Enhanced integration of primary and secondary health systems and patient empowerment through improved continuity of patient care and clinical handover

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Effective integration of care between community (primary) and hospital care (secondary) health services is essential for a patient whose needs extend beyond the initial episode, and more care is required by the next level of health provider. This may include referral to a hospital if a primary care doctor cannot manage the condition or the continuation of medication and check-ups in the primary care after a hospital admission. The crucial stage is communication of patient-specific information from one caregiver to another or to the patient and family, for the purpose of ensuing patient care continuity and safety, termed clinical handover. A review of evidence in the high-income countries showed that the consequences of ineffective handover led to incorrect treatment, delays in medical diagnosis, life-threatening adverse events, patient complaints, increased health care expenditure, increased length of stay, increased re-admissions, and other impacts on health systems. Although we have not been able to find similar data for LMIC, experience and discussions with partners and experts indicate that the rate of adverse events and other unwanted outcomes due to poor handover are even greater in LMICs due to huge gaps in integration of health providers. It is likely therefore, that considerable scope exists to improve practice in a way that is cost-effective and potentially even cost releasing. These may be adapted from methods that have been successfully implemented in high-income countries (e.g. check-lists, patient held records). There is a global focus from the WHO on health systems development, critical for a better response to challenges of emergencies, infectious and other diseases. The rise in elderly populations and deteriorating lifestyle behaviours (e.g. smoking rates) in LMICs have increased the burden of heart related, diabetes and other long term diseases. Due to their need for on-going care, these are particularly adversely affected by poor integration between primary and secondary care. Thus the main drivers for our proposal are evidence for the following: -clinical handover processes are at the core of patient safety and consequences of inadequate clinical handover result in poor patient outcome and high cost to the health system- Clinical handover is a global priority identified by the WHO Patient Safety Programme. There is need and interest in many LMICs to improve integration between-levels of health care, but little evidence to guide local decision makers in how to identify and overcome barriers to improved practice -initial interventions can be culturally and politically acceptable, affordable and sustainable, but that such interventions have not been systematically explored, tested or implementedThe objectives of this one year project (part of a extensive five-year programme) are: 1) describe existing situation in terms of policies, training, activities, and culture for clinical handover between primary and secondary care during referrals and discharge 2)identify barriers and facilitators (health care system and patient related) for improving clinical handover 3)develop options for intervention 4)build health systems research capacity. These will be achieved through a range of complex research methods that would involve all stakeholders from policy makers to patients.The immediate benefits of this phase will be for the hospital and community health care practitioners and policy makers who will be able to use the findings to start addressing some of the affordable solutions identified, researchers who will learn health system assessment techniques novel to them, and ultimately the patients who will receive a better seamless health care through the development and implementation of interventions. The follow-on intervention study is hoped to roll out into long-term programmes that could dramatically improve integration of primary and hospital care services.