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BEYOND THE RHETORIC: WHAT DO WE MEAN BY A MODEL OF CARE?

Associate Professor Patricia Davidson RN BA MEd, PhD, School ot Nursing, College of Health and Science. University of Western Sydney and Nursing Research Unit, New South Wales, Sydney West Area Health Service. New South Wales, Australia

[email protected]

Elizabeth Haicomb RN BN (Hons) PhD Candidate, Senior Research Feliow School of Nursing, Coiiege of Heaith & Science University of Western Sydney New South Wales and Centre for Applied Nursing Research Sydney South West Area Heaith Service, New South Waies, Australia

Hickman i RN BN MPH PhD Candidate. Associate Lecturer School of Nursing. Coiiege of Health & Science University of Western Sydney, New South Wales, Australia

Phillips JRNB App Sci (Nurs) Grad Dip Health Promotion PhD Candidate, Project Officer Mid North Coast Division of General Practice, Coffs Harbour. NSW. Associate Lecturer School of Nursing. College of Health & Science. University of Western Sydney New South Wales, Australia

Graham, B RN RM MMGm (Pub Heaith) Prof Doctoral Candidate. Clinicai Redesign Coordinator Sydney South West Sydney Area Heaith Service. New South Waies, Austraiia and University of Technology Sydney New South Wales

Accepted tor publicalioti May 2005

Key words: models of care, systems, health care delivery, development, evaluation

ABSTRACT

Background: Contemporary health care systems are constantly

challenged to revise traditional methods of health care delivery. These challenges are multifaceted and stem from: (I) novel pharmacological and non- pharmacological treatments; (2) changes in consumer demands and expectations; (3) fiscal and resource constraints; (4) changes in societal demographics in particular the ageing of society; (5) an increasing burden of chronic disease; (6) documentation of limit- ations in traditional health care delivery; (7) increased emphasis on transparency, accountability, evidence- based practice (EBP) and clinical governance struc- tures; and (8) the increasing cultural diversity of the community. These challenges provoke discussion uf potential alternative models of care, with scant reference to defining what constitutes a model of care.

Aim: This paper aims to define what is meant by the

term ^model of care' and document the pragmatic

systems and processes necessary to develop, plan, implement and evaluate novel models of care delivery.

Methods:

Searches of electronic databases, the reference lists of published materials, policy documents and the Internet were conducted using key words including 'model*', 'framework*', 'models, theoretical' and 'nursing models, theoretical'. The collated material was then analysed and synthesised into this review.

Results:

This review determined that in addition to key conceptual and theoretical perspectives, quality improvement theory (eg. collaborative methodology), project management methods and change manage- ment theory inform both pragmatic and conceptual elements of a model of care. Crucial elements in changing health care delivery through the develop- ment of innovative models of care include the planning, development, implementation, evaluation and assessment of the sustainabilitv of the new model.

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Conclusion: Regardless of whether change in health care

delivery is attempted on a micro basis (eg. ward level) or macro basis (eg. national or state system) in order to achieve sustainable, effective and efficient changes a well-planned, systematic proeess is essential.

BACKGROUND Contemporary health care systems are challenged to

provide quality care as a consequence of fiscal constraints (Duffield, Donoghue. and Pelletier 1996); the changing expectations of consumers and health professionals (Edwards, Courtney, and Spencer 2003); a greater emphasis on quality and transparency changes in treatment patterns (Blendon cl al 2002); the ageing of the population and the inereasing burden of chronie disease (Williams and Botti 2002). Existing models of eare are often historically based and subsequently not responsive to the changing needs of eontemporary health systems.

In response to pereeived inadequacies in contemporary health care delivery, health professionals have been prompted to develop novel models of care. Eor example, the increasing burden of heart failure has inspired research informing innovative models of care, including nurse-led post-discharge programs and rehabilitation incorporating lifestyle interventions. This research has largely evaluated the effectiveness of modifications of eare based on acute, episodic eare to better meet tlie needs of those with chronic disease (Grady et al 2000; McAlister et al 2001; MeAlister et al 2004; Tsai. Sally. and Keeler). Unfortunately, many of these valuable lessons are broadly available to Australians (Clarke et al 2004).

