Effective team-based primary care: observations from innovative practices

Capacity to Address Social Needs Affects Primary Care Clinician Burnout

PURPOSE

Primary care clinicians disproportionately report symptoms of burnout, threatening workforce sustainability and quality of care. Recent surveys report that these symptoms are greater when clinicians perceive fewer clinic resources to address patients' social needs. We undertook this study to better understand the relationship between burnout and clinic capacity to address social needs.

METHODS

We completed semistructured, in-person interviews and brief surveys with 29 primary care clinicians serving low-income populations. Interview and survey topics included burnout and clinic capacity to address social needs. We analyzed interviews using a modified grounded theory approach to qualitative research and used survey responses to contextualize our qualitative findings.

RESULTS

Four key themes emerged from the interview analyses: (1) burnout can affect how clinicians evaluate their clinic's resources to address social needs, with clinicians reporting high emotional exhaustion perceiving low efficacy even in when such resources are available; (2) unmet social needs affect practice by influencing clinic flow, treatment planning, and clinician emotional wellness; (3) social services embedded in primary care clinics buffer against burnout by increasing efficiency, restoring clinicians' medical roles, and improving morale; and (4) clinicians view clinic-level interventions to address patients' social needs as a necessary but insufficient strategy to address burnout.

CONCLUSIONS

Primary care clinicians described multiple pathways whereby increased clinic capacity to address patients' social needs mitigates burnout symptoms. These findings may inform burnout prevention strategies that strengthen the capacity to address patients' social needs in primary care clinical settings.

A Multi-sourced Data Analytics Approach to Measuring and Assessing Biopsychosocial Complexity: The Vancouver Community Analytics Tool Complexity Module (VCAT-CM)

Operationalization of the fundamental building blocks of primary care (i.e. empanelment, team-based care and population management) within the context of Community Health Centers requires accurate and real-time measures of biopsychosocial complexity, at both client and population-levels. This article describes the conceptualization, design and development of a novel software tool (the VCAT-Complexity Module) that can calculate and report real-time person-oriented biopsychosocial complexity profiles, using multiple data sources. The tool aligns with a profile approach to conceptualizing health outcomes, and represents a potentially significant advance over disease-oriented complexity assessment tools. The results and face validity of the software's complexity score outputs are discussed, along with their practical implications on functions related to the development of primary care within Vancouver Coastal Health, a Canadian Regional Health Authority.

Measuring Health

Primary care clinicians care for an extremely diverse range of patients, and they therefore have numerous opportunities to measure and act to improve the health of various populations. In order to take effective actions to improve the health of their patient populations, primary care clinicians must measure health. Strong population health metrics are characterized by their high validity, consistency, feasibility, and interpretability. Population health metrics should be applied longitudinally to obtain the most information from available data. Optimal population health metrics are actionable and facilitate the implementation of effective strategies to improve population health through administrative or clinical programs.

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers

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PrEP implementation in primary care has been slow.

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Primary care providers equally favor training all vs. having a PrEP specialist.

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Efforts to promote knowledge of clinical guidelines may enhance PrEP implementation.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP’s preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs’ PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers (“all trained”) (42%) or having an onsite PrEP specialist (“on-site specialist”) (43%). Only 15% preferred referring patients out of the practice to a specialist (“refer out”). Compared to those who preferred to “refer out,” participants who preferred the “all trained” model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the “refer out” or on-site specialist” models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.

How Do Innovative Primary Care Practices Achieve the Quadruple Aim?

The Patient-Centered Medical Home (PCMH) now defines excellent primary care. Recent literature has begun to elucidate the components of PCMHs that improve care and reduce costs, but there is little empiric evidence that helps practices, payers, or policy makers understand how high-performing practices have improved outcomes. We report the findings from 38 such practices that fill this gap. We describe how they execute 8 functions that collectively meet patient needs. They include managing populations, providing self-management support coaching, providing integrated behavioral health care, and managing referrals. The functions provide a more actionable perspective on the work of primary care.

