Collaboration between general practitioners and specialists for patients with complex chronic conditions: the case of spinal cord injury in rural Switzerland

Multimorbid patients benefit from integrated care, but these approaches are not widely developed or implemented in Switzerland. Integrated care aims to improve care continuity by linking levels of care, particularly by enabling health care professionals to collaborate and benefit from complementary skills and expertise. To demonstrate the potential of integrated care for complex, multimorbid patients, spinal cord injury is an excellent example. Persons with a spinal cord injury regularly consult primary and secondary care physicians for their holistic needs. The expertise of medical specialists for spinal cord injury is required, but in remote areas of Switzerland general practitioners (GPs) compensate for a potential undersupply of specialized services. Therefore, an integrated care model based on collaboration between rural GPs and specialists could be a case in point. The SCI-Co intervention study aims to develop, implement and evaluate such a care model in remote areas in Switzerland. This thesis consists of three publications, which either informed the SCI-Co intervention design or analyzed data collected in the SCI-Co study. The studies provide an overview of how collaboration was improved in other intervention studies, assess how physicians partaking in the SCI-Co study evaluated collaboration and explore how they perceive collaboration and role distribution at baseline. Results of this thesis demonstrated that GPs and specialists participating in the SCI-Co intervention rated collaboration well. Especially the interpersonal factors, seem to provide a foundation for expanding the collaboration. However, there appears to be room for improvement, particularly in referral and discharge processes. These organizational challenges are likely due to a fragmented health care system requiring support for finding solutions from multiple stakeholders. Furthermore, this thesis showed the GPs' role in caring for persons with a spinal cord injury needs clarification. The reality of the GPs' services provided to their patients differs from the specialists' perceptions. As suggested by the literature and physicians, a potential setting for this could be continuous medical education events. At these events, physicians can get to know each other, learn from each other and negotiate their roles, responsibilities and tasks. Research, clinical practice, and policy stakeholders should address challenges to support physicians in improving collaboration to advance integrated care in Switzerland.