One GP said: To give the patient a role to play e.g. to measure their waist circumference on a regular basis. This makes it interesting for both the patient and the GP. This suggests that in some practices there was a new pattern of collaboration in which patients were involved in discussions about their care and in elements of self-management. There was evidence of more involvement of practice staff, apart from the GP, in communication with the patient, and of improving collaboration with AHPs. This included actively seeking information from patients (see Table 1; 3.2). The facilitator observed this happening in a practice: The [ practice] team agreed to get feedback from patients, after referral, on the AHP & mark the address book [containing the practice s frequent contacts] as positive or negative. Three-way communication took place by phone between GPs, patients and AHPs, to track progress and negotiate goals for the care plan and discuss patient progress (see Table 1; 3.3). One of the collaborative strategies practices in the training evening was to model teamworking by roleplaying a team consultation. This approach was commended by one GP, as reflected in this observation by the facilitator: GP stated that he has had great success with phoning the AHP and discussing the patient s care, while the patient is present in the room...it also breaks the ice and establishes a rapport with allied health before the patients consult[ation] There was also evidence of communication and sharing within the practice and with the AHPs located outside the practice (see Table 1; 3.4). This included delegation and shared planning:...he [GP] is able to delegate to others and the working of the practice is more structured between all staff now. As one AHP described: [Contact] GPs to discuss management plan with AHPs or their practice nurse if the case is straightforward. Both GPs and practice staff were also involved in more direct communication with AHPs than previously: They [GP and practice staff] like to exchange referral information with AHPs. They like to communicate more with them by phone and welcome them to visit the surgery. (Facilitator s report) Discussion Participants reported an improvement in teamwork, which included an enhanced role for the patient, as suggested by Stewart [4] and Boon [7]. On the basis of the qualitative findings, we propose a simple aspirational model of team work to describe the collaborations involved (see Fig. 1). Each arrow represents a collaborative pathway between the GP practice team, patients and AHPs which was observed 522

Finding common ground? Figure 1 The multidisciplinary collaborative care model. within the Team-link intervention and the care process. The shaded arrows describe the enhanced pathways following the intervention. These collaborative pathways were observed which built upon the standard processes of written referral from the GP and written report back to the GP following consultation or treatment. These developments followed a relatively low-intensity intervention that included training and structured facilitation visits as well opportunities for joint working between GPs, practice staff and AHPs. In this study improved collaboration appeared to depend on the development of personal relationships among the team members, facilitated by face-to-face or telephone meetings and discussion of patients needs. Following the intervention there was evidence of increased patient participation in their care by the pathway connecting GPs and patients as GPs encouraged patients to take control over their own health. Practice staff played an important supporting role with AHPs who increasingly took the initiative in follow-ups. Some GPs shared tasks, which had previously been their sole province, with reported benefits for the efficiency of care and the GP s personal workload as GPs delegated jobs; practice nurse increasingly acted as case managers. There was also evidence from some practices that patients were seen as partners in care, as sources of information about their condition, and as contributors to decisions about future care. This paper reports qualitative findings in urban Australian general practices with relatively high availability of AHPs, and it cannot be inferred that this approach of education and structured facilitation will be successful in other settings. It does, however, illustrate elements of increased teamwork between GPs, practice staff, AHPs and patients, and it points to some of the factors that might limit teamwork, such as lack of face-to-face interaction and poor understanding of roles and capabilities. The practices responded voluntarily to requests from their DGP to participate in the study. They may thus have been more receptive to change than practices that did not participate. Our findings fit well with the literature and in particular the synthesis of D Amour et al. [8]. There was evidence of increased sharing of responsibilities between GPs, practice staff, AHPs and patients, including goal setting, sharing data and some collaborative decision making. Collaborative processes became more evident during the intervention, including team consultations that included and empowered the patient. These processes depended on the financial incentives and subsidies provided by the Medicare TCAs and the Enhance Primary Care subsidies for patients. The major benefit of improved teamwork should be an improvement in the quality of patient care as understood in the widely accepted Chronic Care Model [13]. The introduction of financial incentives such as TCAs and Enhanced Primary Care subsidies does not ensure multidisciplinary care or teamwork per se. Our previous paper showed that a short intervention made up of one interdisciplinary workshop, structured facilitation within the practice and telephone support was feasible in Australian primary care [11]. This paper shows how new collaborative pathways developed between GPs, practice staff, AHPs and patients. We conclude that this intervention to assist in increasing collaborative teamwork may contribute to more effective multidisciplinary care for people with chronic diseases. Our findings form the basis of an aspiration model of teamwork (see Fig. 1) which maps the main collaborative actions and processes required if we are to provide patient-centred and multidisciplinary care for the increasing numbers of Australians with chronic diseases. This model should be expected to enhance internal and external teamwork in chronic disease management based on our research. 523

Chan et al. Acknowledgements The authors acknowledge all participating practices and Divisions of General Practice. We thank Ms Julie McDonald for her secondary analysis of qualitative data. This paper is presented on behalf of the Team-link project research team which includes: Dr Teresa Anderson, Dr Andrew Boyden, Dr Jeff Flack, Ms Elizabeth Harris, Dr Upali Jayasinghe, Dr Stephen Lillioja, A/Prof Judy Proudfoot, A/Prof Gawaine Powell-Davies, Dr Thanuja Athukorlalage, Dr Joyce Chong, Ms Bettina Christl, Ms Sheila Cooper, Ms Maureen Frances, Ms Sue Kirby, Dr Mahnaz Fanaian, Ms Linley Marshall and Ms Danielle Noorbergen. Funding This work was supported by an Australian Health Ministers Priority Driven Research Grant. References 1. Harris MF, Zwar N. Care of patients with chronic disease: the challenge for general practice. Med J Aust 2007;187:104 7. 2. Harris M. Divisions Diabetes & CVD Quality Improvement Project. Paper presented at Action on Quality Conference, Sydney, 2003, November. 3. Harris MF, Chan CB, Dennis SM. Coordination of care for patients with chronic disease (Editorial). Med J Aust 2009;191:85 6. 4. Stewart M, Brown JB, Weston WW et al. Patient-Centred Medicine: Transforming the Clinical Method. 2nd edn. Abington: Radcliffe, 2003. 5. Mickan SM. Evaluating the effectiveness of health care teams. Aust Health Rev 2005;29:211 17. 6. Kirby SE, Chong JL, Frances M et al. Sharing or shuffling realities of chronic disease care in general practice. Med J Aust 2008;189:77. 7. Boon H, Verhoef M, O Hara D et al. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res 2004;4:15. 8. D Amour D, Ferrada-Videla M, San Martin Rodriguez L et al. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care 2005;(Suppl 1);19:116 31. 9. Harris MF, Harris E. Facing the challenges: general practice in 2020. Med J Aust 2006;185:122 4. 10. Zwar NA, Hermiz O, Comino E et al. Do multidisciplinary care plans result in better care for patients with type 2 diabetes? Aust Fam Physician 2007;36:85 9. 11. Harris MF, Chan BC, Daniel C et al. Development and early experience from an intervention to facilitate teamwork between general practices and allied health providers: the Team-link study. BMC Health Serv Res 2010;10:104. 12. Nvivo, Version 8, Melbourne: QSR International Pty Ltd, 2008. 13. Wagner E. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1:2 4. 524