A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'.
Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient's well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients' medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice's repertoires are characterised by care and are driven by the moral imperative to care. They do 'whatever it takes', although there is a cost to this form of care. Well-functioning communities of clinical practice use patient's well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the 'messiness' of community-based care.
The health system in New Zealand and Australia requires health practitioners to prepare for the challenge of long-term conditions. Wagner's 1998 Chronic Care Model advocates a move away from the traditional acute model of primary health care to a model that addresses the long-term episodic nature of chronic disease. Nurse case management has been developed over the last 2 decades as a means to coordinate health services for people with long-term conditions. This meta-synthesis combines the results of 15 qualitative research studies that have a similar research question regarding peoples' perceptions of nurse case management. The research synthesises the experiences of people with long-term conditions on the quality of care under a nurse case management model of primary health care. Over 1000 people were represented across the studies, and the results suggest that people had a high degree of confidence and trust in their nurse case manager, were better able to manage their health conditions with nurse case management support, and had better access to appropriate health care. This research suggests that nurse case management is an effective model of care and may contribute to improved quality of life and better health care for those with long-term health conditions.
The increasing prevalence of multimorbidity, a growing ageing population and lack of success in addressing the negative effect of socioeconomic and cultural determinants of health are major challenges for New Zealand’s primary care sector. Self-management support strategies, personalised care planning, integrated care and shared health records have all been proposed as mechanisms to address these challenges. The organisation of the health system, however, remains largely unchanged, with limited accommodation and few funding concessions made for the requirements of these different approaches and tools. As a result, the primary care system is no longer a good match for the population it serves. With one in four New Zealanders reporting multimorbidity, and people aged >65 years predicted to double in number by 2050, this article argues that over the next decade, New Zealand requires a health system focused on incorporating self-management support, personalised and integrated care and shared health records. This will require further educating of not only health professionals, but also patients in the purpose behind these approaches. In addition, it will mean transitioning to a primary care system more suited to the needs of people with long-term conditions. The key gain from a radical redesign will be a more equitable health system focused on a broader range of health needs.
A research study to evaluate the implementation of a long-term conditions model of care provoked questions regarding the potential impact of the researcher’s role in health service research. Traditional methods of qualitative interviewing require researchers to be a disembodied presence, objective, and free from bias. When health service research is conducted by health professionals, role conflict may occur if the topic is one they have expertise in, and therefore the ability to provide guidance or information. An alternative perspective to the idea of an independent and objective researcher is the notion of a partnership. In this research collaboration, participants utilised the interview process to reflect and explore different perspectives, and the researcher bracketed their own participation in the phenomenon being studied. Reflexivity was utilised by both participants and the interviewer to ensure transparency and thus bridge the gap between subjectivity and objectivity in qualitative health service research interviewing.
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