Evaluation of the GP Super Clinics Program 2007-2008

7.3.1 Multi-disciplinary Care

Page last updated: 2012

Multi-disciplinary care involves a range of professionals and commonly includes medical, nursing and allied health professionals. Multi-disciplinary care has been demonstrated to improve outcomes especially for patients with chronic illnesses.16,38 Key to the primary care reform under the GP Super Clinics Program was improved care and outcomes for people with or at risk of a chronic illness, and for older people.

High quality chronic disease management requires “a longitudinal and preventive orientation manifested by well-designed, planned interactions between a practice team and a patient in which the important clinical and behavioral work of modern chronic illness care is performed predictably”.39 Ideally, this requires an integrated and coordinated approach by a multi-disciplinary care team with regard to assessment, treatment, support for self-management and follow-up.39

Evidence for multi-disciplinary care is derived from research on specific models and from the roles of particular disciplines. There is evidence that multi-disciplinary teams can improve outcomes in a range of patient groups.16,38,40 In both acute and primary care settings multi-disciplinary care is associated with improved clinical outcomes and other indicators such as reduced hospital admissions.41 Indeed, there is increasing evidence that the design of the care team and the contribution of disciplines are the primary determinants of quality of care for people with chronic illnesses.39 Importantly, evidence exists that these outcomes accrue to disadvantaged groups within communities.23

Primary care nurses undertake a multitude of tasks in general practice, only some of which are funded under some form of fee-for-service model.42 The funding arrangements changed in 2012 to provide incentives for practices to enable employment of nurses to undertake broader roles than those funded under the fee-for-service model. Nurses can provide the same quality of care and achieve equivalent health outcomes for patients with certain conditions as doctors, and given the right organisational climate can contribute to improving the quality of care in General Practice.42,43 Similarly, allied health staff in primary care have demonstrated improvements in quality of life and reduced hospital admissions for patients with chronic illnesses.44

The elements required for effective and integrated models for multi-disciplinary care include flexibility and cooperative team-work with a clearly identified coordinator and supported by effective communication processes. These models are enhanced through the use of evidence-based polices, guidelines and protocols pertinent to the multi-disciplinary team.45

The provision of multi-disciplinary care alone within a single practice will not ensure that care is integrated for patients across the discipline spectrum. The challenges facing most modern health care systems require integration between the elements of health care in order to meet patients’ needs, particularly those with chronic illness.17 Integrated care is defined as patient care that is “coordinated across professionals, facilities, and support systems; continuous over time and between visits; tailored to the patients’ needs and preferences; and based on shared responsibility between patient and caregivers for optimizing health.”17 Promoting the concept of integrated care assumes that patient experiences and outcomes are better under models where care is integrated among systems, facilities and clinicians.17

Integrated care goes beyond the sharing of information, such as provided through a shared electronic health record.46 It needs to be complemented by formal and informal relationships among disciplines to support communication, and by shared care planning.47 Mechanisms which have traditionally been applied to support integrated care, but were less than optimal, have been sharing of written patient records, informal communication within practices, referral letters and visit summaries with providers external to the practice.47

The GP Super Clinics are implementing multi-disciplinary care especially for patients with chronic illnesses. That is, patients are receiving aspects of their care from multiple disciplines. The high level of positive patient experience in relation to the care provided at the GP Super Clinics is an indication of contribution to patient need. In most but not all instances, this care was integrated within the GP Super Clinic setting. The co-location of multiple disciplines under one roof and the shared electronic health record were perceived as major contributors to integration.

The extent to which the models of multi-disciplinary care were evidence-based was not as obvious. Co-location and a shared health record alone may facilitate, but do not constitute, multi-disciplinary care. Indeed, there is a risk that in the absence of a greater focus on applying evidence-based guidelines which reflect the multi-disciplinary nature of care, health outcomes which are expected to accrue from this type of model of care may be less than optimally achieved. An over-reliance on corridor conversations and shared electronic health records has the potential to neglect evidence and quality, and thus limit patient outcomes.

There are a number of unanswered challenges in relation to the application of multi-disciplinary models in GP Super Clinics. Guidelines which are being used in GP Super Clinics, have commonly been adapted from those developed by the RACGP or other discipline specific organisations. The GP Super Clinics are a relatively new structural approach to provision of care and hence offer a range of opportunities for research questions and testing interventions specific to this type of setting. As they are sites of excellence in new models of primary care, GP Super Clinics have potential to work in partnership with universities and other research bodies to answer some of these questions.

