Dedicated prevention role

New, supplementary roles have been introduced in several countries and regions worldwide with the aim of improving access, especially in the field of preventive care and health promotion. Expanding prevention roles of primary care providers has been increasingly recognized, bringing individual health promotion and prevention closer to and integrated into primary care.

Primary care providers are central in providing individual health promotion and prevention activities, this was also demonstrated by the systematic reviews. In these reviews, they took on supplementary roles to promote healthy diets and physical activity or deliver interventions targeting various risk factors. Nurses, pharmacists, dieticians and GPs performed diet-related health advice in school settings including education and counselling to school children and their parents (Reference Bhattarai, Prevost and WrightBhattarai et al., 2013; Reference Schroeder, Travers and SmaldoneSchroeder, Travers & Smaldone, 2016). Moreover, various professions performed counselling, and provided advice and motivational interviewing to increase physical activity in sedentary adults (Reference Orrow, Kinmonth and SandersonOrrow et al., 2012), among other interventions. Dedicated prevention roles covered various skill-mix interventions across several countries, but the majority of the findings demonstrated a positive effect on prevention-related outcomes. Outcomes included significantly reduced body mass index scores for adults and children, increased dietary intakes of healthy food (for example, vegetables and fruits) and physical activity (Chapter 4).

Home visits were common skill-mix interventions implemented to reach out to specific groups, particularly to vulnerable populations. The professions conducting home visits ranged from qualified professions (including nurses, social workers and midwives) to lay or lower-qualified workers (including community health workers and other lay workers). The tasks performed varied considerably within and across the professions covered. Generally, higher qualified professions also performed more specialized tasks – including with a focus on clinical tasks. Lay workers provided generally no or very limited clinical tasks, but instead focused on providing general information and health advice. The home visits were often tailored to the needs of specific target populations and involved multilingual advice, counselling and referrals, and were sometimes combined with transport services or phone calls. In particular, the multicomponent approaches showed positive effects in terms of expanding access to services.

Innovative skill-mix interventions were targeted towards preventing child maltreatment and reducing health disparities and demonstrated significantly improved patient-related outcomes and significantly reduced health care utilization, such as emergency care use or hospital (re-)admissions (Chapter 4 and Chapter 8). Most studies adding supplementary roles to perform outreach and educational activities showed promising effects towards increasing the access to screening services and earlier treatment (Chapter 8). Cost savings were reported for maternity home visits to prevent child maltreatment (Reference Dalziel and SegalDalziel & Segal, 2012), but were based on estimates and modelling; hence, require more research including costing studies and cost-effectiveness analyses to arrive at a more robust evidence base (Chapter 4).

Care coordinator roles and skills

Many countries have health systems that are fragmented and not well coordinated, particularly for people with chronic conditions and with highly complex care needs. Several skill-mix changes have been introduced establishing new roles to explicitly improve the coordination of care. Two models emerged, either new roles at the interface of hospital and ambulatory care sector, often as a one-off activity; or along the patient pathway as a supporting and coordinating role over a longer period of time. Coordinator roles have been established in many high-income countries, including virtually all European countries; however, the terms used and professions working in these roles vary considerably (care coordinator, case manager, transition coordinator).

New roles focusing on the transition, specifically from hospital to ambulatory care, were mostly referred to as transition coordinators, navigators or various terms related to discharge management. These roles were central for patients with often severe or multiple conditions who were close to discharge and they were aimed at improving the continuity of care from hospital to ambulatory care. Examples are provided in Chapter 5. Skill-mix interventions often comprised multiple components including discharge planning, patient education, medication reconciliations and sometimes home visits. These roles were primarily performed or led by nurses, including advanced practice nurses and other specialized nurses, pharmacists or sometimes social care workers. The new roles actively managed the early transitioning of care to the ambulatory setting. Introducing new roles in transitional care overall showed positive effects on at least one patient-related or health-system-related outcome. However, whereas patient satisfaction, patients’ knowledge about the disease and self-management improved, findings on mortality and health-system-related outcomes, such as readmissions and service utilization, showed mixed results (Chapter 5).

To improve the coordination of care and patient centeredness over a longer period of time, new roles in care coordination – in particular case manager roles – were undertaken. These roles were most frequently performed by nurses and/or pharmacists depending on different country and care contexts. Case management roles focused on patients with chronic diseases, with major acute conditions or with long-term care needs, in particular patients with dementia. More detailed information is provided in Chapter 5 (acute care), Chapter 6 (chronic care) and Chapter 7 (long-term and palliative care). For patients with mental health problems, interdisciplinary care coordination showed significant improvements in mental health outcomes (Chapter 6).

