Assessing the Impact of Primary Care-Led Optimisation Clinics in the Management of Type 2 Diabetes: A Service Redesign Pilot Study.

Background Many individuals diagnosed with type 2 diabetes (T2D) in the London Borough of Waltham Forest, treated solely with oral hypoglycaemic medications (OHAs), exhibit increased levels of glycated haemoglobin (HbA1c). While specialised community and secondary care clinics are at full capacity, a gap exists for dedicated diabetes optimisation services at the primary care level. This study aimed to launch a remote Primary Care Network (PCN)-based clinic during the coronavirus disease 2019 (COVID-19) pandemic to enhance the management of OHAs, introduce motivational interviewing, and incorporate patient empowerment strategies in tandem with a secondary care endocrinologist. The primary objective was to evaluate the impact on HbA1c levels and other metabolic parameters. Concurrently, the "behaviour change model" served to measure patient engagement. Methodology We recruited 43 patients in this study, each undergoing a 30-minute consultation focused on diabetes management. A dedicated administrator ensured patient engagement and a three-month follow-up with repeat metabolic profile testing. Sustained, high-quality care was upheld through bimonthly remote consultations, receiving expertise from an endocrinology consultant. Results Of the pilot's 38 patients managed solely with OHAs, 31 achieved an HbA1c reduction of more than 11 mmol/mol. The overall median reduction for the entire cohort was significant (initially 88 mmol/mol versus 70 mmol/mol, p < 0.0001). Triglyceride levels also saw a notable median decline (1.56 mmol/L down to 1.20 mmol/L, p = 0.0247). Of the 38 completing the pilot, 14 had behavioural stages recorded both initially and at follow-up. Employing motivational interviewing led to significant diabetes-related behavioural changes in 11 of the 14 patients. Conclusions A PCN-based optimisation clinic, augmented with active recall strategies, was a cost-effective method to boost awareness, self-management, and glycaemic control among individuals with T2D. These PCN-led clinics orchestrated by primary care clinicians offer a streamlined solution for achieving treatment benchmarks even amid the challenges of the COVID-19 pandemic.

Comparative evaluation of an electrocardiogram workflow model for athletic cardiovascular screening: Primary care network versus sports cardiology interpretation.

BACKGROUND: Electrocardiogram (ECG) testing in pre-participation screening (PPS) remains controversial due to its cost, resource dependency, and the potential for inaccurate interpretations. At most centres, ECGs are conducted internally by providers trained in athletic ECG interpretation. Outsourcing ECG requisitions to an athlete's primary care network (PCN) may reduce institutional demands. This study compared PCN-conducted athletic ECG interpretation to expert sports cardiology interpretation. METHODS: This was a retrospective, single-centre chart-review study of all athletes who underwent cardiovascular PPS between 2017 and 2021. All athletes submitted an ECG with their screening package, which was conducted and interpreted within their PCN. All ECGs were reinterpreted by a sports cardiologist using the International Criteria (IC) for electrocardiographic interpretation in athletes. Overall, positive, and negative percent agreement were used to compare PCN-conducted ECG interpretation with IC interpretation. RESULTS: A total of 740 athletes submitted a screening package with a valid ECG (mean age: 18.5 years, 39.6% female). PCN-conducted ECGs were interpreted by 181 unique physicians. Among 41 (5.5%) PCN-conducted ECGs that were initially interpreted as abnormal, only 5 (0.7%) were classified as abnormal according to the IC. All PCN-conducted ECGs reported as normal were also classified as normal according to the IC. The overall agreement between PCN-conducted and IC ECG interpretation was 95.1% (positive percent agreement: 100%, negative percent agreement: 95.1%). CONCLUSIONS: Normal PCN-conducted athletic ECGs are interpreted with high agreement to the IC. Majority of PCN-conducted ECGs interpreted as abnormal are indeed normal as per the IC. These findings suggest that a PPS workflow model that outsources ECG requisitions to a PCN may be a reliable approach to PPS, all while reducing screening-related institutional costs and resource requirements.

Family Physician Prescribing Practices and Perspectives on Shared Decision-Making Regarding the Use of Oral Anticoagulants for Stroke Prevention in Patients 75 Years or Older With Atrial Fibrillation.