Optimally, model of care development should be multifaeeted and multidisciplinary, incorporating the best available evidence from patient-centered research with the needs and preferences of individuals, communities. health professionals, policy makers, funding agencies, professional organisations and underpinned by sound theoretical and conceptual principles (Saekett et al 2000; Wagner et al 2001; Cretin, Shorteil, and Keeler 2004). Regardless of theoretical perspectives informing models of eare development (Kikuchi 2004). it must be emphasised that the delivery of nursing eare oeeurs in complex and dynamic settings which are responsive to social, politieal, eeonomie and clinical faetors (Davidson etal 2003).

Significantly, the development of models of care is often an iterative process and consequently does not have finite commencement and completion dates. Whilst sueh flexibility is an advantage of this approach, it creates challenges for the utilisation of traditional evaluation teehniques such as randomised controlled trials. Methods of evaluation such as pre-test - post-test design and case study designs lend themselves more readily to the measurement of outcomes to assess the effeetiveness of

changing models of eare (Ovretveit and Gustafson 2002). The substantial improvements in individual patient and organisational outeomes, whieh can be attained by adapting models of care, fuels the development of this methodology in eontemporary health care in spite of the methodologieal challenges inherent in its evaluation (Ovretveit atid Gustafson 2002).

Often model of eare development involves the interseetion of research and implementation of findings in a usual care environment. Establishment of new models of eare often involves the development of skills, systems. processes and resourees to elose the gap between research evidence and eiinieal practice (Bero et a! 1998). An example of this is the New South Wales (NSW) Chronie Care Program through which 60 Priority Health Care Programs have been established (New South Wales Health 2003). These programs focus primarily upon the priority target areas of respiratory disease, cardiovascular disease and cancer. The programs have been establishing a range of innovative programs, informed by the best available evidence to aehieve a more integrated, coordinated and patient-foe used approach for people with chronie illness in New South Wales (New South Wales Health 2003. 2001).

Agendas of health reform have increased the dialogue and debate concerning model of care development and evaluation. The following eomments of Wimpenny (2002) caution us to avoid a rhetorical perspeetive of the term 'models' and to systematically define what we mean when we use tbis term.

'Since tiic mid 1970s consUk'niblc writing ami dis- cussion has occurred about models of nursing, fn the 2 Lst cenlurv lhe impact und relevance of nursing models to lhe practicing nurse is characterized hy divergent and often ambivalent views. The almost cvangelieal adoption of a model of nursing in the I97()s to I99()s has changed and made way for a more eritieal and skeptieal view of their purpose and value. Many nurses in eiinieal praetice, education and researeh may view this as wholly appropriate as the uncritical acceptance of these 'early' vears resulted in deeisions and usage of models, which have had a lasting legaey'{W\mpenny 2002. p 346).

What do we mean by a model of care? Ambiguity exists in the literature, with lhe terms

model of care, nursing model, philosophy, paradigin. tramework and theory often used interchangeably, despite referring to diverse, yet parallel concepts (Tierney 1998). In tlicir recent review of the literature, the Queensland Government (Auslralia) I'eported that they found no consistent definition of'model of eare' (Queensland Health 2000). They concluded that a model of care is a multi- dimensional concept that defines the way in which health eare serviees are delivered (Queensland Health 2000).

More specifically, Davidson and Elliott (2001) described a model of eare as a conceptual tool that is 'a standard or example for imitation or eoniparison. combining concepts, belief and intent that are related in

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Figure 1 . World Health Organisation Chronic Care Framework

Innovative care for chronic conditions frame

Encourage quality through eadership and incentn/es

Support self-management 8. prevention

Better Outcomes for Chronic Conditions

Building Bkxks for Action Innovative Care fa Chronic Conditions Clobal Report World Health Organisation 2002

some way" (p. 121). They eonsider it to be eritiea! that

models of eare should:

• be evidenee based and/or grounded in theoretical propositions;

• be based upon assessment of patient and health provider needs;

• ineorporate evaluation of health-related and intervention outcomes;

• be inclusive of eonsultation with key stakeholders;

• be eonsiderate of the safety and wellbeing of nurses;

• involve a multidisciplinary approach where applicable;

• eonsider the optimal and equitable utilisation of health eare resources;

• optimise equity of aceess for all members of society; and

• include interventions that are culturally sensitive and appropriate (Davidson and Elliott 2001, p. 123).