Introducing case management in the community setting for long-term care patients and their caregivers showed some improvements, nonetheless, the evidence remains mixed for most outcome parameters (Chapter 7). Patients with dementia showed reduced feelings of isolation and embarrassment of the condition after case management roles were introduced that focused on counselling, coordinating, monitoring, assessing and educating. Yet, evidence on other outcomes such as mortality, depression and functional status remained inconclusive (Reference Backhouse, Ukoumunne and RichardsBackhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov and VedelKhanassov & Vedel, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Pimouguet, Lavaud and DartiguesPimouguet, Lavaud & Dartigues, 2010; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015). The reasons for these mixed, and therefore inconclusive results, are unknown and may be influenced by multiple factors: the intervention itself and differences in the intensity of the interventions, the different roles and professions involved. It may also be related to the fact that the severity of the condition (for example, dementia) has less potential for improvements in clinical outcome measures than if compared with case management skill-mix interventions for patients with acute or stable chronic conditions.

Patient navigator roles were widely implemented and researched, encompassing different tasks such as coordinating, discharge planning, educating and follow up. The patient navigator role was evaluated for cancer patients (Chapter 6), for whom the new role originally emerged. Patient navigators were also introduced for patients with acute conditions and to facilitate the access to screenings, especially for vulnerable population groups (Chapter 5 and Chapter 8). Patient navigators were shown to be health professionals with professional education, but they sometimes also involved former patients/peers, community health workers or other lay workers with some training acting as navigators through the system, particularly for vulnerable groups.

Patient navigators were particularly crucial in overcoming language barriers for vulnerable patients with limited language proficiency. Improved uptake of screenings and completion of diagnostics illustrated the positive impact of patient navigation for vulnerable patients (Chapters 4 and 8). Moreover, community health workers acting as patient navigators to improve chronic disease management showed significant positive effects regarding health outcomes for disadvantaged patients (Chapter 8).

Skill-mix to empower patients and caregivers

Empowering patients and their caregivers in the self-management of their conditions has received policy attention over the past decade as a cost-effective strategy to support self-care and person-centred care of people. Several skill-mix interventions have specifically targeted patient self-management and empowerment. Skill-mix interventions result in extended roles and new tasks, for example, providing (tailored) educational activities, motivational interviewing or coaching, consultations and self-management skills trainings. In the systematic reviews, these services were primarily provided by nurses, pharmacists or peers for patients with single chronic conditions. Overall, these interventions fostering patient autonomy in the care process showed positive effects on several health outcomes including on blood pressure and glycated haemoglobin (HbA1c) levels (Chapter 6).

Introducing peer educators was another common skill-mix intervention. Peer educators are “peers”, defined as other patients usually with the same condition, often with no health profession-specific background but with extensive knowledge on the disease and having received additional, short trainings to serve as peer educators. The advantage is that they have often had a similar experience as patients in the health system. Peer educators, who have regular contact with patients, have been shown to positively impact health or peer-related outcomes (Chapter 6). For example, a peer support model for diabetes patients, which comprised face-to-face management, peer coaching and phone-based support, showed improvements in blood pressure, body mass index and physical activity, among other positive health-related outcomes (Reference Dale, Williams and BowyerDale, Williams & Bowyer, 2012).

For vulnerable groups, community health workers, peer counsellors or professionals with various other backgrounds emerged as a common intervention across the systematic reviews resulting in primarily positive outcomes for patients. Lay and community-based workers focused on education and navigation assistance, usually collaborating with other health professionals (Chapter 8). Interventions delivered by community health workers, who worked alongside other professionals such as nurse case managers and psychologists, showed significant improvements in the management of chronic diseases including positive effects on blood pressure levels and cardiovascular disease risk reduction (Reference Kim, Choi and ChoiKim et al., 2016). Similarly, lay health workers and peer counsellors assisting mothers and their children with low socioeconomic status through home visits, reminders, education and the facilitation of meetings indicated reduced child mortality and morbidity. Additionally, the interventions increased the uptake of immunization rates as well as the likelihood for women to seek care for childhood sicknesses (Reference Lewin, Munabi-Babigumira and GlentonLewin et al., 2010).

Interventions to support and strengthen patients and their caregivers in long-term care encompassed assessing the specific needs, planning of support interventions, monitoring, coaching and counselling (Chapter 7).

Pain management targeted at patients in palliative care and their family caregivers covering different components such as face-to-face education and follow ups demonstrated significantly improved medication adherence; yet, showed mixed results on caregivers’ knowledge, for example, about pain management.

