Carmel Mary Martin

Monash University (Australia)

The Universal Health (UHC) movement in its latest iteration, has adopted key objectives of Primary Health Care (PHC). This is a notable shift in the right direction but achieving what appears to be simple targets is a highly complex endeavour across both wealthy and less wealthy countries and jurisdictions. Improving health for all targets requires...

Multimorbidity and Acute Potentially Preventable Diagnoses in HealthLinks Chronic Care (HLCC) Dandenong Cohort. A work in evolution. Context Potentially Preventable Hospitalisation (PPH) is an admission for a condition where hospitalisation might have been prevented through provision of appropriate and timely community support and/or medical inte...

WONCA COVID-19 Webinar Series 2 - Complexity SIG Making Sense of Complexities of COVID-19 in Primary Care https://www.youtube.com/watch?v=BOlwWeTRv5c

Rationale, Aims, and Objectives HealthLinks: Chronic Care is a state‐wide public hospital initiative designed to improve care for cohorts at‐risk of potentially preventable hospitalizations at no extra cost. MonashWatch (MW) is an hospital outreach service designed to optimize admissions in an at‐risk cohort. Telehealth operators make regular phone...

The emergence of a coronavirus (SARS‐CoV‐2) with novel characteristics that made it highly infectious and particularly dangerous for an older age group and people with multiple morbidities brought our complex adaptive system (CAS) “society”—the economy, health systems, and individuals—to a virtual standstill. The COVID‐19 pandemic—caused by SARS‐Co...

Rationale, aims and objectives Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of a complex adaptive system (CAS) that is particularly responsive to bottom‐up rather than top‐down management approac...

Universal health care (UHC) is primarily a financing concern, whereas primary health care (PHC) is primarily concerned with providing the right care at the right time to achieve the best possible health outcomes for individuals and communities. A recent call for contributions by the WHO emphasized that UHC can only be achieved through PHC, and that...

BACKGROUND The Victorian HealthLinksChronicCare (HLCC) hospital algorithm identifies patients with predicted 3+ hospitalisations per year in order to generate a capitated funding pool. Hospitals can innovate with the fund to address anticipated admission risk. MonashWatch (MW) is a hospital outreach service implemented to address potentially preven...

Background MonashWatch is a telehealth public hospital outreach pilot service as a component of the Government of Victoria’s statewide redesign initiative called HealthLinks: Chronic Care. Rather than only paying for hospitalizations, projected funding is released earlier to hospitals to allow them to reduce hospitalization costs. MonashWatch intro...

Introduction: Multiple dynamics of internal and external network interactions result in the emergent observable state of a person’s health and care. A tsunami of Big Data predictions are developing to identify specific interventions to improve health. Anticipatory care on the other hand, can be understood, using Rosen's model – to recognize our inn...

Introduction: Potentially preventable hospitalizations (PPH) are hospitalizations that could be avoided with ambulatory care. Post hospital syndrome(PHS) is described as a transient period of generalized susceptibility, after hospital discharge, to disease and risk for adverse events, including hospital readmission and death. International efforts...

Background: In the context of increasing demand and constrained funding, delivering holistic, effective and efficient models of care that reduce reliance on hospitals without increasing service costs is a priority. HealthLinks: Chronic Care uses funding to encourage innovative patient centric approaches to chronic disease management. Activity based...

Big data provide the hope of major health innovation and improvement. However, there is a risk of precision medicine based on predictive biometrics and service metrics overwhelming anticipatory human centered sense-making, in the fuzzy emergence of personalized (big data) medicine. This is a pressing issue, given the paucity of individual sense-mak...

Health is an adaptive state unique to each person. This subjective state must be distinguished from the objective state of disease. The experience of health and illness (or poor health) can occur both in the absence and presence of objective disease. Given that the subjective experience of health, as well as the finding of objective disease in the...

Purpose: Potentially preventable hospitalizations (PPH) are minimized when adults (usually with multiple morbidities ± frailty) benefit from alternatives to emergency hospital use. A complex systems and anticipatory journey approach to PPH, the Patient Journey Record System (PaJR) is proposed. Application: PaJR is a web-based service supporting �we...

