出版社：Utrecht University, Maastricht University, Groningen University
摘要：Background : Persisting systems gaps and fragmented care within and between primary and secondary healthcare teams are key national and international issues. For patients, this fragmentation is compounded by poor communication. Continuity and coordination of patient-centred care requires effective communication, coordination, teamwork, and judicious use of eHealth tools within a medical home and across the health neighbourhood. This Integrated Healthcare Homes and Neighbourhood (IHH&N) program is a response. Conceptual framework : General practice is the logical Healthcare Home and hub of the Healthcare Neighbourhood to coordinate care across primary, secondary, acute, aged and social sectors. Multidimensional integration of data/information, clinical & managerial workflow, and professional practice with a person-centred multidisciplinary team, underpinned by the Chronic Care Model, is essential. The Healthcare Neighbourhood includes primary ambulatory and secondary care services in a locality that relates largely to a hospital-based service provider. It is a logical denominator to assess the comparative effectiveness of interventions. Its size may vary based on geography and/or population requirements. Aim : To describe an Australian case study to (1) demonstrate the data, clinical, managerial and inter-professional integration required, and (2) highlight the governance, clinical, managerial and evaluation challenges. Setting and context : A network of general practice- and hospital-based services in SW Sydney established by the UNSW/SWSLHD Academic General Practice Unit to support its health services research and development (R&D) program. Methods : A mixed methods case study using data collected from review of protocol documents and publications, staff and patient interviews, participant observation, record linkage and EHR data quality assessment. A self-assessment of Informatics Capability Maturity (ICM) describes how the organisation collects, links, manages and shares information, manages technologies and change, governs data quality and use, and uses “business intelligence” to plan and monitor care. Key findings : Primary and secondary care clinicians fail to share data beyond traditional referral letters and discharge summaries. Quality, privacy and security standards were reported governance issues. Available tools to collect/extract, assess and manage the quality of data were inconsistent. Tools must be validated transparently and robustly within a data and clinical governance framework. The pseudonym-based record linkage was highly accurate, enabling reliable tracking of patient journeys across primary and secondary care services reliably. Sound-alike ethnic names were a common problem Serious data quality deficiencies persist in primary care and hospital systems. Feedback through structured data quality reports (SDQR) improved quality. The T2DM case finding algorithm was accurate and improved with increasing sample size and number of attributes. Record linkage of cases from general practices, Diabetes Clinic and local hospital suggest GP and clinic visits protect and renal complications predispose to admission. Australian and international collaborators highlighted shared common issues plus: interoperability, proprietary software and transparency; business model and sustainability; multiple ethical perspectives; and cognitive load on patients and clinicians from managing multi-morbidity. Conclusion & recommendations : IHH&N and integrated care requires integrated health data and systems, with local customisations and a sociotechnical approach to implementation. Governance, clinical, managerial and evaluation matters must be addressed through partnerships of local health districts, primary health networks and academic institutions.
关键词：healthcare homes ; health neighbourhoods ; integration ; governance ; clinical ; managerial ; evaluation
