Evaluating the Preventative Integrated Care Service for adults living with chronic disease

The Preventative Integrated Care Service (PICS) is a rapid access, specialised, multidisciplinary, outpatient care model that was recently established in South-East Queensland, Australia. It provides a 14-day, rapid assessment and medical stabilisation service offering intensive specialised medical management of adults living with chronic respiratory diseases, chronic cardiovascular diseases, and/or diabetes. PICS is delivered by a specialist-led, multidisciplinary care team, and is delivered through multimodalities (e.g., in clinic, telephone, remote biometric monitoring, home visit). This programme was rolled out in South-East Queensland, Australia, was rolled out without implementation evaluation planning at its inception. This research will be conducted over three, six-month phases: - Phase 1: Context assessment (t1, August-September 2024). The primary outcomes of core components, programme determinants, and patient experiences, and secondary outcome of barriers and enablers will be identified and measured. - Phase 2: Process evaluation (t2, February-March 2025). The primary outcomes of fidelity and adoption will be measured. - Phase 3: Service iteration and adaption for quality improvement (t3, August-September 2025). The primary outcome of service iteration and adaption will be measured. There are four groups of participants that will be engaged in the research: - Adopters (Consumers): Patients who have received PICS. Consumers will be recruited to participate in 45-60min semi-structured interviews (one baseline, and a six-month follow-up) on their perspectives and experience of receiving the PICS. Patients will not be required to undertake additional physical or psychometric assessments. Patients will receive reciprocity for their time. Engagement of patients is only during Phase 1 Context assessment. Further detail is provided in Section 7 Recruitment. Deidentified, clinical patient information will be utilised for secondary outcome measurement (Phase 2 secondary outcome - clinical effectiveness) for data between t1 (01 August 2024) and t3 (01 August 2025). A waiver for consent has been approved by the Human Research Ethics Committee. - Adopters & implementers (PICS service delivery staff): Participants will be recruited at all three phases of research. Participation will involve semi-structured interviews (Phase 1 and 2), with the opportunity to provide feedback on interview summary notes to the researcher. A subsample of participants will be recruited to Phase 3, to participate in collaborative workshops for service iteration and adaption. Following the completion of their semi-structured interview, participants will be offered to the opportunity to nominate to participate in the collaborative workshop, A representative sample cross disciplines and professional delegation (i.e., clinician, team leader, executive) will be determined by the research team. The collaborative workshop will involve two x four-hour face-to-face workshops, facilitated by the research team. Active participation in responding to researcher queries and participating in conversation with colleagues will be required. The workforce profile for the PICS includes Nurse Practitioners, Registered Nurses, Senior Medical Officers, Dietitian, Pharmacist, Physiotherapists, Occupational Therapists, and Social Workers. - Implementation leaders and decision makers: Participants will be recruited at all three phases of research. Participation will involve semi-structured interviews (Phase 1 and 2), with the opportunity to provide feedback on interview summary notes to the researcher. A subsample of participants will be recruited to Phase 3, to participate in collaborative workshops for service iteration and adaption. Following the completion of their semi-structured interview, participants will be offered to the opportunity to nominate to participate in the collaborative workshop, A representative sample cross disciplines and professional delegation (i.e., clinician, team leader, executive) will be determined by the research team. - Wider system referrers: Participants will be recruited at Phase 3, with the opportunity to provide feedback on interview summary notes to the researcher.