Abstract
Background: This study presents the theory of change underpinning a population-wide health systems project in a regional area in New South Wales, Australia that aims to improve people’s access to the right care at the right place - the project has an emphasis on primary care access for underserved priority populations of young people, Aboriginal and Torres Strait Islander people, and people living in lower socioeconomic geographic areas.
Approach: Commissioners of a three year multi-million-dollar, multi-faceted regional service - incorporating a digitally-enabled telephonic triage service with an integrated booking tool for accessing GP appointments and inclusion of community pharmacies in care pathways, undertook a human-centric co-design process. This included focus groups with consumer representatives and concept testing with potential service-users. Our team were commissioned as independent evaluation partners to conduct developmental, formative and summative evaluation embedded throughout all project stages. The theory of change presented in this paper proposes attributes of an effective regional strategy aiming to enhance primary care access, particularly to underserved groups and identifies key questions for its’ evaluation. To develop the theory of change we reviewed project design documentation, observed co-design sessions, and conducted thematic analysis of semi-structured interviews (n=11) and workshops (n=2, each involving 10-15 program staff/contractors) with a purposive sample of stakeholders selected to provide expertise in primary care access, and engaged in project design or implementation. We then applied a mid-range theory of public health care seeking to develop priority research and evaluative questions related to each of the main assumptions in the theory of change.
Results: A theory of change model summarised the positive processes of change which could be initiated through residents in the region having increased access to triage services, health advice, and direct integrated bookings with GPs and community pharmacists. On the supply-side, positive change could be achieved through successful proof-of-concept of local system change initiated by practice support payments to participating GPs to quarantine no-cost appointments for people triaged to this level of care, and through inclusion of community pharmacists in care pathways. Stakeholders believed that the benefits of the population-wide reengineered system would accrue to the priority target groups. They also believed that a strong data cycle through monitoring and evaluation coupled with a flexible model would enable adaption to the changing health system context, identify implementation risks, and allow for parallel solution development. The research and evaluation questions identified were used as the focus for a series of quality improvement insights reports and resulted in modifications to implementation processes. Lessons learned for design and evaluation of similar initiatives are identified.
Implications: This study has revealed priority areas for the ongoing development and evaluation of a regionally-commissioned model of care that aims to ensure population-wide access to the right services, at the right time and in the right place. It provides a worked example of a theory-driven approach to embedding a participatory evaluation process to support integrated care across different levels of the design and delivery of a regionally-led program, and demonstrates its value.