Sharing care between specialist health services and primary health care using interactive e-care plans

Abstract

Background: Public health services are looking for more integrated models of care due to increasing demands of long term care for people with multiple problems across multiple services, limited resources and diverse patient needs.

Currently general practitioners and specialist services develop separate care plans and often patients are unaware of the content of these plans. An interactive shared e-care plan can support the sharing of information and collaboration.

Successful collaboration needs shared goals, knowledge and mutual respect, supported with communication and structural interventions that support health services and general practices.

Aims: Improve communication, collaboration and shared care between health services and primary health care of people with long term conditions using a web-based shared e-care plan.

Methods: Observations and qualitative interviews from a feasibility study for cancer shared follow-up care and implementation of a feasibility study and RCT for people living with severe mental illness.

Results: In cancer follow-up, specialists, patients and GPs were receptive to shared e-care which was enhanced when communication through the care plan was evident. There was variation in patient engagement.

Implementation in mental health has proven more challenging. Processes for care and communication between services is complex and demanding. Resources are limited. Patients are infrequent users of general practice and have multiple GPs.

Conclusions: There are common pathways for implementation of interactive e-care plans in sharing care between specialist health services and GPs. However, solutions are needed to improve relational coordination within and between health services and additional resources to introduce and support these processes.