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A Realist Framework for the Implementation of Integrated Primary Care

Author:

Marcella McGovern

University College Dublin, IE
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Abstract

Introduction: An obstacle for the implementation of Integrated Primary Care (IPC) has been termed the “Paradox of Primary Care” [1].This paradox observes that the greatest value of IPC lies in its generalist approach; integrating care horizontally within Primary Care for individuals and populations. To date however, the literature is dominated by targeted (e.g. diabetes) and specified (e.g. care pathways) integrated primary care interventions [2], which contribute to the evidence of vertical integration across levels of healthcare. It is argued that to maximise the potential for IPC, implementers need a generalist framework within which targeted and specified evidence can be situated as only part of an IPC programme.

Description of Policy Context and Objective: In the Republic of Ireland, Primary Care – A New Direction [3] proposed the establishment of a network of inter-professional Primary Care Teams (PCTs), delivering health and social care services in the community. Implementation of this strategy has been slow and widely criticised [4] [5] but there have been few attempts to feedback the evidence-based experiences of Irish PCT members to inform ongoing implementation [6] [7] The objective of this study is to explore the Irish experience and situate that evidence within the international literature on how do implement IPC.

Targeted Population: PCTs are the targeted population of this research. Irish PCTs (n=5) were recuited for a cross-sectional, qualitative study, involving: urban (n=2) and rural (n=3) PCTs and partially co-located (n=3) and virtual PCTs (n=2). Participants included: 9 PHNs; 7 GPs; 5 OTs; 4 CMHNs; 3 Physiotherapists; 3 Team Support/Administrative Staff; 2 SLTs; 2 Social Workers; 2 Home Help Managers; 1 Practice Nurse & 1 Community Representative.

Highlights: The adoption of Realist Evaluation [8] as the theoretical framework for this study informs the three research questions: what are the Components of an IPC programme?; what are the Mechanisms for implementing IPC?; and what Context factors either enable or inhibit the activation of IPC Mechanisms? Concept mapping and semi-structured interviews are adopted as two complimentary methods, respectively collecting broad, collective conceptualisations of the implementation of IPC and in-depth, individual descriptions of participant's implemenation experiences. A methodological trianguation of both data sets generated Component– Mechanism–Context hypotheses for the implemention of IPC.

Transferability: The Realist Framework presented is intended to offer transferable guidance on the implementation of IPC to Irish and international PCTs.

Conclusions: The Realist Framework presented is the first to specify a cohesive set of Mechanisms (x12) to implement the Components (x9) of IPC. The value of this framework for PCT members, as well as the managers and policy makers seeking to support implementation, is that it reflects the generalist nature of Primary Care. By comprehensively framing IPC, with sensitivity to Context factors (x16), this framework contributes to the development of a set of testable theoretical hypotheses for IPC. It was beyond the scope of this exploratory study to identify Outcomes generated by specific Components and Mechanisms. This is a key limitation of this study which requires future research.

References:

1- K. Stange and R. Ferrer, "The Paradox of Primary Care," Annals of Family Medicine, 2009;7(4):293-299.

2- A. Blount, "Integrated Primary Care: Organizing the Evidence," Families, Systems & Health, 2003;21(2):121-133.

3- Department of Health and Children, "Primary Care - A New Direction," The Stationary Office, Dublin, 2001.

4- Primary Care Partnership, "Primary Care: A Framework for the Future," http://nagp.ie/wp-content/uploads/2016/09/PrimaryCarePartnership.pdf, Dublin, 2016.

5- M. O'Riordan, "Primary Care Teams: A GP Perspective," Irish College of General Practitioners, Dublin, 2011.

6- M. O'Sullivan, W. Cullen and A. MacFarlane, "Primary care teams in Ireland: a qualitative mapping reivew of Irish grey and published literature," Irish Journal of Medical Science. 2015;184(1):69-73.

7- N. Kennedy, C. Armstrong, O. Woodward and W. Cullen, "Primary care team working in Ireland: a qualitative exploration of team members' experiences in a new primary care service," Health and Social Care in the community. 2015;23(4):362-37.

8- R. Pawson and N. Tilley, Realistic Evaluation, London: Sage Publications, 1997.   

How to Cite: McGovern M. A Realist Framework for the Implementation of Integrated Primary Care. International Journal of Integrated Care. 2017;17(5):A415. DOI: http://doi.org/10.5334/ijic.3734
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Published on 17 Oct 2017.

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