This special forum on resilience explores particular worldviews of resilience—clinical, psychosocial, sociological, complexity science, organizational, and political economy through eight papers. This forum aims to open up the wealth of understandings and implications in health care by taking a transdisciplinary overview.

All life requires the capacity to recover from challenges that are as inevitable as they are unpredictable. Understanding this resilience is essential for managing the health of humans and their livestock. It has long been difficult to quantify resilience directly, forcing practitioners to rely on indirect static indicators of health. However, meas...

Rationale, aims, and objectives Monash Watch (MW) aims to reduce potentially preventable hospitalisations in a cohort above a risk “threshold” identified by Health Links Chronic Care (HLCC) algorithms using personal, diagnostic, and service data. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record S...

Monash Watch (MW) aims to reduce avoidable hospitalizations in a cohort above a risk ‘threshold’ identified by HealthLinks Chronic Care (HLCC) algorithms using personal, diagnostic, and service data. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act a...

Background: General practice is regarded as central to the Australian health system. However, issues affecting the general practitioner (GP) workforce have been focused mainly on remuneration, numbers and distribution. The focus is shifting to how best to enable GPs to deliver effective, efficient and equitable care. Objective: The aim of this p...

Hospital readmissions are the consequence of an individual unstable health journeys in the context of their local health services and community configurations. The Patient Journey Record System (PaJR) has developed a conversational approach with care guides and clinician coaches who support such health journeys irrespective of condition and locatio...

Newell and Lewith’s paper [1] would have been more powerful had it put the emphasis on the second part of the title - “What is real medicine?” While there is not much disagreement with the general gist of their paper their line of argument is less convincing and somewhat superficial at the crucial points. We would suggest that the real question the...

Rationale: Much is written about "multimorbidity" as it is a difficult problem for health systems, as it reflects a complex phenomenon unique to each individual health journey and health service context. This paper proposes the adoption of 2 constructs or knowledge streams into mainstream "multimorbidity" care which are arguably most important to...

We argue that 'multimorbidity' is the manifestation of interconnected physiological network processes within an individual in his or her socio-cultural environment. Networks include genomic, metabolomic, proteomic, neuroendocrine, immune and mitochondrial bioenergetic elements, as well as social, environmental and health care networks. Stress syste...

Terminology matters - as Lakoff emphasised, words and phrases evoke powerful images and frames of understanding. It is for that reason that we need to discern and use appropriately the term complex/complexity in the health science/professional/policy domain. Complex is the fashionable term used when in reality one means 'complicated', 'difficult to...

This chapter firstly provides an overview of multimorbidity as a complicated clinico-epidemiological, yet reductionist construct of multiple discreet disease(s) occurring in one individual. Current multimorbidity studies highlight taxonomic challenges about the actual nature of disease or chronic disease singly or in clusters and their underlying p...

Rationale, Aims and Objectives. Pressures on hospital emergency services, hospital wards and many adverse health outcomes are deemed avoidable through timely access to primary care (PC). This paper analyses the problem of PC practices providing access, to mitigate avoidable emergency hospital utilization, within the context of the delivery of compr...

Big data’ has become a universal catchphrase for the massive data sets accumulated for administration purposes. Artificial intelligence and machine learning are also highly prevalent terms in contemporary media. How can Australia’s health system capitalize on one of its most valuable assets by transforming data from administration innovation. This...

Rationale, aims and objectives: Person-centred health care is prominent in international health care reforms. A shift to understanding and improving personal care at the point of delivery has generated debates about the nature of the person-centred research agenda. This paper purviews research paradigms that influence current person-centred resear...

Rationale, aims and objectives: Self-rated health (SRH) is a single measure predictor of hospital utilization and health outcomes in epidemiological studies. There have been few studies of SRH in patient journeys in clinical settings. Reduced resilience to stressors, reflected by SRH, exposes older people (complex systems) to the risk of hospitali...

Rationale, aims and objectives: Timely access to general practitioner (GP) care is a recognized strategy to address avoidable hospitalization. Little is known about patients seeking planned (decided ahead) and unplanned (decided on day) GP visits. The Patient Journey Record System (PaJR) provides a biopsychosocial real-time monitoring and support...