Advanced practice roles among nurses, pharmacists and other professions

Skill-mix models in the literature frequently analysed the effects of advanced practice roles of nurses or pharmacists, performing an expanded set of tasks, traditionally provided by physicians or other health professionals. Other professions covered were physiotherapists or dental hygienists working in expanded roles. Advanced roles ranged from introducing advanced practice providers, with a considerably expanded scope-of-practice (for example, advanced practice nurses including nurse practitioners with usually at least a Master’s degree; or pharmacists) to the expansion of a limited set of additional tasks, such as for nurses or dental hygienists. This practice was found across almost all different care segments in the overview of reviews. In health promotion and prevention, advanced practice nurses (for example, nurse practitioners) or professional nurses performed screenings and skin cancer assessments and examinations.

For instance, nurses in advanced practice roles delivering skin cancer screening showed higher sensitivity to identify malignant lesions compared with physicians or general and expert dermatologists (Reference Loescher, Harris and Curiel-LewandrowskiLoescher, Harris & Curiel-Lewandrowski, 2011). Nurse-delivered colorectal cancer screenings detected higher rates of adenomas, and were shown to result in lower costs compared with physician-led services (Reference Joseph, Vaughan and StrandJoseph, Vaughan & Strand, 2015). This is one example whereby nurse-led screenings were associated with reduced costs; however, to date the evidence on nurse-led screenings on costs is scarce and requires more cost-effectiveness studies (Chapter 4).

The highest number of reviews focused on task shifting and a new division of work for chronically ill patients. Nurses and pharmacists took on considerably advanced roles, which had traditionally been performed by physicians. One model was nurse-led care, defined as nurses leading the treatment and care process for a defined group of patients, like with diabetes. Nurse-led care included a wide range of different components such as prescribing of medicines, management of medication adherence, disease management or education. Models ranged from delivery either autonomously or in collaboration with other health professionals, usually with physicians. Nurse-led care for single chronic diseases indicated better or equivalent health outcomes compared with usual care (mainly physician-provided), in particular for titration and medication adherence (Reference Parker, Maresco-Pennisi and CliftonParker et al., 2016; Reference Shaw, Mcduffie and HendrixShaw et al., 2013), yet, nurse-led care revealed insufficient evidence for health system outcomes and cost effectiveness. Inconclusive findings were demonstrated for multimorbidity (Chapter 6).

Pharmacists in expanded roles took over tasks from physicians such as health screenings, immunizations and monitoring medication adherence. Pharmacists delivering care for patients with chronic conditions were shown to positively influence cardiovascular disease outcomes such as blood pressure in several systematic reviews (Reference Blalock, Roberts and LauffenburgerBlalock et al., 2013; Reference Cheema, Sutcliffe and SingerCheema, Sutcliffe & Singer, 2014; Reference Fazel, Bagalagel and LeeFazel et al., 2017; Reference Greer, Bolduc and GeurkinkGreer et al., 2016; Reference Morgado, Morgado and MendesMorgado et al., 2011; Reference Nkansah, Mostovetsky and YuNkansah et al., 2010; Reference Tan, Stewart and ElliottTan et al., 2014; Reference Van Eikenhorst, Taxis and Van Dijkvan Eikenhorst et al., 2017). Moreover, evidence showed improvements in medication adherence for patients with hypertension (Reference Blalock, Roberts and LauffenburgerBlalock et al., 2013; Reference Cheema, Sutcliffe and SingerCheema, Sutcliffe & Singer, 2014; Reference Morgado, Morgado and MendesMorgado et al., 2011) and demonstrated reduced hospitalization, emergency department visits and costs for pharmacist-led chronic care (Reference Entezari-Maleki, Dousti and HamishehkarEntezari-Maleki et al., 2016; Reference Manzoor, Cheng and LeeManzoor et al., 2017).

Skill-mix interventions and task shifting practices were also identified for (minor) acute illnesses where pharmacists, physiotherapists and mid-level dental care providers had extended the scope of practices (Chapter 5). In the United Kingdom, pharmacy-based minor ailment consultations suggested less costly services than usual care delivered by GPs and an overall satisfaction among patients, GPs and pharmacists (Reference Paudyal, Watson and SachPaudyal et al., 2013). Positive effects regarding health outcomes were also reported for mid-level dental providers such as dental hygienists delivering care (Dasanayake et al., 2012; Reference Wright, Graham and HayesWright et al., 2013).

