1. UNSW research centre for primary health care and equity Facilitating Multidisciplinary Teamwork between General Practice and Allied Health Professionals Dr Bibiana Chan, Team-link Co-ordinator Bettina Christl & Danielle Noorbergen, Data collectors

2. UNSW Research Centre for Primary Health Care & Equity Investigators Chief Investigators CIAProfessor Mark Harris CIBProfessor Nick Zwar CICProfessor Patrick Crookes CIDA/Professor David Perkins CIEA/Professor Judy Proudfoot CIFA/Professor Gawaine Powell-Davies Associate Investigators A/Professor Stephen Lillioja Dr Jeff Flack Mrs Elizabeth Harris Dr Teressa Anderson Dr Andrew Boyden Dr Upali Jayasinghe

3. UNSW Research Centre for Primary Health Care & Equity Aims The specific objectives of the study are: To design a practice-based intervention to improve multidisciplinary teamwork within general practices and between practices and other services ( by allied health professionals) To evaluate the impact of this intervention on the quality of care for patients with diabetes, ischaemic heart disease and hypertension

4. UNSW Research Centre for Primary Health Care & Equity The Team-link Study To evaluate the outcomes of multidisciplinary care in General Practice in chronic disease management QUAN Data  The quality of care to patients with diabetes, ischaemic heart disease/hypertension ( Clinical audits, SF12, Clinical Care Interviews, Practice Profile Interviews )  Patient satisfaction ( PACIC )  Measures of Multidisciplinary Linkages ( MoML_GP, MoML_RS ) QUAL Data  Facilitator’s Practice- visit reports  GPs Feedback  AHPs comments

5. UNSW Research Centre for Primary Health Care & Equity Defined roles Protocol External Linkages Training Leadership Communication Building effective teams requires

6. UNSW Research Centre for Primary Health Care & Equity Structure of intervention  Education session for GPs and referral services (2 hrs) –Focus on roles and responsibilities, effective teamwork, and communication –element of shared learning - allow for building personal links e.g. Case Conferences involving GPs, AHPs and patients 3 Structured practice visits over 6 months (1 - 1.5 hr each) –Conducting needs analysis, –helping practices formulate PDSA cycles –linkages with AHPs (visits by AHPs, small group learning sessions at DGPs, referrals and electronic record download) Ongoing support –IT Support, troubleshooting & guidance –Provide info on evidence based care of diabetes, CVD, and hypertension.

7. UNSW Research Centre for Primary Health Care & Equity Research Participants DivisionCentralSE SydneySW SydneyMacarthurTotal GP 13561034 Nurse 10179 Receptionist 1079834 Practice Manager 511310 Diabetes Educator 213 (8%) Dietician 2314*10 (26%) Ex Physiologist 21025 (13%) Incontinence Nurse 11 (3%) Physiotherapist 224 (10%) Podiatrist 241613 (33%) Psychologist 134 (10%) Occupation Rx 11 (3%) AHPs Sub-total8 (RR 31%) 10(RR 40%)3 (RR 23%)18 (RR 30%)39/41* RR = 31% RR - Response Rate * Two of the Dieticians were also Ex Physiologist s Average

8. UNSW Research Centre for Primary Health Care & Equity QUAL Data: Organisational Collaboration Local DGPs Board Members, Program managers, project officers, IT officers AHPs In-house AHPs, AHPs based at DGPs, private practices and public services Practices GPs, Practice Nurses, Non-Clinical staff Support and Training

9. UNSW Research Centre for Primary Health Care & Equity GPs AHPs Prac Nurses & staff Patients Why referred? Practices Referrals Reports & Visits feedback Support concerns Staff meetings Professional Advice Admin stuff & Follow-ups New paths Team-link Qual data : Communication Info from practice Info from AHPs 3-way communication via phone between GP, patient and an AHP

10. GPs Team-link Qual data: Partnership UNSW Research Centre for Primary Health Care & Equity AHPs Prac Nurses and other staff GPs - delegate jobs PNs - case manager Follow-ups and other admin stuff Team leaders with decision making POWER Team members GPs acknowledge the roles of AHPs; Building up TRUST within the team Patients PNs provide education Patients- Self-manage GPs acknowledge patient’s control of their own health Team members provide admin support & clinical care services, Free up GP’s time for patient consultations provide specialised care & monitor patient progress Patient- centred care Referrals & Timely reports

11. UNSW Research Centre for Primary Health Care & Equity Most benefit was opportunity to interact with AHPs and find out what they need from us and what they can do for us and our patients to improve patient health. (Small Group Learning Central) 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. The professional relationship takes time to build up, usually relies on the GPs to initiate the process. (AHP Survey). At the beginning GP did not entirely trust allied health professionals (dieticians) to treat the patient as he wanted them treated, so he was doing all the work himself. Now he is using Division’s dieticians and can see the value of their participation. (Macathur) TRUST Where does TRUST (sharing) start?

12. UNSW Research Centre for Primary Health Care & Equity Developing educational strategies for patients in self- management. GP is keen in supplying education on lifestyle changes for his patients in relation to their chronic conditions (SW Syd).. I think it is more important to have a relationship with the doctor than the practice nurse as it is the Dr who has the decision making power regarding treatment (AHP Survey). GP knows his patients idiosyncrasies and will pick an AH professional that deals with the individual needs of his patients. (Macathur) POWER Who holds the POWER?

13. UNSW Research Centre for Primary Health Care & Equity GP suggested regular internal group meetings in the future will be helpful for them to strengthen the exchange of ideas within the internal team (SW Syd).. The management of chronic disease depends on the patient moving in and out of the various layers of the health system easily (AHP Survey). 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 (Macarthur). PARTNERSHIP How to establish PARTNERSHIP?

14. UNSW Research Centre for Primary Health Care & Equity Power Maintain status quo Sharing Need to establish personal relationship and trust Interdependency Understand values and roles of Team Members Core concepts of inter-professional collaboration (D’Amour et al 2005) Within the Team-link Intervention Process

15. UNSW Research Centre for Primary Health Care & Equity Power Maintain status quo - referral protocol - reverse referral (inappropriate) - relationship and interaction - patient empowerment (self-management) - Medicare Sharing Need to establish personal relationship and trust - patient’s vital clinical data - care plans (TCAs) - communication channels - responsibilities (clarified roles) - clinical experiences (case studies) - knowledge (small group learning) Interdependency Understand values and roles of Team Members - GPs recognise contributions of PNs - GPs acknowledge the roles of AHPs - GPs endorse multidisciplinary care Core concepts of inter-professional collaboration (D’Amour et al 2005) Within the Team-link Intervention Process

16. GPs’ overall feedback on Team-link Intervention … prior to the study, communication within the practice was disjointed and now he is happy to delegate to others which reduces his workload. Mac PN stated that the structure had made it easier to work with the patients. The patients are encouraged by the interest taken in their care, which makes the patient more compliant. Mac Overall there is better understanding than a year ago. The study has highlighted the importance of better communication and understanding of each others roles. Mac 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. … Mac there has not been enough passage of time to come to a conclusion as to whether there is better communications with AHPs at this time. Mac Dr said, “I have a low opinion of 'teamwork'.” SES

17. UNSW research centre for primary health care and equity Thank you For more information, contact M.F.Harris@unsw.edu.au or Bibi.chan@unsw.edu.au www.cphce.unsw.edu.au