INTRODUCTION: Atrial Fibrillation (AF) is common in older adults, yet guideline-recommended oral anti-coagulants (OACs) for stroke prevention are underused in this population. With a growing population of older adults at risk of AF seeking primary care, the objective of the study was to determine the management practices and perspectives of family physicians on the initiation of OACs for stroke prevention in AF patients 75 years or older, including their engagement of patients in shared decision-making. METHODS: This was an online survey of family physicians affiliated with a Primary Care Network in Alberta, Canada. RESULTS: Patient's risk (of falls, bleeding, or stroke) was the most common factor (17/20, 85%) physicians considered when deciding to initiate OAC in older adult patients with AF. Physicians used the CHADS2VASC (13/14, 93%) and HASBLED (11/15, 73%) tools to determine stroke and bleeding risks, respectively. Majority (11/15, 73%) of the physicians agreed that they feel confident initiating OAC for AF patients ≥75, while 20% (3/15) were neutral. All physicians agreed that their patients participated in shared decision-making to initiate OAC for stroke prevention. CONCLUSION: Family physicians strongly consider patient risks and utilize risk-assessment tools when initiating OAC in older adults with AF. Despite all physicians reporting the use of shared decision-making and that their patients were educated on the indications for OAC, confidence in initiating treatment was variable. Further exploration into factors impacting physician confidence is needed.

Building a Data Bridge: Policies, Structures, and Governance Integrating Primary Care Into the Public Health Response to COVID-19.

PURPOSE: The effective integration of primary care into public health responses to the COVID-19 pandemic, particularly through data sharing, has received some attention in the literature. However, the specific policies and structures that facilitate this integration are understudied. This paper describes the experiences of clinicians and administrators in Alberta, Canada as they built a data bridge between primary care and public health to improve the province's community-based response to the pandemic. METHODS: Fifty-seven semistructured qualitative interviews were conducted with a range of primary care and public health stakeholders working inside the Calgary Health Zone. Interpretive description was used to analyze the interviews. RESULTS: SARS-CoV-2 test results produced by the local public laboratory were, initially, only available to central public health clinicians and not independent primary care physicians. This enabled centrally managed contact tracing but meant primary care physicians were unaware of their patients' COVID-19 status and unable to offer in-community follow-up care. Stakeholders from both central public health and independent primary care were able to leverage a policy commitment to the Patient Medical Home (PMH) care model, and a range of existing organizational structures, and governance arrangements to create a data bridge that would span the gap. CONCLUSIONS: Primary care systems looking to draw lessons from the data bridge's construction may consider ways to: leverage care model commitments to integration and adjust or create organization and governance structures which actively draw together primary care and non-primary care stakeholders to work on common projects. Such policies and structures develop trusting relationships, open the possibility for champions to emerge, and create the spaces in which integrative improvisation can take place.

[Management of congestive heart failure in the elderly after hospitalization for acute decompensation Interest of a dedicated territorial geriatric network ; the GERICCO-78 study]. / Prise en charge de l'insuffisance cardiaque chronique chez le sujet âgé fragile après hospitalisation pour décompensation aiguë ; apport d'une cellule de coordination ville-hôpital ; étude GERICCO-78.

AIMS: Heart failure (HF) is the leading cause of hospitalisation in the elderly in France. Early rehospitalisations are common, often through an emergency department. The aim of this study was to assess the impact of a primary care-hospital coordination network, with interventions by coordination nurses (IDEC), on the rehospitalisations after a first hospitalisation for acute decompensation in frail elderly HF patients. METHODS: From 01/10/2019 to 01/10/2021, 237 patients aged > 75 years with frailty criteria, hospitalised in 8 departments of 5 private or public hospitals in the Yvelines Sud health territory were followed by an IDEC (hospital visit, telephone contacts, home visit(s)) within 3 months of their return home. This prospective observational study analysed the rate of consultations to the emergency room, rehospitalisations (total and for acute HF), and the number of events avoided at 90 days after discharge. RESULTS: The mean age of the patients was 87 years, 54% were women, 68% had a left ventricular ejection fraction > 40%, and 70% had atrial fibrillation. Non-cardiac comorbidities were very frequent. At 3-month follow-up, mortality was 9.3% (22/237), only 27 patients (11.3%) consulted the emergency room for acute HF, and the rehospitalisation rate for HF was 19.8%, without difference according to left ventricular ejection fraction. A consultation to the emergency room or a rehospitalisation for heart failure could be avoided for 10% of patients. CONCLUSION: This study suggests that a primary care-hospital coordination network with dedicated coordination nurses is useful for the management of very elderly frail patients following hospitalisation for heart failure, limiting visits to the emergency room and rehospitalisations.

Developing integration among stakeholders in the primary care networks of Singapore: a qualitative study.