Purpose: Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. Methods: We performed a historical integrative review using the following systematic search strategy: medical subject hea...

1. Complexity in Health - An Introduction.- 2. Complexity, uncertainty and mess as the links between science and the humanities in healthcare.- Part 1 - Complexity Theory and Methods.- 3. Understanding Complex Systems.- 4. The Complex Nature of Knowledge.- 5. Mathematical Principles: Tales of Tails.- 6. Modelling.- 7. A methodology for the analysis...

The notion of health care, and in particular primary health care, being a public good was strongly expressed in the Declaration of Alma-Ata in 1978 [ 1 ] .

Avoidable hospitalizations are the subject of considerable interest to decision makers, because such admissions are deemed to be expensive, unhelpful to patients, and reflect underperformance of health systems’ organization [2–7]. Hospitalizations that might have been averted by health service interventions for older people are of particular concer...

A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) i...

More of the same, paraphrasing Einstein, can only lead to more of the same, or using Lakoff’s terminology [1], the way we talk about things is the way we think about them. Currently, and in contrast to most other disciplines, medicine remains largely stuck in the simplistic “reductionist” scientific world view and is resisting the move to the compl...

Common to complex systems are two fundamental themes—the universal interconnectedness and interdependence of all phenomena, and the intrinsically dynamic nature of reality [2]. “At each level of complexity we encounter systems that are integrated, self-organizing wholes consisting of smaller parts and, at the same time, acting as parts of larger wh...

This chapter is an introduction to user driven learning that initially dwells on features that are unchanged such as the role of collaborative social interactions in human learning and certain aspects that are evolving and helping create a learning transformation through web based technologies. The chapter is interspersed with user driven learning...

In the past decades, countries have reformed or restructured their health systems with different strategies to provide universal and accessible care, to improve the quality of services delivery and their outcomes and most of all to provide health care that is affordable. The main concern was to keep the cost under control while ensuring services ef...

The Patient Journey Record system (PaJR) is an application of a complex adaptive chronic care model in which early detection of adverse changes in patient biopsychosocial trajectories prompts tailored care, constitute the cornerstone of the model. To evaluate the PaJR system's impact on care and the experiences of older people with chronic illness,...

The aim of this study was to provide baseline data on chronic disease management (CDM) provision in Irish general practice (GP). The survey instrument was previously used in a study of primary care physicians in 11 countries, thus allowing international comparisons. The response rate was 72% (380/527).The majority of GPs (240/380; 63%) reported sig...

It is the 'moral compass', however subtle, that underpins leadership. Leadership, meaning showing the way, demands as much conviction as gentile diplomacy in the discourse with supporters and detractors. In particular, leadership defends the goal by safeguarding its principles from its detractors. The authors writing in the Forum on Complexity in M...

Everyone wants a sustainable well-functioning health system. However, this notion has different meaning to policy makers and funders compared to clinicians and patients. The former perceive public policy and economic constraints, the latter clinical or patient-centred strategies as the means to achieving a desired outcome. Theoretical development a...

Complex adaptive chronic care (CACC) is a framework based upon complex adaptive systems' theory developed to address different stages in the patient journey in chronic illness. Simple, complicated, complex and chaotic phases are proposed as diagnostic types. To categorize phases of the patient journey and evaluate their utility as diagnostic typolo...

This chapter argues the need for a paradigm shift to focus health care from a top down fragmented process driven activity to a user-driven journey of the individual whose health is at stake. Currently many person/patients express needs that are often overlooked or not understood in the health system, and the frontline care workers express frustrati...

This chapter argues the need for a paradigm shift to focus health care from a top down fragmented process driven activity to a user-driven journey of the individual whose health is at stake. Currently many person/patients express needs that are often overlooked or not understood in the health system, and the frontline care workers express frustrati...

This chapter articulates key considerations for the translation of the concept of the Patient Journey Record Systems (PaJR) into real world systems. The key concept lies in the ‘discovery’ of the use of patient narratives to locate the phase of illness in a patient journey. We describe our developmental framework of in the context of Ambulatory Car...

