Patients’ Experiences of the Western HealthLinks Integrated Care Chronic Illness Management Program: A Prospective Mixed-Methods Observational Cohort Study

Julia L. Jones; Kirsty Barnes; Catherine Grant; Jason Plant; Natalie G. Lumsden; Koen Simons; Edward D. Janus; Craig L. Nelson; Ann Allenby

doi:10.5334/ijic.8980

Patients’ Experiences of the Western HealthLinks Integrated Care Chronic Illness Management Program: A Prospective Mixed-Methods Observational Cohort Study

International Journal of Integrated Care

Volume 26 (2026): Issue 3

By: Julia L. Jones , Kirsty Barnes , Catherine Grant , Jason Plant, Natalie G. Lumsden , Koen Simons , Edward D. Janus , Craig L. Nelson and Ann Allenby

Open Access

|Sep 2026

Abstract

Introduction: Western HealthLinks, an integrated care chronic illness management program, supported patients with chronic and complex conditions to stay well at home after hospital discharge. This study assessed patients’ experiences of the program.

Methods: A prospective mixed-methods observational cohort study, conducted as an implementation evaluation with six-monthly assessments over 30 months included: A visual analogue scale (VAS) rating healthcare satisfaction; an Assessment of Quality of Life 4 Dimensions (AQoL4D) tool; a survey regarding healthcare satisfaction. VAS and AQoL4D were analysed with a simple random effects model using time as a linear variable; survey was analysed with thematic analysis.

Results: Median baseline VAS was 79 and AQoL4D 0.15, with no evidence for change over time. Themes across timepoints included: Local/home-based care; hospital access; individualised, coordinated and consistent care; communication; reduced waiting; healthcare provider qualities; transport/parking.

Discussion: No evidence of change to VAS and AQoL4D suggests maintained healthcare satisfaction and QoL over time despite increasing age and disease burden. Surveys showed patients value integrated care. Limitations include the absence of control group and loss to follow-up with risk of bias for VAS and AQoL4D.

Conclusion: Western HealthLinks patients maintained healthcare satisfaction and QoL over time after hospital discharge. Patients value integrated care and future models of care may benefit from incorporation of themes from analysis.