BACKGROUND: Integrating healthcare services across and between the different health system levels can be achieved in a few ways; however, examining the social side of integration is essential and challenging. This paper explores the concept of integration perceived by general practitioners (GPs) and primary care network (PCN) representatives from the regional health systems (RHS) in a GP-RHS PCN and their perceived partnership success. METHODS: In this study, we explored three GP-RHS PCNs in Singapore. We used a qualitative research design and, overall, performed 17 semi-structured in-depth interviews with GPs (n = 11) and PCN representatives (n = 6) from the RHS. All interviews were audiotaped and transcribed verbatim. We conducted thematic analysis to inductively identify themes from the data. Singer's conceptual model of integration types was used as guiding principles to derive relevant and salient themes for integration. RESULTS: GPs and the RHS perceived the concept of integration through a series of interrelated strategies. Within the normative dimension, a sense of urgency motivated GPs to integrate improvements into their general practice. Participants perceived teamwork and relational climate as appropriate enablers for achieving interpersonal integration in a primary care partnership. While developing a trusted relationship was a perceived success of this partnership across the network, developing camaraderie and gaining knowledge in chronic disease management through the components of functional integration was a perceived success at an individual general practice level. The data also revealed some operational challenges within the structural dimension and some inabilities of the PCN to achieve complete process integration. CONCLUSIONS: Our study points to multi-faceted integration, comprising various forms that need to be manifested at all levels of care to achieve coordinated, seamless, and comprehensive care for patients suffering from chronic conditions. The present iteration of the PCN has been shown to offer integration at a level that warrants praise but still requires structural and process integration improvement.

Tavistock Neighbourhood Nursing Network: collaboration across settings.

The modern matron role in Tavistock has been developed to extend beyond the community hospital to oversee the provision of high-quality care across community nursing services by promoting a collaborative approach to learning and development, via the establishment of a Neighbourhood Nursing Network (NNN). The Tavistock NNN helps nurses to support each other to improve practice and work collaboratively. The aim is to target health promotion and ill health prevention where it will be most effective in order to make services sustainable for the future, including engaging with young people for the purpose of preventing illness. By being part of the network, the nurses have greater power to identify patients or groups of patients at risk of health inequalities and develop innovative ways to promote good health and prevent ill health. The project aims to ensure that high-quality care is delivered throughout the neighbourhood, giving patients and residents the confidence that standards will be consistent in all settings. The network has removed barriers between nursing services and facilitated multidisciplinary working for the benefit of the community they serve.

Primary care networks: an opportunity to improve community wound care.

Primary care networks (PCNs) were introduced in England in 2019 to bring about closer collaboration between general practice and community health services. The ambition is that greater collaboration between services will achieve better patient outcomes and reduce costs through more effective sharing of staff and resources. Wound care might be considered an ideal focus for PCNs, since general practice and community health services not only have a predominant role in the management of wounds, but variable and suboptimal practice continues and poor outcomes persist. This article investigates some ways in which PCNs might enable health-system changes that could improve the provision of wound care.

Encontros na rua: possibilidades de saúde em um consultório a céu aberto / Encounters on the street: possibilities of health in a street health care center / Encuentros en la calle: posibilidades de salud en un consultorio a cielo abierto

O presente estudo debate o Consultório na Rua, envolvendo a cartografia do trabalho de uma equipe de saúde para "pensar": encontros na rua, redução de danos, respeito às pessoas em seus modos de ser/existir/constituir vida e inscrição em modelos próprios de saúde. Foram usados vídeos gravados na rua, atas de equipe e vivências dos autores. No desenvolvimento, foram construídos quatro âmbitos expressivos do contato com essa população: experiência do morar na rua, experiência do atuar com saúde na rua, experiência do aprender em ato de equipe multiprofissional/interdisciplinar e intercessão sociocultural proveniente do "encontro" com essa população. Na conclusão, destaca-se que a presença do consultório na rua não é simplesmente técnica, trata-se de uma presença política na esfera dos direitos, da equidade e da justiça, assim como intervenção política e cultural, respeitando modos de vida, promoção da saúde e defesa da multiplicidade na cidadania.(AU)

The present study discusses street health care and maps out the work of a health team to reflect about: encounters on the street, reducing harm, respecting people in their modes of being/existing/building a life, and the inscription of suitable healthcare models. Videos recordings, team annotations and the experiences of the authors were used for data analysis. The following expressive dimensions were constructed from our contact with the street population: the experience of living on the streets, the experience of working with health on the streets, the experience of on-the-job learning of a multiprofessional/interdisciplinary team, and the sociocultural intersection that originated from our "encounter" with this population. Providing health care on the streets is not a merely technical action, but represents a political presence involving the spheres of human rights, equity and justice, as well as political and cultural interventions. It is a way to respect ways of life, promote health, and defend multiplicity in citizenship.(AU)