This chapter introduces the reader to a world of clinical problem solving in blood disorders as presented in hematology lectures. These lectures encompass multiple perspectives, the patient, his/her relatives, healthcare students, consultant health professionals and society. This style of lecture aims to enable these key stakeholders in the health...

This chapter presents the narratives of some people with autistic spectrum disorders (also known as autism spectrum conditions) as well as those of their families and carers. It describes the history and development of the diagnostic concept of autistic spectrum disorders and how the clinical features impact on daily life and their families. It exa...

Psychiatric illness is perhaps the richest and most challenging narrative for consumers to develop because core symptoms of disease may distort perceptual and interpretative brain functions. These distortions may fragment and disrupt personal narratives of wellness, illness, and recovery. Advances in psychopharmacology enable better management of c...

This is a personal view on experiences in learning medicine from a physician academic and erstwhile vice chancellor of an Indian university. It summarizes his lessons learnt in a medical career that has made him explore medical traditions primarily to refute false dogmas that in his view continue to permeate the sciences to this day.

This chapter discusses the role of e-health in creating persistent clinical encounters to extend the scope of health care beyond its conventional boundaries utilizing social networking technology to create what the authors’ term ‘user driven health care’. It points out the necessity to direct the development of health information systems such that...

This chapter discusses the role of integrating medical education with medical practice through online collaborative learning among the various stakeholders involved with healthcare education and practice. It elaborates the discussion with examples of information needs and information-seeking behaviors of patients and physicians. The role of the Int...

This chapter is an introduction to user driven learning that initially dwells on features that are unchanged such as the role of collaborative social interactions in human learning and certain aspects that are evolving and helping create a learning transformation through web based technologies. The chapter is interspersed with user driven learning...

We evaluate and illustrate the utility of Google Tools for assessing research communications in Global Health. Page Ranks (PR) appear to be an important tool or utility for ranking the impact pages with the logic that PR determine which pages will be seen in a search. Google Trends provided very intriguing results as with this one can assess the te...

This chapter illustrates a life in medical practice and emphasizes the importance of lifelong learning in medicine through sharing of lived experiences. The life narratives display the authors own observations of what he has learned and unlearned over the years. Also added are observations about his retirement project - editing and publishing abstr...

The care of the critically-ill patient in the acute setting, an ‘everyday’ occurrence in most urban emergency departments, often proceeds through the dictates of Parsonian paternalism: the Physician knows best. But through a discussion of three such ‘everyday’ encounters, we hope to complicate this notion and find a place for healthcare users in th...

Doctors have unique and privileged opportunities to observe and participate in the illness narratives (stories) that patients present with. Hearing, understanding and respecting the patient narrative is as important as correctly practising the technical aspects of medical diagnosis and treatment, and yet traditionally has received much less emphasi...

This chapter explores the author’s personal journey in teaching math and traces her path from teacher controlled work toward beginning to implement student user driven learning strategies in math. It begins by spelling out the need for different math learning strategies and progresses to illustrate student user output which she has savored over the...

This chapter contains physician and patient perspectives of their gastrointestinal system problem solving experiences beginning from one anatomical end, stomodeum and continuing toward the other end proctodeum of the gastrointestinal tube. These experiences reflect user driven health care to the extent that they have been largely shared and develop...

In this study of narratives in relation to chronic illness, a number of themes relevant to patients were identified from the literature for discussion and analysis. Themes included responsibility and control of chronic illness, stigma and non-legitimation. Discussions and blogs on the Internet were identified and examined representing patient exper...

This chapter reports on a qualitative research project which explored patients’ experiences of counselling and which provided the impetus for changes to be incorporated in the rehabilitation and health care provided at a spinal cord rehabilitation unit in Auckland, New Zealand. Navigating different landscapes of meaning, philosophies, ideas and pra...

This chapter traces the learning experiences of a medical student through his career journey in medical training from two different world settings of Nepal and US. The chapter sketches the author’s interactive learning with his patients through his case notes right from his medical student days in Nepal to residency in the US. The juxtaposed commen...

The personal experience of Medicine by each physician is the product of a large number of dynamic and diverse factors: inborn talents and deficiencies, social and cultural environments, type of schooling,