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Belinda Kate Ford, Andrew JR White, Lisa Keay; A realist evaluation of collaborative care models. Invest. Ophthalmol. Vis. Sci. 2019;60(9):5475.
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© ARVO (1962-2015); The Authors (2016-present)
Chronic eye diseases place high demand on eye care services. To improve access, some health systems use ‘collaborative’ care involving multidisciplinary teams of nurses, optometrists and ophthalmologists to deliver standardised care.This study aims to understand factors for successful implementation and scalability of collaborative care.
Semi-structured interviews were conducted in Finland and UK from Sep-Oct 2018; with 13 health system stakeholders, including clinicians, managers and administrators. Qualitative data were analysed using a realist framework to identify contexts, mechanisms, and outcomes of implementation.
Context: Collaborative care covered glaucoma, DR, AMD, and cataract. National policy and targets often pre-empted the introduction of such models. It was unanimously reported as a necessity to improve access and equity under limited resources.Mechanisms: System change was always clinician-led and relied on using existing resources to gain support of hospitals.Task-shifting meant better skill use across teams. Some felt clinicians also needed courage and motivation. Often monetary incentives were used.Training enhanced optometrist and nurse skills; and regular feedback fostered confidence in decision making. Ophthalmologists also felt that these mechanisms built the trust needed to shift clinical responsibility.Models relied on centralised IT systems for communication and sharing patient records- this was integral to success or failure. Audits were used to measure and benchmark success. However, many felt that current IT systems did not adequately support all aspects of the model.Outcomes: Success was primarily measured by patient volume and staff productivity. Other success measures were cost, wait-time, hospital capacity, or maintaining clinical care.Indirect benefits included staff satisfaction from upskilling/opportunities and improved understanding of care pathways. However, staff reported stress when the system failed.Models were suited for patients of all ages with low level disease; and patients were mostly satisfied. Clinicians suggested the models were less suited to patients with co-morbidities, rapid changes, or mobility and cognitive issues.
A range of factors lead to the success of collaborative care models, and learning from these can inform adoption and scalability in other settings.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.
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