In order to decrease ambiguity it is useful to not only define what we mean by a 'model' but also to distinguish between a "nursing model*, a 'model of eare'. and a •framework". A model has been defined as, 'a descriptive picture of praetiee which adequately represents the real thing" (Pearson and Vaughan 1986, p.2). That is, an idea that ean be explained by using symbolie and physical visualisation. It ean also be used to facilitate thinking

about abstract concepts and the relationships between them (Marriner 1986).

A 'nursing modeP pertains solely to the practice domain of nursing, whereas a 'model of eare' describes the delivery of health care within the broader context of the health system. In relation to this understanding of a model of care, the framework shapes and guides the implementation and evaluation phases of the models' development". Using a building analogy, the 'framework' is the braee and girders that support the model.

With these eoneepts in mind, a model of care is an

overarching design for the provision of a particular type

of health care service that is shaped by a theoretical

basis, EBP and defined standards. It consists of defined

core elements and principles and has a framework that

provides the structure for the implementation and

subsequent evaluation of care. Having a clearly defined

and articulated model of care will help to ensure that all

health professionals are ail aetually 'viewing the same

picture', working toward a common set of goals and, most

importantly, are able to evaluate performanee on an

agreed basis.

As illustrated in Figure I, the World Health Organisation (WHO) Chronic Care Framework (World Health Organisation 2002) positive policy environments and links between the community and health care organisations are critical faetors to support chronie eare delivery models.

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National Health Service Framework, United Kingdom The rolling program of National Service Frameworks

(NSFs) in the UK commenced in April 1998 (UK Department of Health 2003). The aims of these frameworks are to: establish national standards and identify key interventions for defined serviees or care groups: apply strategies to support implementation ol" models of care; establish mechanisms to ensure advancement toward agreed aims within a pre-spccified time-scale; and form one of a range of strategics to improve quality and deerease variations in service provision (UK Department of Health 2003). To date. NHS frameworks eover: caneer (September 2000); pediatrie intensive care; mental health (September 1999); coronary heart disease (March 2000); older people (March 2001); diabetes (Standards December 2001, Delivery Strategy January 2003); and the first part of the Children's NSF (April 2003)(UK Department of Health 2003). Each NSF is developed in conjunction with an external reference group which brings together key stakeholders, including health professionals, consumers and earers, health service managers, partner agencies, and other advocates (UK. Department of Health 2003).

Clinical Service Frameworks, New South Wales (NSW) Australia

The NSW Clinical Service Frameworks have emerged from the Chronic Care Program to optimise health care delivery. This program was established under the NSW Government's Action Plan for Health in order to address the ehallenges presented by the increasing prevalence of chronic and complex diseases. The three health areas of respiratory disease, eancer and cardiovascular disease (and its associated risk factors, including diabetes) were identified as being of priority. These frameworks are designed to foster implementation of best practice within a structure of clinical governance (New South Wales Health 2003).

National Palliative Care Framework, Australia The National Palliative Care Strategy provides a guide

for the development and implementation of palliative care policies, strategies and serviees to improve the quality. range and coverage of palliative care services in Australia (Commonwealth Department of Health and Aged Care 2000). This has informed the NSW Palliative Care Framework which provides a basis for the planning of local service delivery that will promote access, continuity of care and standard levels of care regardless of the location in whieh the service is provided (NSW Health Department 2001).

AIM Informed by the conceptual principles above, whieh

define what is meant by the term model of care, the purpose of this discussion paper is to identify and discuss

the key processes necessary to develop models of care to achieve desired outcomes.

METHOD CINAHL, PubMed and MEDLINE electronic

databases were searched to identify relevant literature published in the English language. Keywords used in this seareh included: 'model*", 'framework*", "models, theoretiear and 'nursing models, theoretieal'. Reference lists of retrieved articles were searched for additional literature. Relevant journals held locally were hand searched for pertinent artieles and the Internet was searched using the Google search engine for related organisations or electronic documents using the keywords listed previously. These searches were not confined to health related literature, as many paradigms were found to describe key elements of model development pertinent to this enquiry.

