Enhanced integration of primary and secondary health systems and patient empowerment through improved continuity of patient care and clinical handover

Effective integration of care between community (primary) and hospital care (secondary) health services is essential for a patient whose needs extend beyond the initial episode, and more care is required by the next level of health provider. This may include referral to a hospital if a primary care doctor cannot manage the condition or the continuation of medication and check-ups in the primary care after a hospital admission. The crucial stage is communication of patient-specific information from one caregiver to another or to the patient and family, for the purpose of ensuing patient care continuity and safety, termed clinical handover. A review of evidence in the high-income countries showed that the consequences of ineffective handover led to incorrect treatment, delays in medical diagnosis, life-threatening adverse events, patient complaints, increased health care expenditure, increased length of stay, increased re-admissions, and other impacts on health systems. Although we have not been able to find similar data for LMIC, experience and discussions with partners and experts indicate that the rate of adverse events and other unwanted outcomes due to poor handover are even greater in LMICs due to huge gaps in integration of health providers. It is likely therefore, that considerable scope exists to improve practice in a way that is cost-effective and potentially even cost releasing. These may be adapted from methods that have been successfully implemented in high-income countries (e.g. check-lists, patient held records). There is a global focus from the WHO on health systems development, critical for a better response to challenges of emergencies, infectious and other diseases. The rise in elderly populations and deteriorating lifestyle behaviours (e.g. smoking rates) in LMICs have increased the burden of heart related, diabetes and other long term diseases. Due to their need for on-going care, these are particularly adversely affected by poor integration between primary and secondary care.
Thus the main drivers for our proposal are evidence for the following:
-clinical handover processes are at the core of patient safety and consequences of inadequate clinical handover result in poor patient outcome and high cost to the health system
- Clinical handover is a global priority identified by the WHO Patient Safety Programme. There is need and interest in many LMICs to improve integration between-levels of health care, but little evidence to guide local decision makers in how to identify and overcome barriers to improved practice
-initial interventions can be culturally and politically acceptable, affordable and sustainable, but that such interventions have not been systematically explored, tested or implemented
The objectives of this one year project (part of a extensive five-year programme) are: 1) describe existing situation in terms of policies, training, activities, and culture for clinical handover between primary and secondary care during referrals and discharge 2)identify barriers and facilitators (health care system and patient related) for improving clinical handover 3)develop options for intervention 4)build health systems research capacity. These will be achieved through a range of complex research methods that would involve all stakeholders from policy makers to patients.
The immediate benefits of this phase will be for the hospital and community health care practitioners and policy makers who will be able to use the findings to start addressing some of the affordable solutions identified, researchers who will learn health system assessment techniques novel to them, and ultimately the patients who will receive a better seamless health care through the development and implementation of interventions. The follow-on intervention study is hoped to roll out into long-term programmes that could dramatically improve integration of primary and hospital care services.

Design: Observational prospective study using mixed-methodology; Setting: One rural, urban and periurban hospitals in 2 states of India
Objectives
1.situation analysis of policies, training, activities, and culture for clinical handover between primary and secondary care during referrals and discharge
2.identification of barriers and facilitators (health care system and patient related) for improving clinical handover
3.exploration of options for complex health systems and patient related interventions to improve clinical handover
4.pilot data collection tools for handover intervention evaluation
5. build health systems research capacity in order to enable further research and progress in integration of health systems for the development and implementation of a future cluster-RCT testing out potential interventions
Methods: These will be achieved through mixed-methodology research to include:
a)semi-structured interviews, focus groups, patient journey observation, and expert groups with health care academics, policy makers, managers, providers in primary and secondary care and patients: Views will be elicited on barriers, facilitators, potential interventions and identifying training needs
b)document content review
c)health care provider surveys
d)patient and case note surveys on admission, discharge, 3 weeks and 3 months post-discharge for high-burden tracer health conditions requiring follow-up: stroke, diabetes, hypertension, and elderly (>65 years) with multiple co-morbidities.
A range of analytical frameworks will triangulate the findings together with evidence of best practice, to identifying opportunities for improvement and options for intervention definition. The findings will be used by local policy makers, managers and practitioners to start addressing the identified low-cost barriers and solutions, while a systematic application of the findings will develop a complex-health systems intervention programme for a cluster trial to follow.

The impact of the development phase will be realised by many different groups, in the short and long term, directly and indirectly: Internationally academic impact will be felt as new methods of research and knowledge are shared publications and presentations, setting new agenda for research. Local researchers will learn from the experience of the mixed-methodology employed in this project, and local service providers begin to meaningfully consider service integration and optimal clinical handover. Our findings of barriers, facilitators and intervention options for optimal clinical handover will empower the policy makers and managers with evidence in order to begin to act to improve the system. A local process of better cohesion will develop amongst practitioners through multi-disciplinary research and expert groups consulted on the research questions. Patients will also benefit through helping to design services for their community which is a positive, empowering and even enjoyable experience.

However, the full impact will be achieved through the implementation of the follow-on trial, there will have wider impact at the local, national and international levels: This will test out a package of complex, but affordable and cost-effective health service design interventions. Patients will benefit from the impact of the study in the short term through the provision of safer, improved and integrated health care, and in the longer term from generic knowledge about the science and art of service improvement. Front line staff will gain in knowledge and experience through acquiring generic skills in service innovation to improve the quality and safety of care and will benefit from the inclusive ideology of the proposed methods. Any lacunae in technical knowledge will be remedied and they will have a practical introduction to systems thinking and the principles of safety and implementation of effective care. They will also have experience of working on cognitively demanding tasks in teams involving doctors, nurses and mangers, as well as service users. Managers and policy makers will benefit through the experience of state-of-the-art techniques of service redesign and quality improvement and involvement in a program that has aspects of action research embedded in it. The national and international experts and policy makers will benefit through their involvement at the start of the program and at regular intervals thereafter as findings emerge and theories develop and can explore emerging themes that can be applied more generically to other LMIC settings. Local academics will benefit as they learn through application of new methods of health systems situation analysis, development of complex service design improvement interventions, evaluation of interventions through a large cluster randomised controlled trial, and the development of pre-service and in-service training courses to sustain and embed knowledge and attitudes within the system. Economic impact will be felt by individual patients as their out-of-pocket expenditures are reduced through improved and safer services, and society as the whole will benefit as the members thereof become healthier, productive and better-of economically. The health services spend less on unnecessary adverse events and litigation (emerging in middle-income countries), and retain their staff through motivation, training and integration.

These impacts are maximised through involvement of all stakeholders in the health system and community from the start, the use of evidence based practice, training and capacity building, a comprehensive and managed communication and dissemination plan and robust governance and project management plans. The latter will include weekly virtual meetings with field staff and monthly all Co-I and managers project steering group meetings.