En este articulo se discute el Consultorio en la Calle, envolviendo la cartografía del trabajo de un equipo de salud para "pensar": encuentros en la calle, reducción de daños, respeto a las personas en sus modos de ser/existir/constituir vida, e inscripción en modelos propios de salud. Se usaron videos grabados en la calle, actas del equipo y vivencias de los autores. En el desarrollo se constituyeron cuatro ámbitos expresivos del contacto con esta población: experiencia del vivir en la calle, experiencia del actuar con salud en la calle, experiencia del aprender en acto de equipo multi-profesional/inter-disciplinario e intercesión sociocultural proveniente del "encuentro" con esta población. En la conclusión, se subraya que la presencia del consultorio en la calle no es simplemente técnica, sino que se trata de una presencia política en la esfera de los derechos, de la equidad y de la justicia, así como una intervención política y cultural, respetando modos de vida, promoción de la salud y defensa de la multiplicidad en la ciudadanía.(AU)

PRIMARY CARE NETWORK (PCN) AS A MODEL OF CARE FOR GP CHRONIC DISEASE MANAGEMENT

Objectives: The Primary Care Network (PCN), comprising small private General Practitioner (GP) clinics supported by a mobile team of dedicated nursing and allied health professionals, as well as a chronic disease register (CDR), can be an alternative model for good chronic disease management. GPs in the network manage the mobile team, set common goals for each clinic and self-evaluate. In this paper we share the data and experience of the first year of the pilot PCN in Singapore. Methodology: Process indicators for diabetic patients seen from April 2011 to March 2012 (pre-PCN) and April 2012 to March 2013 were compared. McNemar test was performed. Results: There was statistically significant improvement in process indicators of yearly DRP, DFS and Urine ACR screening for diabetes in the first year post-PCN compared to baseline data. Rates of regular HbA1c and LDL-C testing, as well as smoking blood pressure and weight assessment also showed statistically significant improvement. Conclusion: The PCN has shown promise in improving quality of care for diabetes among small private GP clinics. Key challenges to the success of PCN include good clinician leadership, suitable IT support, and creating a viable business model for GPs.

Consultório de/na rua: desafio para um cuidado em verso na saúde / Consultation office of/in the street: challenge for a healthcare in verse / Consultorio de/en la calle: desafío para el cuidado de la salud en verso

Este artigo discute práticas de cuidado do Consultório de/na rua, serviço que se delineia no Sistema Único de Saúde, destinado à atenção às pessoas em situação de rua. A intenção é problematizar as estratégias de acolhimento e cuidado em saúde, bem como as diretrizes ou valores desse trabalho, muitas vezes destoantes entre si, como: as ações programadas de rastreamento e autoridade moral sobre pessoas com vida na rua e as ações disruptivas do modelo urbano de cidade saudável e segura, para uma forte inclusão de pessoas que, por variados motivos, levam esse tipo de vida. Como recurso de análise, estão diários de campo escritos pelos trabalhadores de um desses consultórios – localizado em Porto Alegre, Brasil – que, em seu cotidiano, percorrem as ruas e redes de saúde e intersetorial com todas as suas dificuldades e potências.

This paper discusses healthcare practices relating to consultation offices in the street, which are a service delineated within the Brazilian National Health System that is directed towards caring for people living on the streets. The intention was to pose questions regarding healthcare and reception strategies, along with the guidelines or values of this work. These are often discordant with each other, like the programmed actions of tracking and moral authority over people living on the streets and the disruptive actions of the urban model for healthy and safe cities, in relation to strong inclusion of people who, for various reasons, live in such situation. Field diaries written by workers at one these consultation offices, located in Porto Alegre, Brazil, comprise an analysis resource. In these workers’ day-to-day routine, they pass through the streets and health and intersectoral networks with all their difficulties and strengths.

Este articulo discute prácticas de cuidado del “Consultorio de/en la calle”, un servicio delineado en el Sistema Brasilleño de Salud destinado a la atención de las personas que viven en la calle. La intención es problematizar las estrategias de acogida y de cuidado de la salud, así como las directrices o valores de este trabajo que muchas veces no concuerdan entre sí, como las acciones programadas de rastreo y autoridad moral sobre personas que viven en la calle y las acciones disruptivas del modelo urbano de ciudad saludable y segura para una fuerte inclusión de personas que viven en esa situación. Como recursos de análisis están los diarios de campo escritos por los trabajadores de uno de estos consultorios, localizado en Porto Alegre, Brazil, que en su cotidiano recorren las calles y las redes de salud e intersectorial con todas sus dificultades y puntos fortes.