Measuring attributes of team functioning in primary care settings: development of the TEAMS tool

This study examines attributes of a high-functioning primary care team by creating a survey measuring staff perceptions of team culture in primary care practices with innovative team-based workforce models. Survey data from a national study of 30 exemplar primary care practices with innovative team-based workforce models was used. Staff and clinicians (n = 943) at the 30 primary care sites completed a 31-item survey online. Survey items came from previous surveys of adaptive reserve and team culture. Factor analysis, reliability and validity were examined for the survey. Case summaries from site visits and survey comments were compared for high and low scoring sites to establish validity. Three core attributes of a high-functioning team were identified: joy in practice (4 items), personal growth (3 items), and leadership and learning (20 items). Four items did not measure any attribute. Using item correlations, the 20 items for leadership and learning were reduced to 7 items. All three attribute subscales had good reliability and validity. The final 14-item survey measuring joy in practice, personal growth and leadership and learning may be useful in clinical practice as a practical tool to gauge progress in developing a high-functioning team. Further research is needed to determine the sensitivity of this instrument to change over time with interventions designed to improve team functioning in primary care.

Development and Implementation of a Team-Based, Primary Care Delivery Model: Challenges and Opportunities

In this article, we describe the implementation of a team-based care model during the first 2 years (2016-2017) after Mayo Clinic designed and built a new primary care clinic in Rochester, Minnesota. The clinic was configured to accommodate a team-based care model that included complete colocation of clinical staff to foster collaboration, designation of a physician team manager to support a physician to advanced practice practitioner ratio of 1:2, expanded roles for registered nurses, and integration of clinical pharmacists, behavioral health specialists, and community specialists; this model was designed to accommodate the growth of nonvisit care. We describe the implementation of this team-based care model and the key metrics that were tracked to assess performance related to the quadruple aim of improving population health, improving patient experience, reducing cost, and supporting care team's work life.

Pharmacist-provided services and community pharmacist integration into a patient-centered medical home: A qualitative study of primary care clinic staff perceptions

OBJECTIVES

To describe patient-centered medical home (PCMH) staff members' views toward community pharmacist involvement in patient care within the PCMH and to identify areas in which pharmacist-provided services can improve the quality of care in their clinics.

DESIGN

Qualitative semistructured interview study.

SETTING

One primary care clinic.

PARTICIPANTS

Multidisciplinary clinic staff members.

OUTCOME MEASURES

Views of staff toward implementing a community pharmacist into their clinic and top pharmacist services to help improve medication management within the clinic.

RESULTS

A total of 14 staff members of the clinic participated in the study. Participants included physicians, clinical staff members such as registered nurse assistants, licensed practical nurses, and medical assistants, and clinic management. Key themes included the following: the clinic was open to implementing pharmacy services; the providers would be very receptive to pharmacist recommendations; the clinic is willing to try different pharmacist integration models to see what works best within the workflow; the pharmacist must be readily available for consultation; the pharmacist should hold an introductory meeting with the clinic; opinions vary on the best timing of pharmacist appointments with patients; and ideas vary about the best location for pharmacist consultations. The top 5 pharmacist services mentioned by participants included chronic condition management, medication reconciliation training, Beers List education, diabetes education, and adherence counseling.

CONCLUSION

Primary care clinic staff support the integration of pharmacy services. Further research is needed to apply the results to other clinics and to identify barriers and opportunities in the implementation process.

A Model for Sustaining Health at the Primary Care Level

As the healthcare industry in USA is changing from a fee-for-service to a value-based system, the need for a shift in how patients are treated is evident. Healthcare organizations are reimbursed based on value and quality of service. The system shift recognizes that each patient possesses differing medical needs moving care from generalized medical treatments to individualistic care. To deal with this change and attempt to increase quality and value, many healthcare organizations are adopting a team care approach through the development of Patient-Centered Medical Homes (PCMH). In many examples of the team approach, the Primary Care Practitioner (PCP) is viewed as the main coordinator of care. Having this responsibility can create added stress for practitioners, which can lead to a decrease in the quality of care. The proposed model, in this article, outlines an example of how individualistic care can be achieved and assembled in the PCMH with the PCP as the main coordinator of care to sustain patient health.