The eclectic and heterogenous material for this review precluded the use of a formal systematic review methodology. Further, the aim of this artiele is not to undertake a discourse of nursing theories, but moreover, articulate pragmatic and achievable principles to undertake a rctlcctive and iterative review of nursing practice and determine appropriate strategics to implement innovative and appropriate care, onee a philosophical or conceptual path is identified (Morse 1995; Harvey etal 2002).

RESULTS The literature revealed several key perspectives

informing pragmatic elements of model of care development. These are: (1) EBP movement (Foxcroft and Cole 2003); (2) quality improvement and eollaborative methodology (Berwick, James, and Coye 2003); (3) ehange management theory (Carney 2002, 2000); (4) projeet management methodology (Loo 2003; O'Kelly and Maxwell 2001); (5) disease management literature (Glasgow et al 2002); (6) theoretical perspeetives that dictate eritieal elements of model of eare development such as the health promotion mode! and self-eare theories (.laarsma et al 199S; Jaarsma ct al 2000); and (7) consumer participation and identification of needs, whieh is inereasingly recognised as a critical factor (Edwards, Courtney, and Spencer 2003; Johnson. Leeder and Lewis 2001; Weilard et al 2003). These key elements are briefly discussed below.

Evidence based practice Evidenee-based praetice (EBP) is based upon

demonstration of improvement in patient outeomes when the best available evidence is used to guide clinical practice (Leape, Berwick, and Bates 2002; French 2000). The EBP movement is motivated by a desire to ensure individuals receive those treatments proven through systematic enquiry to be most effeetive, after

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consideration of their unique values and beliefs and the expert eiinieal assessment of clinicians (Saekett et al. 2000). Research evidence about clinical problems is evaluated according to rigid 'levels of evidence". Within such appraisal significantly more weight is afforded to evaluation methods such as randomised control trials, with less value placed upon qualitative evaluation or case- study approaehes (National Health and Medieal Research Council 1999).

Following systematic identification and assessment of the quality of available evidence, synthesis of findings can be undertaken and guidelines formulated to guide clinicians in their deeision-making. The principles of EBP are generic and can be utilised to improve the standards in all aspects of health eare. There is some eontention. however, as to how much of nursing scienee and scholarship is valued within traditional positivistic domains (Rycroft-Malone et al 2004).

Quality improvement Model of care development and evaluation is entrenched

in a desire to improve patient and organisational outcomes. Thus, it ean be seen to be informed by quality improvement (Ql) principles. Ovreteit and Gustafson (2002) describe quality programs as planned aetivities performed by an organisation or health system to improve the quality of health eare.

Health professionals are eontinually evaluating models of care in their seareh for more efficient service delivery and improved patient outeomes (Stutts 2001). Ovreteit and Gustafson (2002), suggest there is some doubt about the impaet of QI programs, as there is little independent and systematic researeh about the effectiveness or the conditions required for effective Ql programs. However. they believe this eould be improved by: assessing the level of the intervention; validating measures of assessing implementation; eonsidering wider outeome assessment; conducting longitudinal studies; consideration of economic implications; and utilising a theory or model that explains how the intervention caused the outeomes (Ovretveit and Gustafson 2002). The Q\ principles when applied to model development assist in shaping the model to aehieve desired outeomes and assist with an iterative process of evaluation.

Health promotion model The heaith promotion model eertainly lends itself

appropriately to health care systems wishing to create eonsumer engagement and participation and the promotion of healthy communities. Health promotion is the proeess of enabling people to inerease eontrol over the determinants of health and thereby improve their health and wellbeing. As such, the health promotion model has informed many population-based approaches of model of care development.

