Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review

Barriers and enablers to implementing interprofessional primary care teams: a narrative review of the literature using the consolidated framework for implementation research

BACKGROUND

Interprofessional primary care teams have been introduced across Canada to improve access (e.g., a regular primary care provider, timely access to care when needed) to and quality of primary care. However, the quality and speed of team implementation has not kept pace with increasing access issues. The aim of this research was to use an implementation framework to categorize and describe barriers and enablers to team implementation in primary care.

METHODS

A narrative review that prioritized systematic reviews and evidence syntheses was conducted. A search using pre-defined terms was conducted using Ovid MEDLINE, and potentially relevant grey literature was identified through ad hoc Google searches and hand searching of health organization websites. The Consolidated Framework for Implementation Research (CFIR) was used to categorize barriers and enablers into five domains: (1) Features of Team Implementation; (2) Government, Health Authorities and Health Organizations; (3) Characteristics of the Team; (4) Characteristics of Team Members; and (5) Process of Implementation.

RESULTS

Data were extracted from 19 of 435 articles that met inclusion/exclusion criteria. Most barriers and enablers were categorized into two domains of the CFIR: Characteristics of the Team and Government, Health Authorities, and Health Organizations. Key themes identified within the Characteristics of the Team domain were team-leadership, including designating a manager responsible for day-to-day activities and facilitating collaboration; clear governance structures, and technology supports and tools that facilitate information sharing and communication. Key themes within the Government, Health Authorities, and Health Organizations domain were professional remuneration plans, regulatory policy, and interprofessional education. Other key themes identified in the Features of Team Implementation included the importance of good data and research on the status of teams, as well as sufficient and stable funding models. Positive perspectives, flexibility, and feeling supported were identified in the Characteristics of Team Members domain. Within the Process of Implementation domain, shared leadership and human resources planning were discussed.

CONCLUSIONS

Barriers and enablers to implementing interprofessional primary care teams using the CFIR were identified, which enables stakeholders and teams to tailor implementation of teams at the local level to impact the accessibility and quality of 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.

A novel perspective of Australian primary care dietetics: Insights from an exploratory study using complex adaptive systems theory

Aims

Effective quality improvement strategies are essential to enhancing outcomes of dietetic care. Interventions informed by complex adaptive systems theory have demonstrated effectiveness in other healthcare settings. This study aimed to explore primary care dietetics practice using complex adaptive systems theory and to identify factors that individuals across the healthcare system can examine and address to improve the quality of dietetic care.

Methods

Qualitative analysis of semi‐structured interviews of healthcare consumers and professionals involved in the provision of dietetic care. Data collection and analysis was guided by a complexity‐informed conceptual framework. The Framework Method was used to code transcripts and identify themes describing primary care dietetics.

Results

Twenty‐three consumers and 26 primary care professionals participated. Participants described dietetic care as being delivered by individuals organised into formal and informal systems that were influenced by the wider environment, including legal, economic, and socio‐cultural systems. Dietitians described interactions with consumers as a learning opportunity and sought education, mentoring, or supervision to address knowledge and skill gaps. Relationships underpinned transfer of information between individuals.

Conclusion

Complex adaptive systems theory proved to be a useful conceptual framework for primary care dietetics. Factors identified at the macro (e.g., funding), meso (e.g., professional networks), and micro (e.g., consumer education) levels should be examined and addressed to improve the quality of dietetic care.

Comparative effectiveness of team-based care with a clinical decision support system versus team-based care alone on cardiovascular risk reduction among patients with diabetes: Rationale and design of the D4C trial

BACKGROUND

Diabetes has become a major public health challenge worldwide, especially in low- and middle-income countries (LMICs). Uncontrolled hyperglycemia, hypertension, and dyslipidemia major risk factors for all-cause mortality and cardiovascular disease (CVD) are common in patients with diabetes in China. We propose to compare the effectiveness of team-based care plus a clinical decision support system (CDSS) with team-based care alone on glycemic, blood pressure (BP), and lipid control, and clinical CVD reduction among patients with type-2 diabetes and at high risk for CVD.

METHODS

The Diabetes Complication Control in Community Clinics (D4C) study is a cluster-randomized trial conducted among 38 community health centers in Xiamen City, China. Nineteen clinics have been randomly assigned to team-based care plus CDSS and 19 to team-based care alone. Team-based care includes primary care providers, health coaches, and diabetes specialists working collaboratively with patients to achieve shared treatment goals for CVD risk factor reduction. The CDSS integrates guideline-based treatment algorithms for glycemic, BP, and lipid control, along with a patient's medical history and insurance policy, to recommend treatment and follow-up plans. In phase 1, the co-primary outcomes are mean reduction in glycated hemoglobin (HbA1c), systolic BP (SBP), and low-density lipoprotein (LDL)-cholesterol over 18 months, and the proportion of patients with controlled HbA1c, SBP, and LDL-cholesterol at 18 months' between the 2 comparison groups. In phase 2, the primary outcome is the difference in major CVD incidence (non-fatal stroke, non-fatal myocardial infarction, hospitalized heart failure, and CVD mortality) between the 2 comparison groups. Mean reduction in HbA1c, SBP, and LDL-cholesterol levels will be simultaneously modeled for a single overall treatment effect.

CONCLUSION

The D4C trial will generate evidence on whether a CDSS will further reduce the CVD burden among patients with diabetes beyond team-based care at community clinics. If proven effective, this implementation strategy could be scaled up within primary care settings in China and other LMICs to reduce CVD incidence and mortality among patients with diabetes.