Skill-mix and relocation of care

The relocation of care settings comprised hospital-at-home, nurse-led clinics if provided in a new setting and palliative care at home interventions. Hospital-at-home services are defined as highly specialized services at patients’ homes for individuals who would usually require hospitalization for their condition. Three systematic reviews including two Cochrane Reviews assessed hospital treatment at home by various health professionals in highly specialized teams (Reference Gonçalves-Bradley, Iliffe and DollGonçalves-Bradley et al., 2017; Reference Qaddoura, Yazdan-Ashoori and KabaliQaddoura et al., 2015; Reference Shepperd, Cradduck-Bamford and ButlerShepperd et al., 2017). One Cochrane review analysed home services delivered by a specialist respiratory nurse (Reference Jeppesen, Brurberg and VistJeppesen et al., 2012). Positive or no effects were reported for mortality rates across the reviews and mixed results were shown for readmission and patient outcomes. However, no negative outcomes were reported, suggesting that hospital-at-home may be a safe model of care provision, for instance for patients with acute respiratory conditions, provided that the professions are adequately trained, possess the right skills and perform close monitoring (Chapter 5).

Nurse-led cardiac clinics suggested a positive impact on the quality of care for patients with chronic conditions. Studies demonstrated that nurse-led clinics provided equivalent or better care compared with usual care or clinics run by other health professionals. To illustrate, significant improvements were found for mortality rates and equivalent effects for self-reported mental or physical health and hospitalization episodes compared with usual care (Reference Al-Mallah, Farah and Al-MadaniAl-Mallah et al., 2016; Reference Schadewaldt and SchultzSchadewaldt & Schultz, 2010). Similarly, nurse-led clinics for patients with multimorbidity indicated equivalent care compared to other clinics (Reference Clark, Smith, Taylor and CampbellClark et al., 2011) (Chapter 6).

While the number of systematic reviews on palliative care at patients’ homes was small, effects on pain management through interventions mostly delivered by teams or in collaboration showed improved pain-related outcomes. Palliative teams were composed of nurses, psychologists and researchers and targeted patients and their caregivers in palliative care. Improved caregiver satisfaction and lower caregiver burden were reported for implementing case managers and multidisciplinary collaboration models. Additionally, health system outcomes such as hospital admission and length of stay and profession-specific outcomes including communication and service relationships suggest positive impacts of palliative care delivered at patients’ homes (Chapter 7).

Changing teamwork and collaboration

Skill-mix interventions involving teamwork and collaboration were identified across all care segments included in the study, ranging from health promotion, prevention to long-term and palliative care. Teamwork took various forms, for example, multiprofessional teams, shared care whereby two professionals worked closely together sharing tasks, as well as networks of care providers and multiprofessional clinics.

Skill-mix interventions involving multiprofessional teams for chronic conditions and multimorbidity evaluated different ways of collaboration such as consultation liaison, joint care coordination or shared care performed by various professions, and was compared with usual care generally provided by physicians alone (Chapter 6). For consultation liaison involving collaborative care between physicians and specialists, moderate positive effects on physical health outcomes was demonstrated (Reference Foy, Hempel, Rubenstien and SuttorpFoy et al., 2010; Reference Mitchell, Burridge and ZhangMitchell et al., 2015). There was evidence that collaborative care involving mental health specialists and primary care providers improved mental health outcomes, patient satisfaction and quality of life (Reference Archer, Bower and GilbodyArcher et al., 2012; Reference Coventry, Hudson and KontopantelisCoventry et al., 2014). Reduced utilization of inpatient care and other health care services was shown for other multiprofessional care models such as primary care provider networks (Reference Carter, Riverin and LevesqueCarter et al., 2016) and multiprofessional cardiac clinics (Reference Gandhi, Mosleh and SharmaGandhi et al., 2017). Collaborative care targeting patients with multimorbidity showed improved adherence to medication and health outcomes; but, little or no evidence on cost savings.

Overall, the reviews suggest that multiprofessional care models can have a positive effect for patients with mental health problems and multimorbidity (Chapter 6).

Skill-mix interventions provided by multiprofessional teams were frequently reported for transitional care and early discharge planning. For instance, transitional care teams focused on care transitioning across different care settings including the inpatient/ambulatory interface and different phases of life (paediatric to adulthood). The evidence on transitional care involving various professions demonstrated positive effects on selected patients and health system outcomes; however, not all reviews and underlying studies differentiated between multiprofessional and single-profession interventions (Chapter 5)

In long-term care, multiprofessional community mental health teams and collaborative models were evaluated. Multiprofessional community mental health teams were composed of mental health nurses, social workers, psychologists, consultant psychiatrists and GPs. The mental health teams provided intensive care management and team diagnosis.

Multiprofessional collaboration models included interventions such as shared care plans and joint decision-making. Although the evidence was limited because it covered only a few studies, introducing multiprofessional teams for long-term conditions such as mental health or Parkinson’s disease were suggested to improve quality of life and function and mobility rates. Intensified collaboration among health professionals delivering care for patients in palliative care also demonstrated positive effects on patients and their caregivers, but was limited to few individual studies (Chapter 7).