Linkage, coordination and integration: evidence from rural palliative care.

OBJECTIVE Review the findings from the evaluations of three rural palliative care programs. DESIGN Review by the authors of the original material from each evaluation. The conceptual framework for the review was provided by the work of Leutz, including his distinction between linkage, coordination and full integration. SETTING Community-based palliative care in rural Australia. INTERVENTIONS Fifteen projects across all six states of Australia that focused on integration between general practitioners and other community-based health providers. RESULTS The projects set out to improve networking and collaboration between providers; improve coordination and integration of care for patients; reduce duplication of services; and achieve a multidisciplinary, collaborative approach to palliative care. The most common interventions were establishment of formal governance structures, provision of education programs, case conferencing, dissemination of information, development of formal arrangements, development of protocols and use of common clinical assessment tools. The terms 'integration' and 'coordination' were used frequently but without clear definitions. Coordination required someone specifically designated to do the coordinating, usually a nurse. Formal arrangements to improve linkage and coordination were difficult to maintain. The main mechanism to achieve full integration was the development of common clinical information systems. CONCLUSIONS The 'laws' proposed by Leutz and the concepts of linkage, coordination and full integration provide a useful framework to understand the barriers to integrating GPs and other health providers. It is important to be clear on what level of integration is required. Improving links might be sufficient (and realistic), rather than striving for full integration.