title: Implementation challenges in delivering team-based care ('TEAMcare') for patients with chronic obstructive pulmonary disease in a public hospital setting: a mixed methods approach.
abstract: Chronic obstructive pulmonary disease (COPD) is considered a multisystem disease, in which comorbidities feature prominently. COPD guidelines recommend holistic assessment and management of relevant comorbid diseases but there is limited information as to how this is best achieved. This pilot study aimed to explore the views of stakeholders, including patients and the healthcare team, on the feasibility, acceptability and barriers to a collaborative, multidisciplinary team-based care intervention ('TEAMcare') to improve health outcomes in COPD patients, within the context of a local hospital outpatient clinic.
  
  
  
  A mixed methods study design was used. A COPD care algorithm was developed based on the Australasian guidelines, COPDX. COPD participants were consecutively recruited from an outer metropolitan hospital's respiratory clinic. Participants attended for follow up visits at 5 and 10 months to ascertain clinical status, algorithm compliance and to review and revise management recommendations. The intervention was conducted using existing resources, involving collaboration with general practice and the publicly-funded local chronic disease management programme (Medicare Local). Stakeholders provided qualitative feedback about the intervention in terms of feasibility, acceptability and barriers via structured and semi-structured interviews. All interviews were recorded, transcribed verbatim and analysed using qualitative thematic analysis to identify key concepts and themes.
  
  
  
  The study protocol was abandoned prematurely due to clear lack of feasibility. Of 12 participants, 4 withdrew and none completed pulmonary rehabilitation (PR). The main reasons for non-participation or study withdrawal related to reluctance to attend PR (6 of 16) and the burden of increased appointments (4 of 16). PR conflicted with employment hours, which presented problems for some participants. Similarly, themes that emerged from qualitative data indicate healthcare provider perception of deficiencies in funding (for infrastructure and staffing). Health literacy, motivation, organisation and functional impairment were issues for patients.
  
  
  
  Available data from this small pilot provided valuable insights to inform future design and implementation strategies. Delivering structured team-based care to COPD patients presents challenges. In addition to enhancing health resources for engaging COPD patients, a focus on health literacy and improving health service access, including colocalisation and access outside business hours, may be required.
  
  
  
  ACTRN12616000342415 ; 16/03/2016.
authors.affiliation: School of Medicine, Western Sydney University, Penrith, NSW, Australia.|Department of Respiratory and Sleep Medicine, Macarthur Health, Campbelltown, NSW, Australia.
authors.forename: Belinda
authors.initials: B
authors.lastname: Cochrane
authors.affiliation: School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia.|Discipline of Obstetrics, Gynaecology and Neonatology, Sydney Medical School/Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.|Ingham Institute, Liverpool, NSW, Australia.
authors.forename: Jann
authors.initials: J
authors.lastname: Foster
authors.affiliation: South Western Sydney Primary Health Network, Campbelltown, NSW, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Boyd
authors.affiliation: School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia. E.Atlantis@westernsydney.edu.au.|School of Medicine, The University of Adelaide, Adelaide, SA, Australia. E.Atlantis@westernsydney.edu.au.
authors.forename: Evan
authors.initials: E
authors.lastname: Atlantis
mesh_terms: D000368:Aged; D015897:Comorbidity; D005260:Female; D058006:General Practice; D006282:Health Personnel; D006297:Health Services Accessibility; D006779:Hospitals, Public; D006801:Humans; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D010348:Patient Care Team; D010349:Patient Compliance; D010865:Pilot Projects; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D012107:Research Design
keywords: Clinical practice guideline; Clinical protocols; Comorbidity; Multidisciplinary communication; Pulmonary disease, chronic obstructive (COPD)