Understanding patterns and identifying common clusters of chronic diseases may help policymakers, researchers, and clinicians to understand the needs of the care process better and potentially save both provider and patient time and cost. However, only limited research has been conducted in this area, and ambiguity remains as those limited previous studies used different approaches to identify common clusters and findings may vary with approaches. This study estimates the prevalence of common chronic diseases and examines co-occurrence of diseases using four approaches: (i) identification of the most occurring pairs and triplets of comorbid diseases; performing (ii) cluster analysis of diseases, (iii) principal component analysis, and (iv) latent class analysis. Data were collected using a questionnaire mailed to a cross-sectional sample of senior Australians, with 4574 responses. Eighty-two percent of respondents reported having at least one chronic disease and over 52% reported having at least two chronic diseases. Respondents suffering from any chronic diseases had an average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified: (i) asthma, bronchitis, arthritis, osteoporosis and depression; (ii) high blood pressure and diabetes; and (iii) cancer, with heart disease and stroke either making a separate group or “attaching” themselves to different groups in different analyses. The groups were largely consistent across the approaches. Stability and sensitivity analyses also supported the consistency of the groups. The consistency of the findings suggests there is co-occurrence of diseases beyond chance, and patterns of co-occurrence are important for clinicians, patients, policymakers and researchers. Further studies are needed to provide a strong evidence base to identify comorbid groups which would benefit from appropriate guidelines for the care and management of patients with particular disease clusters.

There has been a surge in experience-based co-design (EBCD) efforts for quality improvement in health care and systems design globally. Service users together with staff are playing a far greater role than ever before in the redesign of services and systems of care. EBCD offers a systematic, bottom-up approach to improving service user and staff experiences of care. There is growing interest in the application and potential of EBCD; however, studies indicate common shared challenges, which coalesce around power, commitment to the process, methods for gathering experiences, designing improvements, implementation, and subsequent impact.

Previous studies have found that integrating non-dispensing pharmacists in general practice may improve patient safety, improve patient outcomes, deliver health system efficiencies and generate savings. However, the employment of pharmacists in general practice is not common in Australia. A naturalistic study was conducted in the Australian Capital Territory with three general practices, each employing a part-time pharmacist for 12 months. This study reports on stakeholder perspectives of the benefits, barriers and enablers for integrating pharmacists into general practice. Patients, practice staff and community pharmacists that had interacted with a practice pharmacist were asked to complete a self-administered questionnaire. Patient questionnaire respondents (n=44) reported that a practice pharmacist was beneficial and wanted to see this continue. Practice pharmacists were also perceived beneficial by primary healthcare employees surveyed (n=42). Opinions were further explored by individual semi-structured interviews (n=20). The qualitative data explored five themes: perception of the practice pharmacist, collaboration with doctors, pharmacist roles, sustainability and community pharmacy aspects. Patients welcomed improved understanding about their medication, whereas general practice staff appreciated pharmaceutical advice about patients with chronic conditions. Participants discussed options to fund practice pharmacists longer term, which was identified as the main barrier to widespread roll out.

Background: The terms integration and integrated care describe the complex, patient-centred strategies to improve coordination of healthcare services. Frameworks exist to conceptualise these terms, but these have been developed from a professional viewpoint. The objective of this study was to explore consumers' and providers' concepts, expectations and experience of integrated care. A key focus was whether frameworks developed from a professional perspective are effective models to explore people's experiences. Methods: A qualitative pilot study was undertaken at one Australian multidisciplinary primary health care centre. Semi-structured interviews were conducted with consumers (N = 19) and staff (N = 10). Data were analysed using a framework analysis approach. Results: Consumers' experience of integrated care tended to be implicit in their descriptions of primary healthcare experiences more broadly. Experiences related to the typologies involved clinical and functional integration, such as continuity of providers and the usefulness of shared information. Staff focused on clinical level integration, but also talked about a cultural shift that demonstrated normative, professional and functional integration. Conclusions: Existing frameworks for integration have been heavily influenced by the provider and organisational perspectives. They are useful for conceptualising integration from a professional perspective, but are less relevant for consumers' experiences. Consumers of integrated primary health care may be more focussed on relational aspects of care and outcomes of care.