Implications of interprofessional primary care team characteristics for health services and patient health outcomes: A systematic review with narrative synthesis

Interprofessional primary care (IPPC) teams are promoted as an alternative to single profession physician practices in primary care with focus on preventive care and chronic disease management. Characteristics of teams can have an impact on their performance. We synthesized quantitative, qualitative or mixed-methods evidence addressing the design of IPPC teams. We searched Ovid MEDLINE, Embase, CINAHL, and PAIS using search terms focused on IPPC teams. Studies were included if they discussed the influence of team structure, organization, financial arrangements, or policies and procedures, or either health care processes or outputs, health outcomes, or costs, and were conducted in Australia, Canada, the United Kingdom or New Zealand between 2003 and 2016. We screened 11,707 titles, 5366 abstracts, and selected 77 full text articles (38 qualitative, 31 quantitative and 8 mixed-methods). Literature focused on the implications of team characteristics on team processes, such as teamwork, collaboration, or satisfaction of patients or providers. Despite heterogeneity of contexts, some trends are observable: shared space, common vision and goals, clear definitions of roles, and leadership as important to good teamwork. The impacts of these on health care outputs or patient health are not clear. To move the state of knowledge beyond perception of what works well for IPPC teams, researchers should focus on quantitative causal inference about the linkages between team characteristics and patient health.

Influences of the program for access and quality improvement in work processes in primary care

OBJECTIVE

To assess the perception of professionals of Family Health Strategy Teams on the National Program for Access and Quality Improvement in Primary Care and the possible changes in the work processes resulting from its implementation.

METHOD

Oral history methodology conducted with members of Basic Health Units' teams who participated in the first two cycles of the Program in São Paulo.

RESULTS

Six team members participated in the research. The professionals described the use of information to support the planning, diverged on the changes in the organization of the service and identified contributions to the direction of the teams and the control of the activities. The implementation of the Program led to changes in professional practice and favored autonomy and teamwork. The Community Health Workers stood out in the information acquisition process, and the teams found difficulties to organize the information. The collection and retrieval of information contributed to broaden the professionals' view of the service, and the interviewees criticized the fragility of information dissemination in the Units.

CONCLUSION

Despite its limitations, the Program led to direct improvements in the work of the teams in Primary Care.

A mixed-methods analysis of the capacity of the Patient-Centered Medical Home to implement care coordination services for cancer survivors

There are currently 15.5 million cancer survivors in USA who are increasingly relying on primary care providers for their care. Patient-Centered Medical Homes (PCMHs) have the potential to meet the unique needs of cancer survivors; but, few studies have examined PCMH attributes as potential resources for delivering survivorship care. This study assesses the current care coordination infrastructure in advanced PCMHs, known to be innovative, and explores their capacity to provide cancer survivorship care. We conducted comparative case studies of a purposive sample (n = 9) of PCMHs to examine current care coordination infrastructure and capacity through a mixed- methods analysis. Data included qualitative interviews, quantitative surveys, and fieldnotes collected during 10- to 12-day onsite observations at each practice. Case studies included practices in five states with diverse business models and settings. Eight of the nine practices had National Committee for Quality Assurance Level 3 PCMH recognition. No practices had implemented a systematic approach to cancer survivorship care. We found all practices had a range of electronic population health management tools, care coordinator roles in place for chronic conditions, and strategies or protocols for tracking and managing complex disease groups. We identified potential capacity, as well as barriers, to provide cancer survivorship care using existing care coordination infrastructure developed for other chronic conditions. This existing infrastructure suggests the potential to translate care coordination elements within primary care settings to accelerate the implementation of systematic survivorship care.

Formalisation and subordination: a contingency theory approach to optimising primary care teams

OBJECTIVE

While there is consensus on the need to strengthen primary care capacities to improve healthcare systems' performance and sustainability, there is only limited evidence on the best way to organise primary care teams. In this article, we use a conceptual framework derived from contingency theory to analyse the structures and process optimisation of multiprofessional primary care teams.

DESIGN

We focus specifically on inter-relationships between three dimensions: team size, formalisation of care processes and nurse autonomy. Interview-based qualitative data for each of these three dimensions were converted into ordinal scores. Data came from eight pilot sites in Quebec (Canada).

RESULTS

We found a positive association between team size and formalisation (correlation score 0.55) and a negative covariation (correlation score -0.64) between care process formalisation and nurses' autonomy/subordination. Despite the study being exploratory in nature, such relationships validate the idea that these dimensions should be analysed conjointly and are coherent with our suggestion that using a framework derived from a contingency approach makes sense.

