The impact of funding models on the integration of registered nurses in primary health care teams: protocol for a multi-phase mixed-methods study in Canada

BACKGROUND

Family practice registered nurses co-managing patient care as healthcare professionals in interdisciplinary primary care teams have been shown to improve access, continuity of care, patient satisfaction, and clinical outcomes for patients with chronic diseases while being cost-effective. Currently, however, it is unclear how different funding models support or hinder the integration of family practice nurses into existing primary health care systems and interdisciplinary practices. This has resulted in the underutilisation of family practice nurses in contributing to high-quality patient care.

METHODS

This mixed-methods project is comprised of three studies: (1) a funding model analysis; (2) case studies; and (3) an online survey with family practice nurses. The funding model analysis will employ policy scans to identify, describe, and compare the various funding models used in Canada to integrate family practice nurses in primary care. Case studies involving qualitative interviews with clinic teams (family practice nurses, physicians, and administrators) and family practice nurse activity logs will explore the variation of nursing professional practice, training, skill set, and team functioning in British Columbia, Nova Scotia, Ontario, and Quebec. Interview transcripts will be analysed thematically and comparisons will be made across funding models. Activity log responses will be analysed to represent nurses' time spent on independent, dependent, interdependent, or non-nursing work in each funding model. Finally, a cross-sectional online survey of family practice nurses in Canada will examine the relationships between funding models, nursing professional practice, training, skill set, team functioning, and patient care co-management in primary care. We will employ bivariate tests and multivariable regression to examine these relationships in the survey results.

DISCUSSION

This project aims to address a gap in the literature on funding models for family practice nurses. In particular, findings will support provincial and territorial governments in structuring funding models that optimise the roles of family practice nurses while establishing evidence about the benefits of interdisciplinary team-based care. Overall, the findings may contribute to the integration and optimisation of family practice nursing within primary health care, to the benefit of patients, primary healthcare providers, and health care systems nationally.

Family physician leadership during the COVID-19 pandemic: roles, functions and key supports

PURPOSE

Strong leadership in primary care is necessary to coordinate an effective pandemic response; however, descriptions of leadership roles for family physicians are absent from previous pandemic plans. This study aims to describe the leadership roles and functions family physicians played during the COVID-19 pandemic in Canada and identify supports and barriers to formalizing these roles in future pandemic plans.

DESIGN/METHODOLOGY/APPROACH

This study conducted semi-structured qualitative interviews with family physicians across four regions in Canada as part of a multiple case study. During the interviews, participants were asked about their roles during each pandemic stage and the facilitators and barriers they experienced. Interviews were transcribed and a thematic analysis approach was used to identify recurring themes.

FINDINGS

Sixty-eight family physicians completed interviews. Three key functions of family physician leadership during the pandemic were identified: conveying knowledge, developing and adapting protocols for primary care practices and advocacy. Each function involved curating and synthesizing information, tailoring communications based on individual needs and building upon established relationships.

PRACTICAL IMPLICATIONS

Findings demonstrate the need for future pandemic plans to incorporate formal family physician leadership appointments, as well as supports such as training, communication aides and compensation to allow family physicians to enact these key roles.

ORIGINALITY/VALUE

The COVID-19 pandemic presents a unique opportunity to examine the leadership roles of family physicians, which have been largely overlooked in past pandemic plans. This study's findings highlight the importance of these roles toward delivering an effective and coordinated pandemic response with uninterrupted and safe access to primary care.

Primary care practice characteristics associated with team functioning in primary care settings in Canada: A practice-based cross-sectional survey

Team-based care is recognized as a foundational building block of high-performing primary care. The purpose of this study was to identify primary care practice characteristics associated with team functioning and examine whether there is relationship between team composition or size and team functioning. We sought to answer the following research questions: (1) are primary care practice characteristics associated with team functioning; and (2) does team composition or size influence team functioning. This cross-sectional correlational study was conducted in Fraser East, British Columbia, Eastern Ontario Health Unit, Ontario and Central Zone, Nova Scotia in Canada. Data were collected from primary care practices using an organization survey and the Team Climate Inventory (TCI) as a measure team functioning. The independent variables of interest were: physicians' payment model, internal clinic meetings to discuss clinical issues, care coordination through informal and ad hoc exchange, care coordination through electronic medical records and sharing clinic mission, values and objectives among health professionals. Potentially confounding variables were as follows: team size, composition, and practice panel size. A total of 63 practices were included in these analyses. The overall mean score of team climate was 73 (SD: 10.75) out of 100. Regression analyses showed that care coordination through human interaction and sharing the practice's mission, values, and objectives among health professionals were positively associated with higher functioning teams. Care coordination through electronic medical records and larger team size were negatively associated with team climate. This study provides baseline data on what practice characteristics are associated with highly functioning teams in Canada.