To reach a state of eomplete physical, mental and soeial wellbeing an individual or group must be able to

identify and realise aspirations, to satisfy needs and to change or cope with their environment (Nutbeam 1986). Health promotion involves the entire population in the context of their daily lives, rather than focusing on individuals at risk for specific diseases, and is direeted toward taking aetion on either the determinants or eauses of health (Nutbeam 1986). Achieving this requires an optimal mix of responsibility from all involved: individuals; families; communities; a wide variety of professionals (teachers, urban planners, health professionals); and government and non-government sectors. As health promotion draws from a range of diseiplines, including: epidemiology; soeial, behavioural and educational sciences; and management, the use of a model provides direetion and focus, as the concepts and theories from these diseiplines are synthesised to produce strategics to improve health outcomes (Green and Kreuter 1991).

Some of the eore elements of health promotion models concern: accessibility to health eare; evaluation of health care; perceptions of symptoms; threat of disease; social network characteristics; knowledge about disease; demographic characteristics; and behaviour change (Egger, Spark, and Lawson 1990). Health promotion has much to offer clinicians seeking to develop models of care that have behaviour ehange and self management as underlying tenets, as these are eore elements of many health promotion models (Lorig et al 1999; Lorig 2002).

Disease management Disease management is an evolving eoncept that

proposes to improve health outeomes by using a systematie approaeh to provide patient-eentred, comprehensive and integrated care across the health system (Jordan 1999). The development of this model of health care delivery has stemmed from the well- recognised eombination of an ageing population, increasing numbers of the ehronieally ill and finite health resourees (Wagner 2001). Whilst several eommon diseases have been reported as being amenable to disease management strategies (eg. asthma, heart failure, diabetes, depression, hypertension), there are several generic program components.

Jordan (1999) describes the four basie eomponents as: (1) identification of evidenee-based practice for the specific disease; (2) development of a clear plan to drive clinical decision making; (3) delivery of best practice across multiple care providers and sites of care; and (4) measurement of quality indicators to measure eiinieal and economic outcomes. Riegel and LePctri (2001) explain that disea.se management programs are 'comprehensive, integrated, and aimed at improving the quality of care provided to populations of patients rather than individuals' (p. 267).

Project management Project management approaehes, albeit not a

theoretieal perspective, provide useful tools for nurses to

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Table 1: Key stages in model af care development

Stage

Planning

(The set-up phase involving the

identiticatjon of key issues, literature

review and stakeholder identification)

Development

(Progression of the pre-specified pian

in the clinical setting)

Implementation

(Execution of the intervention pian)

Evaluation

(Assessing the efficiency and

effectiveness of the intervention plan)

Key task

• Scoping the problems and issues

• Establishing haseiine data and summarise the current modei of care

• Examine what has worked weil in other settings

• improvement begins with setting aims because an organization wiii not improve

without a defined path

• identify factors to optimise sustainabiiity eg. using funding mechanisms,

key stakehoider involvement, promote and develop clinicai leaders etc

• Start to define the new modei. including goals and objectives

" Streamiining and standardising the process

• Development of data management systems

• Deveiopment of key performance indicators

• Measures need to be identified to indicate whether a change that is made actually

leads to an improvement

•Skiii deveiopment

•Pilot testing of modei

•Support of ciinicai staff

•Communication strategy

• Leadership

• Negotiation

• Re-orientation of health care services and/or providers

• Measuring performance against pre-specified indicators

• Evaluation of serendipitous findings

• Evaluation of the impact of change processes on individuals and systems

appraise the feasibility and implement novel care models.

The term project management emerged in the 1950s-60s

and is defined as the application of knowledge, skills,

tools and techniques to a broad range of activities in

order to meet the requirements of the particular project

(Project Management Institute 2004).

Project management is comprised of five processes:

initiating, planning, executing, controlling and closing,

as well as having nine knowledge areas (Project

Management Institute 2004). These nine areas centre

on project management expertise in integration, scope,

time, cost, quality, human resources, communications,

risk management and procurement management

(Project Management Institute 2004). These processes

relate to health by offering systematic approaches which

allow the project management model to be used to

assist managers and staff to accomplish projects

successfully, deal efficiently with work load stress.

improve learning, and expand essential management

skills that will assist employees during their

professional life. Organisational benefits accumulate with

projects and other activities being completed within

budgets, time limits, and expected quality standards

(Loo 2003).

