Development of a service delivery intervention and implementation plan for optimising primary care management of knee osteoarthritis: the partner project

Purpose: There have been calls for new models of service delivery and knowledge translation interventions to address evidence-practice gaps in the management of knee osteoarthritis (OA). This paper describes the evidence-based and theoretically-driven development of a model to deliver recommended care to people with knee OA in Australian primary care, including the plan to implement the model into practice. Methods: There were three phases of development (Fig. 1). Each phase considered the current Australian healthcare context and was informed by key stakeholder input. In Phase 1, a new model of service delivery was designed. The model aimed to improve upon existing care provided by general practitioners (GPs), and integrate GP care with a new service – the ‘Care Support Team’ (CST), to address care shortfalls and deliver optimal management. In Phase 2, we operationalised the CST. In Phase 3, we developed a plan for implementing the model. This latter phase primarily required a behaviour change intervention targeting GPs. Consistent with the UK Medical Research Council guidance on complex intervention development, these phases did not occur sequentially but concurrently and iteratively. Results: Phase 1 Model Design. Using information derived from clinical practice guidelines, a theoretical rationale for achieving better patient outcomes, chronic disease management frameworks, input from stakeholders, and the opportunities and constraints afforded by the Australian primary care context, we developed the PARTNER model (Fig. 2) for primary care management of people with knee OA. The key features of the model are: i) An effective GP consultation, and ii) Follow-up and ongoing care provided remotely (telephone/email/webpage) by the centralised multidisciplinary team. The evidence-based, patient-centred CST care focusses on education, exercise and/or weight loss advice, and facilitation of self-management and behaviour change using goal-setting, action-planning and behavioural monitoring. Phase 2 Operationalising the CST. Staff recruited for the CST were trained in evidence-based knee OA management and the HealthChange AustraliaTM methodology. The methodology amalgamates psychological and health behaviour change theories and draws on principles from motivational interviewing and cognitive behavioural therapy (CBT), to impact on health literacy, readiness, motivation, and self-efficacy. Patient education resources and the exercise program were developed based on contemporary best-practice. Existing resources were incorporated including an 18-week remote-delivered weight loss program and online CBT-based programs for pain coping, sleep management and depression/anxiety treatment. Phase 3 Implementation of the PARTNER model. The Behaviour Change Wheel was used to design an intervention to facilitate implementation of the model. This primarily required behaviour changes by GPs. We identified key GP behaviours to target as: i) Arriving at and communicating the diagnosis of knee OA without the use of imaging; ii) Focussing the consultation on discussing the importance of strengthening exercise, physical activity and weight loss in managing symptoms; and iii) Referring the patient to the CST. We undertook a behavioural analysis, and, cognizant of research evidence from implementation science on clinician behaviour change and knowledge translation interventions, we developed a multi-modal behaviour change intervention. This comprised of a self-audit/feedback activity and online professional development modules. In addition, we commissioned modifications to desktop electronic medical record software to provide decision support, easy access to helpful patient information resources and facilitated referral to the CST. Conclusions: The PARTNER model including the CST are now ready for evaluation in a cluster randomised controlled trial. Findings will also inform future consideration of scaling up and securing ongoing funding.View Large Image Figure ViewerDownload Hi-res image Download (PPT)