Interprofessional primary care: indispensable for family physicians yet invisible to older patients

There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.

Examining the extent and factors associated with interprofessional teamwork in primary care settings

Despite growing emphasis on adopting team-based models of primary care to facilitate patient access to a diverse range of care providers, our understanding of team functioning within primary care teams remains limited. This study examined interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers - [CHC]) in Ontario and explored team-level and organizational factors associated with interprofessional teamwork. Interprofessional teamwork was measured using the Collaborative Practice Assessment Tool (CPAT), which was completed by providers in each participating team. The CPAT responses of 988 providers representing on average 12 professions (sd = 2.1) across 66 teams (44 FHTs and 22 CHCs) were included in the analysis. The average CPAT score was 46.6 (sd = 2.5). CHCs had significantly higher CPAT scores than FHTs (m_diff = 1.7, p = .02). Using diverse communication mechanisms to share information, increasing quality improvement capacities, and age of practice, had a statistically significant positive association with CPAT scores. Increasing team size, using centralized administrative processes, a high level of information exchange, and having a mixed governance board were significantly negatively associated with CPAT score. Findings illustrate factors associated with interprofessional teamwork and offer insight into the comparative performance of two team-based primary care models in Ontario.

It starts with a strong foundation: constructing collaborative interprofessional teams in primary health care

The purpose of this qualitative study was to explore how team members experience and enact interprofessional teamwork in primary health care (PHC). Fifty-three participants (from eight teams), members of the Association of Family Health Teams of Ontario (AFHTO), were interviewed; interviews were audiotaped and transcribed verbatim. The data analyses used an iterative process with individual and team analysis. Findings revealed components that comprise the foundation and pillars of collaborative interprofessional teamwork in PHC. First, participants described a shared philosophsy of teamwork with six elements: values, vision, and mission; collaboration; communication; trust; respect and team members that 'fit.' Second, findings revealed three 'pillars.' The first pillar, leadership, included the elements of specific leadership attributes, such as leaders encouraging teamwork, mitigating conflict, and facilitating change. In the second pillar, participants described three elements of team building: formal and informal team building activities plus how these activities benefited both the team and patient care. The last pillar, optimizing scope of practice, included the elements of recognizing, appreciating, utilizing, and expanding team members' scope of practice. While each component and their concomitant elements can be enacted individually, collectively applying all elements produces collaborative interprofessional teamwork in primary health care.

Allied health professionals' perceptions of interprofessional collaboration in primary health care: an integrative review

This integrative review synthesizes research studies in order to explore the perceptions of allied health professionals regarding interprofessional collaboration in primary health care. A comprehensive literature search was conducted using three electronic databases and a manual search of the Journal of Interprofessional Care. The Crowe Critical Appraisal Tool was used to assess the quality of included papers. Study findings were extracted, critically examined and grouped into themes. Twelve studies conducted in six different countries met the inclusion criteria. Thematic analysis revealed five themes: (1) shared philosophy; (2) communication and clinical interaction; (3) physical environment; (4) power and hierarchy; and (5) financial considerations. This review has identified diverse key elements related to interprofessional collaboration in primary health care, as perceived by allied health professionals. Opportunity for frequent, informal communication appeared essential for interprofessional collaboration to occur. Allied health professionals working in close proximity to health practitioners from other professions had more regular interprofessional interactions than those who were geographically separated. Co-location of multiple primary health care services within the same physical space may offer increased opportunities for interprofessional collaboration. Future research should avoid reporting on allied health professionals in primary health care collectively, and isolate data to the individual professions. Direct observational methods are warranted to investigate whether allied health professionals' perceptions of interprofessional collaboration align with their actual clinical interactions in primary health care settings.