Change management theory and collaborative methodology

In the United States of America, the institute for Healthcare Improvement has developed a series of projects based on a collaborative model informed by change management theory to aehieve improvement in health care service delivery and outcomes (Flamm, Berwick, and Kabcenell 1998). Key elements of this eollaborative model involve the cyclical process of setting aims, establishing measures, developing informed ehanges to practice, and evaluating the impact of these ehanges. The testing of changes requires a team to plan, do, study, and act (the 'PDSA cycle'). Repeated PDSA cycles inform insight into clinical systems to facilitate clinical improvement (Lynn et al 2002).

Key stages in model ot care deveiopment

Oucial elements in changing models of health care delivery are planning, development, implementation, evaluation and sustaining the ehange (Table 1). Consideration of the evaluation proeess is critical in ensuring that initial goals have been met and due to lhe iterative nature of model of eare development is eritieal in determining evolution of the model and in particular issues related to sustainability.

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Table 2: Model of care evaluabilify assessment tool adapfed from: (Hawe, Degeling, and Hall 1990)

Steps I Questions

Is there a clearly deiined

model of care?

Are there specific goals and

expected outcomes attributed to

the model of care?

Have tfie primary users of the

information derived from the

evaluation, and their needs, been

clearly identified?

Are the casuat assumptions/

theories in the model of

care plausible?

Is there agreement on measurable

and testable key performance

indicators?

Is there agreement on what data

items are necessary in the

evaluation plan?

Is the model of care implemented

as planned?

Prompts

• Are mterventions and strategies informed by haseiine data and evidence of need for

practice change?

• Can the model of care can be readily described?

' Are interventions accessible for the target group and aspects of diversity and

marginalisafion considered?

' Are the interventions based upon best available patient-centered research findings?

' Is fhe welfare of all team members considered including heaiih care professionais

and patients?

' Has there been an attempt fo implement strategies such as promotion of clinical

leadership and change management strategies to enhance sustainability?

' Is the model designed to produce outcomes that reflect accountability fo consumers

and governance structures?

' Does the evaluation framework meet the needs of funding bodies, consumers and

health care professionals?

' Is the model grounded in theoretical propositions?

' Are the philosophical aims and conceptual frameworks reflected in interventions

and care plans (eg. pafienf-centred philosophy is reconciled with interventions

and outcome measurements)?

• Are the performance indicators and criteria clear and transparent?

' Oo the performance indicators reflect process and outcome measures?

" Do data elements in the evaluation (quantitative and qualitative) reflect the data

items in the evaluation plan?

• Do the data items describe measurable concepts?

Is clinical practice improvement and model development fuelled by reflective

pracfice and outcome measurement?

Has a governance structure been adopted to monitor the implementation plan?

Models of care arc often developed to bridge service delivery gaps rather than as a planned strategic response to an identified local need (Eaton 2000). These models of care are often being implemented by health care providers with limited resources in the interests of enhancing care. As has been previously mentioned the application of traditional research methods to measure the outcome of models of care may not always be feasible.

The use of an 'evaluability' assessment proeess has been promoted in health promotion as a way of ensuring that the critical preconditions for evaluation are actually in place before evaluation occurs (Hawe, Degeling, and Hall 1990). Modification of this 'evaluability" assessment process has been used to guide the development of a format to assist clinicians to ensure that a specific model of care is amenable to evaluation, as detailed in Table 2.

CONCLUSIONS ANO KEY RECOMMENDATIONS

The increased focus on the provision of seamless, coordinated care - particularly for the frail and those with

ehronic and complex needs - and emphasis for safe, efficient and quality eare (Heath 2002; Leveille et al 1998; Wagner et al 2001; Wagner 1998) will likely continue to fuel the model of care developtnent agenda. It is important that as far as possibie the development of models of care be considered and undertaken systematically rather than being reactionary and rhetorical. This considered and systematised process should not only optimise health related outcomes but also facilitate the potential to sustain improved health outcomes by novel models of care development.

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Australian Journal of Advanced Nursing 2006 Volume 23 Number 3

SCHOLARLY PAPER

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Australiar) Journal of Advanced Nursing 2006 Volume 23 Number 3