Background Advance care planning (ACP) conversations are associated with improved end-of-life healthcare outcomes and patients want to engage in ACP with their healthcare providers. Despite this, ACP conversations rarely occur in primary care settings. The objective of this study was to implement ACP through adapted Serious Illness Care Program (SICP) training sessions, and to understand primary care provider (PCP) perceptions of implementing ACP into practice. Methods We conducted a quality improvement project guided by the Normalization Process Theory (NPT), in an interprofessional academic family medicine group in Hamilton, Ontario, Canada. NPT is an explanatory model that delineates the processes by which organizations implement and integrate new work. PCPs (physicians, family medicine residents, and allied health care providers), completed pre- and post-SICP self-assessments evaluating training effectiveness, a survey evaluating program implementability and sustainability, and semi-structured qualitative interviews to elaborate on barriers, facilitators, and suggestions for successful implementation. Descriptive statistics and pre-post differences (Wilcoxon Sign-Rank test) were used to analyze surveys and thematic analysis was used to analyze qualitative interviews. Results 30 PCPs participated in SICP training and completed self-assessments, 14 completed NoMAD surveys, and 7 were interviewed. There were reported improvements in ACP confidence and skills. NoMAD surveys reported mixed opinions towards ACP implementation, specifically concerning colleagues’ abilities to conduct ACP and patients’ abilities to participate in ACP. Physicians discussed busy clinical schedules, lack of patient preparedness, and continued discomfort or lack of confidence in having ACP conversations. Allied health professionals discussed difficulty sharing patient prognosis and identification of appropriate patients as barriers. Conclusions Training in ACP conversations improved PCPs’ individual perceived abilities, but discomfort and other barriers were identified. Future iterations will require a more systematic process to support the implementation of ACP into regular practice, in addition to addressing knowledge and skill gaps.

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Context: Since 2015, the College of Family Physicians of Canada's Certificates of Added Competence (CAC) program has included enhanced skill certification in Palliative Care (PC) to support the scope of Family Medicine services available to patients and communities.Objective: To describe the ways in which family physicians with a CAC in palliative care contribute within their communities, the factors that influence the models in which these physicians work, and the perceived impacts of this work.Study Design: Secondary unconstrained content analysis of qualitative data from a multiple case study on the role and impacts of family physicians with a CAC.Population: Six family medicine practices across Canada, between September 2018 and June 2019.Data Source: Interviews with PC and generalist physicians, trainees, and administrators, which included discussion of the PC role, associated with these cases.Outcome Measure: Qualitative descriptions of the models of care, factors influencing the way PC physicians work, and their impacts in the community.Results: Twenty-one participants (nine PC physicians, five generalist family physicians, two residents, five physicians with enhanced skills in other domains) contributed data. PC physicians enhanced the workforce to meet palliative care needs in communities. PC physicians worked in various models, ranging from maintaining and enhancing their own family practice through to working exclusively as a PC physician. In the latter case, PC physicians worked in a collaborative model with other physicians by providing consultations to other physicians, co-managing patients (shared care), or assuming care of the patient as the main provider (transfer of care). PC physicians intentionally built capacity among their colleagues, with some activities not being remunerated. Funding models and other structures favoured the PC physician taking over care.Conclusion: PC physicians with added competency facilitate comprehensive care of people until the end of life, through direct patient care models and by building capacity among others. Remuneration models should support system capacity and relationships that enable family physicians to provide primary palliative care, especially outside the transfer of care model.