National Health Policy Reform for Primary Care in Chile: A Qualitative Analysis of the Health Program Documents

Introduction: Chilean policy makers reformed the national health policy for primary health care (PHC), shifting from the traditional biomedical model to the integral family and community health model with a biopsychosocial approach, to guide the delivery of PHC throughout the country. Purpose: To evaluate the implementation of the national health policy for PHC through an analysis of the program documents for PHC; and to identify to what extent the national health policy is expressed in each program document, and across all the documents. Methods: A qualitative document analysis with a purposive sample of program documents for PHC. The Chilean Ministry of Health website was systematically searched between October and December 2018 to identify relevant program documents. Thematic and content analysis were performed to identify evidence of the biopsychosocial approach to care delivery with each program document, including the types of interactions between professionals that contribute to person-centered or fragmented care. Results: The study included 13 PHC program documents. Three themes and 10 categories emerged from the data. Most program justifications focused on the biopsychosocial approach to care while including biomedical interventions and supporting independent professional work. Only 4 of the 13 programs were consistent in the justification, interventions, and types of stated professional interactions: 2 from the biopsychosocial and 2 from the biomedical perspectives. Conclusion: In terms of the national health policy for PHC in Chile, interprofessional collaboration and person-centered care processes and practices were partially aligned with the written content of the health program documents. As such, policy makers and health sector leaders are advised to analyze draft health program documents for consistency in translating national health policies into the written communications that define the actualization of the care model in PHC and direct professionals how to provide PHC to individuals and families.

A Regional Survey on Residents' Preferences on Patient-Centered Medical Home Design in Rural Areas

OBJECTIVES

This study aims to explore the rural residents' preferences on various aspects of the patient-centered medical home (PCMH) model and the associated physical environment features.

BACKGROUND

The PCMH model has gained popularity as an innovative care model that intends to improve patient experience and outcomes while reducing costs. Yet few studies focused on patients' perspective, even less considered the needs of the rural communities.

METHOD

Using a convenience sample, an exploratory survey was completed by 362 rural residents in the Midwestern region. Survey items were designed to gather information on both rural residents' preferences for five key PCMH attributes (comprehensive, patient-centered, coordinated, accessible, and quality) and of the physical environment that supports these attributes. Analyses were arranged along these key attributes.

RESULTS

Results indicated that residents' demographics affect their preferences for spatial features for PCMH. The three most important environmental factors for PCMH for the rural residents are the privacy, extra chairs in the exam room for family, and space that supports information sharing and communication among patient, family, and healthcare staff. Through structural equation modeling analysis, residents' preferences on comprehensive care, patient-centered care, coordinated care, quality, and safety have shown to affect their preference for the space features. The open-ended survey shows that rural residents are mostly satisfied with their current healthcare environment in terms of supporting patient-centered care, while other aspects still have room for future improvement.

CONCLUSIONS

Overall, this exploratory study identified important attributes of the physical environment that can support PCMH from rural residents' perspective.

Identifying quality improvement targets to facilitate colorectal cancer screening completion

The colorectal cancer (CRC) screening process involves multiple interfaces (communication exchanges and transfers of responsibility for specific actions) among primary care and gastroenterology providers, laboratory, and administrative staff. After a retrospective electronic health record (EHR) analysis discovered substantial clinic variation and low CRC screening prevalence overall in an urban, integrated safety-net system, we launched a qualitative analysis to identify potential quality improvement targets to enhance fecal immunochemical test (FIT) completion, the system's preferred screening modality. Here, we report examination of organization-, clinic-, and provider-level interfaces over a three-year period (December 2011–October 2014).

We deployed in parallel 3 qualitative data collection methods: (1) structured observation (90+ hours, 10 sites); (2) document analysis (n > 100); and (3) semi-structured interviews (n = 41) and conducted iterative thematic analysis in which findings from each method cross-informed subsequent data collection. Thematic analysis was guided by a conceptual model and applied deductive and inductive codes.

There was substantial variation in protocols for distributing and returning FIT kits both within and across clinics. Providers, clinic and laboratory staff had differing access to important data about FIT results based on clinical information system used and this affected results reporting. Communication and coordination during electronic referrals for diagnostic colonoscopy was suboptimal particularly for co-morbid patients needing anesthesia clearance.

Our multi-level approach elucidated organizational deficiencies not evident by quantitative analysis alone. Findings indicate potential quality improvement intervention targets including: (1) best-practices implementation across clinics; (2) detailed communication to providers about FIT results; and (3) creation of EHR alerts to resolve pending colonoscopy referrals before they expire.

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Multi-level qualitative approach identified challenges to 3 clinical processes

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Variation in fecal immunochemical testing (FIT) kit distribution and return

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Incomplete transfer of key FIT result data across clinical information systems

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Suboptimal communication and coordination during colonoscopy referrals