References

Forster AJ, et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Annals of Internal Medicine. 2003;138(3):161–167. DOI: 10.7326/0003-4819-138-3-200302040-00007
Open DOI Search in Google Scholar Back to article
Mitchell SE, et al. Care Transitions From Patient and Caregiver Perspectives. Ann Fam Med. 2018;16(3):225–231. DOI: 10.1370/afm.2222
Open DOI Search in Google Scholar Back to article
Preen D, et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: A randomized controlled trial. International journal for quality in health care: journal of the International Society for Quality in Health Care/ISQua. 2005;17:43–51. DOI: 10.1093/intqhc/mzi002
Open DOI Search in Google Scholar Back to article
NHS England. National Voices: A Narrative for Person-Centred Coordinated Care. 2013 [cited 2023]; Available from: https://www.nationalvoices.org.uk/sites/default/files/public/publications/narrative-for-person-centred-coordinated-care.pdf.
Search in Google Scholar Back to article
Baxter S, et al. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Services Research. 2018;18(1):350. DOI: 10.1186/s12913-018-3161-3
Open DOI Search in Google Scholar Back to article
Struckmann V, et al. Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review. Health Policy. 2018;122(1):23–35. DOI: 10.1016/j.healthpol.2017.08.008
Open DOI Search in Google Scholar Back to article
Trankle SA, et al. Integrating health care in Australia: a qualitative evaluation. BMC Health Services Research. 2019;19(1):954. DOI: 10.1186/s12913-019-4780-z
Open DOI Search in Google Scholar Back to article
Plant NA, et al. Coordinated care versus standard care in hospital admissions of people with chronic illness: a randomised controlled trial. Med J Aust. 2015;203(1): 33–38. DOI: 10.5694/mja14.01049
Open DOI Search in Google Scholar Back to article
Bird S, Noronha M, Sinnott H. An integrated care facilitation model improves quality of life and reduces use of hospital resources by patients with chronic obstructive pulmonary disease and chronic heart failure. Australian Journal of Primary Health. 2010;16(4):326–333. DOI: 10.1071/PY10007
Open DOI Search in Google Scholar Back to article
Flanagan S, Damery S, Combes G. The effectiveness of integrated care interventions in improving patient quality of life (QoL) for patients with chronic conditions. An overview of the systematic review evidence. Health Qual Life Outcomes. 2017;15(1):188. DOI: 10.1186/s12955-017-0765-y
Open DOI Search in Google Scholar Back to article
Conilione P, Jessup R, Gust A. Novel machine learning model for predicting multiple unplanned hospitalisations. BMJ Health Care Inform. 2023;30(1). DOI: 10.1136/bmjhci-2022-100682
Open DOI Search in Google Scholar Back to article
Monash University Centre for Health Economics. AQoL-4D. [cited 2024 22 August 2024]; Available from: https://www.aqol.com.au/documents/AQoL-4D/AQoL-4D_Data_Collection_Copy.pdf.
Search in Google Scholar Back to article
Monash University Centre for Health Economics. Choice of an Instrument: Why AQoL? [cited 2023 20 September 2023]. Available from: https://www.aqol.com.au/index.php/choice-of-an-instrument.
Search in Google Scholar Back to article
Richardson J, et al. Difficulty with life and death: Methodological issues and results from the utility scaling of the assessment of quality of life (AQoL) instrument. Economics and Health. 1988. 1998:121–138.
Search in Google Scholar Back to article
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77–101. DOI: 10.1191/1478088706qp063oa
Open DOI Search in Google Scholar Back to article
Hawthorne G, Korn S, Richardson J. Population norms for the AQoL derived from the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Public Health. 2013;37(1):7–16. DOI: 10.1111/1753-6405.12004
Open DOI Search in Google Scholar Back to article
Hisashige A. The effectiveness and efficiency of disease management programs for patients with chronic diseases. Glob J Health Sci. 2012;5(2):27–48. DOI: 10.5539/gjhs.v5n2p27
Open DOI Search in Google Scholar Back to article
Tsai AC, et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11(8):478–488.
Search in Google Scholar Back to article
de Bruin SR, et al. Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health Policy. 2012;107(2–3):108–145. DOI: 10.1016/j.healthpol.2012.06.006
Open DOI Search in Google Scholar Back to article
Courtney M, et al. Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program. J Am Geriatr Soc. 2009;57(3):395–402. DOI: 10.1111/j.1532-5415.2009.02138.x
Open DOI Search in Google Scholar Back to article
Lim WK, Lambert SF, Gray LC. Effectiveness of case management and post-acute services in older people after hospital discharge. Medical Journal of Australia. 2003;178(6):262–266. DOI: 10.5694/j.1326-5377.2003.tb05191.x
Open DOI Search in Google Scholar Back to article
Brand CA, et al. A transitional care service for elderly chronic disease patients at risk of readmission. Aust Health Rev. 2004;28(3):275–284. DOI: 10.1071/AH040275
Open DOI Search in Google Scholar Back to article
Berthelsen C, Møller N, Bunkenborg G. Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilising an umbrella review. J Clin Nurs. 2024;33(2):481–496. DOI: 10.1111/jocn.16913
Open DOI Search in Google Scholar Back to article
Anderson R, Barbara A, Feldman S. What patients want: A content analysis of key qualities that influence patient satisfaction. J Med Pract Manage. 2007;22(5):255–261.
Search in Google Scholar Back to article
Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf. 2014;23(8):678–689. DOI: 10.1136/bmjqs-2013-002437
Open DOI Search in Google Scholar Back to article
Epstein RM. Making communication research matter: what do patients notice, what do patients want, and what do patients need? Patient Educ Couns. 2006;60(3):272–278. DOI: 10.1016/j.pec.2005.11.003
Open DOI Search in Google Scholar Back to article

Articles in this issue

DOI: https://doi.org/10.5334/ijic.8980 | Journal eISSN: 1568-4156

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Language: English

Page range: 14 - 14

Submitted on: Sep 2, 2024

Accepted on: Aug 25, 2026

Published on: Sep 7, 2026

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Keywords:

© 2026 Julia L. Jones, Kirsty Barnes, Catherine Grant, Jason Plant, Natalie G. Lumsden, Koen Simons, Edward D. Janus, Craig L. Nelson, Ann Allenby, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 26 (2026): Issue 3