CONCLUSIONS

The results provide insights about the structural design of nurse-intensive primary care teams. Non-physicians' professional autonomy is likely to be higher in smaller teams. Likewise, a primary care team that aims to increase nurses' and other non-physicians' professional autonomy should be careful about the extent to which it formalises its processes.

Implementing team-based primary care models: a mixed-methods comparative case study in a large, integrated health care system

BACKGROUND

Successful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.

OBJECTIVE

To identify practice setting components contributing to uptake of new team-based care models.

DESIGN

Convergent mixed-methods design.

PARTICIPANTS

Employees and patients of primary care practices implementing two team-based models in a large, integrated health system.

MAIN MEASURES

Field observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team.

KEY RESULTS

Based on analysis of observations and interviews, the 9 practices were categorized into 3 groups-high, partial, and low uptake of new team-based models. Uptake was related to (1) practices' responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices' ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices.

CONCLUSION

Uptake of new team-based care delivery models is related to practices' ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.

Medication and test prescription by nurses: contributions to advanced practice and transformation of care

Objective:

To carry out a documentary study on the rules, guidelines, policies and institutional support for the nurse to prescribe medicines and request tests with a view to the advanced practice in the scope of Primary Health Care.

Methods:

Documentary research using open-access institutional documents - Federal Nursing Council (COFEN), its regional representations in the respective Brazilian states (COREN) and the Brazilian Nursing Association (ABEN).

Results:

Most of the news/notices were issued by the Regional Nursing Councils in the different Federative Units. The argumentation regarding the prescription of medicines and request for tests by nurses is based on three categories: Autonomy and competencies for the prescription of medicines and/or request of tests; Corporate policies that undermine the full exercise of nursing; and Transformation of health and nursing care in Primary Health Care.

Conclusion:

The prescriptive practice by nurses integrates health care and has been defended by the institutions that represent the category. It emerges as an important element of advanced practice and in the transformation of care in the context of health teams.

Optimizing huddle engagement through leadership and problem-solving within primary care: A study protocol for a cluster randomized trial

BACKGROUND

Team-based care has been identified as a key component in transforming primary care. An important factor in implementing team-based care is the requirement for teams to have daily huddles. During huddles, the care team, comprising physicians, nurses, and administrative staff, come together to discuss their daily schedules, track problems, and develop countermeasures to fix these problems. However, the impact of these huddles on staff burnout over time and patient outcomes are not clear. Further, there are challenges to implementing huddles in fast-paced primary care clinics. We will test whether the impact of a behavioral intervention of leadership training and problem-solving during the daily huddling process will result in higher consistent huddling in the intervention arm and result in higher team morale, reduced burnout, and improved patient outcomes.

METHODS/DESIGN

We will conduct a care-team-level cluster randomized trial within primary care practices in two Midwestern states. The intervention will comprise a 1-day training retreat for leaders of primary care teams, biweekly sessions between huddle optimization coaches and members of the primary care teams, as well as coaching site visits at 30 and 100 days post intervention. This behavioral intervention will be compared to standard care, in which care teams have huddles without any support or training. Surveys of primary care team members will be administered at baseline (prior to training), 100 days (for the intervention arm only), and 180 days to assess team dynamics. The primary outcome of this trial will be team morale. Secondary outcomes will assess the impact of this intervention on clinician burnout, patient satisfaction, and quality of care.

DISCUSSION

This trial will provide evidence on the impact of a behavioral intervention to implement huddles as a key component of team-based care models. Knowledge gained from this trial will be critical to broader deployment and successful implementation of team-based care models.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03062670 . Registered on 23 February 2017.

Internal Medicine Resident Experiences With a 5-Month Ambulatory Panel Management Curriculum

BACKGROUND

Panel management is emphasized as a subcompetency in internal medicine graduate medical education. Despite its importance, there are few published curricula on population medicine in internal medicine residency programs.

OBJECTIVE

We explored resident experiences and clinical outcomes of a 5-month diabetes and obesity ambulatory panel management curriculum.