INTERNATIONALLY, pharmacists have become increasingly integrated into general practice clinics. 1,2 It has been reported that general practice pharmacists perform a range of clinical and administrative duties related to their expertise in medication use and safety; the clinical activities typically include providing drug information to practice staff, educating patients, reviewing medication, undertaking health promotion, and conducting disease management clinics. 1-4 The primary purpose of a general practice pharmacist is to support general practitioners (GPs) to minimise the risks associated with medicines and optimise patient outcomes through the quality use of medicines. 2 The co-location of pharmacists with GPs can enhance interprofessional communication and the development of collaborative working relationships. It can also reduce fragmentation of care and facilitate the delivery of patient-centred interdisciplinary chronic disease and medication management services. A general practice pharmacist can also improve communication between GPs and pharmacists working in community pharmacies and provide a link to existing community pharmacy services. 2 Evidence suggests that general practice-based medication reviews by a pharmacist can be more facilitating than a community pharmacybased service, 5 with key facilitators being: • an established pharmacist-GP relationship • pharmacists having access to medical records to improve the quality and appropriateness of their recommendations • a face-to-face meeting (case conference) between pharmacist and GP to discuss the pharmacist's recommendations. A systematic review by Tan et al found that pharmacists co-located in general practice clinics delivered a range of activities with favourable results in chronic disease management and the quality use of medicines, yet none of the included studies were from Australia. 1 Drawing on the skills of other health professionals is also one approach to tackling the workload pressures in general practice, although previous studies suggest that the main impact of practice-based pharmacists is on quality and safety rather than on GPs' workload. 6 While there has been a strong move to incorporate allied health professionals and nurses within GP-led multidisciplinary teams in Australia, this, to a large extent, has not included pharmacists. 7 Instead, the integration of pharmacists into general practice in Australia has been developing slowly, 2,3 particularly in comparison to the UK, where NHS England has committed to fund an extra 1500 pharmacists to work in general practice by 2020-21 (bringing the coverage to >40% of all practices). 8 In 2015, the Australian Medical Association (AMA) proposed a model whereby general practice

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This paper examines how people with chronic illnesses respond to absences of continuity and coordination of care. Little work has been done on how the ill person might mitigate flaws in a less than optimal system. Our qualitative research, carried out among 91 participants in Australia, reveals that people with chronic illnesses create strategies to facilitate the management of their care. These strategies included efforts to improve communication between themselves and their health care practitioners; keeping personal up-to-date medication lists; and generating their own specific management plans. While we do not submit that it is patients' responsibility to attend to gaps in the health system, our data suggests that chronically ill people can, in and through such strategies, exert a measure of agency over their own care; making it effectively more continuous and coordinated. Participants crafted strategies according to the particular social and bodily rhythms that their ongoing illnesses had lent to their lives. Our analysis advances the view that the ill body itself is capable of enfolding the health system into the rhythms of illness - rather than the ill body always fitting into the overarching structural tempo. This entails an agent-centric view of time in illness experience. A Virtual Abstract of this paper can be found at: https://youtu.be/UwbxlEJOTx8.

Background As digital healthcare expands to include the use of mobile devices, there are opportunities to integrate these technologies into the self-management of chronic disease. Purpose built apps for diabetes self-management are plentiful and vary in functionality; they offer capability for individuals to record, manage, display, and interpret their own data. The optimal incorporation of mobile tablets into diabetes self-care is little explored in research, and guidelines for use are scant. Objective The purpose of this study was to examine an individual’s use of mobile devices and apps in the self-management of type 2 diabetes to establish the potential and value of this ubiquitous technology for chronic healthcare. Methods In a 9-month intervention, 28 patients at a large multidisciplinary healthcare center were gifted internet connected Apple iPads with preinstalled apps and given digital support to use them. They were invited to take up predefined activities, which included recording their own biometrics, monitoring their diet, and traditional online information seeking. Four online surveys captured the participants’ perceptions and health outcomes throughout the study. This article reports on the qualitative analysis of the open-ended responses in all four surveys. Results Using apps, participants self-curated small data sets that included their blood glucose level, blood pressure, weight, and dietary intake. The dynamic visualizations of the data in the form of charts and diagrams were created using apps and participants were able to interpret the impact of their choices and behaviors from the diagrammatic form of their small personal data sets. Findings are presented in four themes: (1) recording personal data; (2) modelling and visualizing the data; (3) interpreting the data; and (4) empowering and improving health. Conclusions The modelling capability of apps using small personal data sets, collected and curated by individuals, and the resultant graphical information that can be displayed on tablet screens proves a valuable asset for diabetes self-care. Informed by their own data, individuals are well-positioned to make changes in their daily lives that will improve their health.