Clinical Governance

Under the GP Super Clinics Program objectives, models of clinical governance and shared care protocols are expected. Clinical governance is defined as a systematic and integrated approach to assurance and review of clinical responsibility and accountability that improves quality and safety resulting in optimal patient outcomes.48 As in other health settings, clinical governance approaches in primary care provide some fragmented evidence of impact on quality.49

Involvement of primary health care providers in clinical governance at the local level is recommended as having most potential, particularly if supported by regional networks and structural changes nationally to allow for funding for time for clinical governance, and information systems to access clinical data.49 A key concept in the GP Super Clinics Program objectives was that clinical governance would reflect the multi-disciplinary nature of care.
There are a range of approaches for achieving effective clinical governance, including: continuous improvement, quality assurance, audits, using clinical indicators, promotion of evidence-based practice, participation in accreditation processes, risk management, and a suite of other activities.50 Reporting of clinical performance data to clinical teams, including those in primary care, as part of clinical governance initiatives, has been shown to result in significantly improved clinical outcomes.51 52

Some of these approaches have been applied to some extent in all GP Super Clinics. However, there was very limited evidence of formal, systematic approaches to and multi-disciplinary involvement in clinical governance approaches. Implementing clinical governance in multi-disciplinary settings such as GP Super Clinics was reported by clinicians as being an area where they had limited previous experience. As such it is an area that requires close attention in the short term, and regular monitoring in the long term.

16McDonald J, Cumming J, Harris M, Powell Davies G, Burns P. Systematic Review of Comprehensive Primary Care Models. Sydney: Australian Primary Health Care Research Institute;2006.
17Singer S, Burgers J, Friedberg M, Rosenthal M, Leape L, Schneider E. Defining and Measuring Integrated Patient Care: Promoting the Next Frontier in Health Care Delivery. Medical Care Research and Review. 2010;68(1):112-127.
23Lee A, Kiyu A, Milman H, Jimenez J. Improving Health and Building Human Capital Through an Effective Primary Care System. Journal of Urban Health. 2007;84(0):75-85.

38Wagner EH. The role of patient care teams in chronic disease management. British Medical Journal. 2000;320(569-572).
39Rothman AA, Wagner EH. Chronic Illness Management: What Is the Role of Primary Care? Annals of Internal Medicine. February 4, 2003 2003;138(3):256-261.
40Wensing M, Vedsted P, Kersnik J, et al. Patient satisfaction with availability of general practice: an international comparison. Int J Qual Health Care. 2002;14:111 - 118.
41McAlister FA, Stewart S, Ferrua S, McMurray JJJV. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomized trials. Journal of the American College of Cardiology. 2004;44(4):810-819.
42Pearce C, Phillips C, Hall S, et al. Following the funding trail: Financing, nurses and teamwork in Australian general practice. BMC Health Services Research.11(1):38.
43Laurant M, S B, Reeves D, Hermens R, Braspenning J, Grol R. Substitution of doctors by nurses in primary care. A systematic review for EPOC. Cochrane Collaboration. 2004.
44Mitchell G, Brown R, Erikssen L, Tieman J. Multidisciplinary care planning in the primary care management of completed stroke: a systematic review. BMC Family Practice. 2008;9(1):44.
45Ehrlich C, Kendall E, Muenchberger H, Armstrong K. Coordinated care: What does that really mean? Brisbane: Griffith University and General Practice Queensland;2008.
46Crooks V, Agarwal G. What are the roles involved in establishing and maintaining informational continuity of care within family practice? A systematic review. BMC Family Practice. 2008;9(1):65.
47Reid RJ, Wagner EH. Strengthening primary care with better transfer of information. CMAJ: Canadian Medical Association Journal. 2008;179(10):987-988.
48Introduction to clinical governance — a background paper. Perth: Office of Safety and Quality in Health Care: Western Australian Department of Health;2001.
49Phillips C, Pearce C, Hall S, et al. Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence. Medical Journal of Australia. 2010;193(10).
50Braithwaite J, Travaglia J. An overview of clinical governance policies, practices and initiatives. Australian Health Review. 2008;32(1):10-22.
51Otoole TP, Cabral R, Blumen JM, Blake DA. Building high functioning clinical teams through quality improvement initiatives. Quality in Primary Care.19(1):13-22.
52Campbell S, Sweeney GM. The role of clinical governance as a strategy for quality improvement in primary care. Britiish Journal of General Practice. 2002;52(Supplement):S12-S18.