METHODS

From August through December 2016, internal medicine residents at the University of Vermont Medical Center reviewed registries of their patients with diabetes, prediabetes, and obesity; completed learning modules; coordinated patient outreach; and updated gaps in care. Resident worksheets, surveys, and reflections were analyzed using descriptive and thematic analyses. Before and after mean hemoglobin A1c results were obtained for patients in the diabetic group.

RESULTS

Most residents completed the worksheet, survey, and reflection (93%-98%, N = 42). The worksheets showed 70% of participants in the diabetic group had appointments scheduled after outreach, 42% were offered referrals to the Community Health Team, and 69% had overdue laboratory tests ordered. Residents reported they worked well with staff (95%), were successful in coordinating outreach (67%), and increased their sense of patient care ownership (66%). In reflections, identified successes were improved patient care, teamwork, and relationship with patients, while barriers included difficulty ensuring follow-up, competing patient priorities, and difficulty with patient engagement. Precurricular mean hemoglobin A1c was 7.7%, and postcurricular was 7.6% (P = .41).

CONCLUSIONS

The curriculum offered a feasible, longitudinal model to introduce residents to population health skills and interdisciplinary care coordination. Although mean hemoglobin A1c did not change, residents reported improved patient care. Identified barriers present opportunities for resident education in patient engagement.

Organizational Influences on Time Pressure Stressors and Potential Patient Consequences in Primary Care

BACKGROUND

Primary care teams face daily time pressures both during patient encounters and outside of appointments.

OBJECTIVES

We theorize 2 types of time pressure, and test hypotheses about organizational determinants and patient consequences of time pressure.

RESEARCH DESIGN

Cross-sectional, observational analysis of data from concurrent surveys of care team members and their patients.

SUBJECTS

Patients (n=1291 respondents, 73.5% response rate) with diabetes and/or coronary artery disease established with practice teams (n=353 respondents, 84% response rate) at 16 primary care sites, randomly selected from 2 Accountable Care Organizations.

MEASURES AND ANALYSIS

We measured team member perceptions of 2 potentially distinct time pressure constructs: (1) encounter-level, from 7 questions about likelihood that time pressure results in missing patient management opportunities; and (2) practice-level, using practice atmosphere rating from calm to chaotic. The Patient Assessment of Chronic Illness Care (PACIC-11) instrument measured patient-reported experience. Multivariate logistic regression models examined organizational predictors of each time pressure type, and hierarchical models examined time pressure predictors of patient-reported experiences.

RESULTS

Encounter-level and practice-level time pressure measures were not correlated, nor predicted by the same organizational variables, supporting the hypothesis of two distinct time pressure constructs. More encounter-level time pressure was most strongly associated with less health information technology capability (odds ratio, 0.33; P<0.01). Greater practice-level time pressure (chaos) was associated with lower PACIC-11 scores (odds ratio, 0.74; P<0.01).

CONCLUSIONS

Different organizational factors are associated with each forms of time pressure. Potential consequences for patients are missed opportunities in patient care and inadequate chronic care support.

Utilization Outcomes of a Pilot Primary Care Team Redesign

Objectives:

To evaluate the effect of a team-based primary care redesign on primary care, emergency department (ED) and urgent care (UC) utilization, and new patient access to primary care.

Study Design:

A retrospective pre–post difference-in-differences analysis of utilization outcomes for patients on a redesigned primary care team compared to a standard primary care group.

Methods:

Within a patient-centered medical home, a pilot team was developed comprising 2 colocated “teamlets” of 1 physician, 1 nurse practitioner (NP), 1 registered nurse (RN), and 2 licensed practical nurses (LPNs). The redesigned team utilized physician–NP comanagement, expanded roles for RNs and LPNs, and dedicated provider time for telephone and e-mail medicine. We compared changes in number of office, ED, and UC visits during the implementation year for patients on the redesigned team compared to patients receiving the standard of care in the same clinic. Proportion of new patient visits was also compared between the pilot and the control groups.

Results:

There were no differences between the redesign group and control group in per-patient mean change in office visits (Δ = −0.04 visits vs Δ = −0.07; P = .98), ED visits (Δ = 0.00 vs Δ = 0.01; P = .25), or UC visits (Δ = 0.00 vs Δ = 0.05; P = .08). Proportion of new patient visits was higher in the pilot group during the intervention year compared to the control group (6.6% vs 3.9%; P < .0001).

Conclusions:

The redesign did not significantly impact ED, UC, or primary care utilization within 1 year of follow-up. It did improve access for new patients.

What matters in patient-centered medical home transformation: Whole system evaluation outcomes of the Brown Primary Care Transformation Initiative

Objectives:

Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices.

Methods:

Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team.

Results:

Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers’ and staff’s emotional exhaustion and depersonalization increased slightly over the course of the intervention from baseline to follow-up, and personal accomplishment decreased slightly. Providers and staff expressed appreciation for the patient-centered medical home as an ideal model, variously implemented some important patient-centered medical home components, increased their understanding of patient-centered medical home as more than specific isolated parts, and recognized their evolving work roles in the medical home. However, frustration with implementation barriers and the added work burden they associated with patient-centered medical home persisted.

Conclusion:

Patient-centered medical home transformation is disruptive to practices, requiring enduring commitment of leadership and personnel at every level, yet the model continues to hold out promise for improved delivery of patient-centered primary care.

Context matters for primary health care access: a multi-method comparative study of contextual influences on health service access arrangements across models of primary health care

Background

Equitable access to primary health care (PHC) is an important component of integrated chronic disease management. Whilst context is known to influence access to PHC, it is poorly researched. The aim of this study was to determine the contextual influences associated with access arrangements in four Australian models of integrated PHC.

Methods

A multi-method comparative case study design. Purposive sampling identified four models of PHC across six sites in two Australian states. Complexity theory informed the choice of contextual factors that influenced access arrangements, which were analysed across five dimensions: availability and accommodation, affordability, acceptability, appropriateness and approachability. Semi-structured interviews, document/website analysis and non-participant observation were used to collect data from clinicians, administrative staff and other key stakeholders. Within and cross-case thematic analysis identified interactions between context and access across sites.

Results

Overall, financial viability, objectives of the PHC model and relationships with the local hospital network (LHN) underpinned access arrangements. Local supply of general practitioners and financial viability were strong influences on availability of after-hours services. Influences on affordability were difficult to determine because all models had nil/low out-of-pocket costs for general practitioner services. The biggest influence on acceptability was the goal/objectives of the PHC model. Appropriateness and to a lesser degree affordability arrangements were influenced by the relationship with the LHN. The provision of regular outreach services was strongly influenced by perceived population need, referral networks and model objectives.

Conclusions

These findings provide valuable insights for policy makers charged with improving access arrangements in PHC services. A financially sustainable service underpins attempts to improve access that meets the needs of the service population. Smaller services may lack infrastructure and capacity, suggesting there may be a minimum size for enhancing access. Access arrangements may be facilitated by aligning the objectives between PHC, LHN and other stakeholder models. While some access arrangements are relatively easy to modify, improving resource intensive (e.g. acceptability) access arrangements for vulnerable and/or chronic disease populations will require federal and state policy levers with input from primary health networks and LHNs.

Transforming primary care: scoping review of research and practice

Purpose

The purpose of this paper is to reflect on research evidence and practice experience of transforming primary care to a more integrated and holistic model.

Design/methodology/approach

It is based on a scoping review which has been guided by primary care stakeholders and synthesises research evidence and practice experience from ten international case studies.

Findings

Adopting an inter-professional, community-orientated and population-based primary care model requires a fundamental transformation of thinking about professional roles, relationships and responsibilities. Team-based approaches can replicate existing power dynamics unless medical clinicians are willing to embrace less authoritarian leadership styles. Engagement of patients and communities is often limited due to a lack of capacity and belief that will make an impact. Internal (relationships, cultures, experience of improvement) and external (incentives, policy intentions, community pressure) contexts can encourage or derail transformation efforts.

Practical implications

Transformation requires a co-ordinated programme that incorporates the following elements – external facilitation of change; developing clinical and non-clinical leaders; learning through training and reflection; engaging community and professional stakeholders; transitional funding; and formative and summative evaluation.

Originality/value

This paper combines research evidence and international practice experience to guide future programmes to transform primary care.

Primary care multidisciplinary teams in practice: a qualitative study

BACKGROUND

Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care.

METHODS

Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis.

RESULTS

Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients.

CONCLUSIONS

Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.