Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

Abstract

BackgroundMost Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform—the introduction of inter-professional teams into traditional PC settings—has been difficult to implement despite financial investment and enthusiasm.ObjectiveTo synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.MethodsAn international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.Results Seven common levers influence a jurisdiction’s ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations’ attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.ConclusionThe combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Improving blood pressure control in primary care: The ImPress study

“…Currently, nurse activity in general practices is supported by annual Australian Government funding (Australian Govenment, 2018). While a fee for service funding system operates in Australian primary care, moves towards block funding (McKittrick and McKenzie, 2018) and wider calls to reform to integrative, team orientated models could further enhance the nursing role (McInnes et al, 2016, Russell, 2018.…”

“…The nursing workforce in general practice has grown significantly in recent decades along with international recognition that the role could be more fully utilised (Bauer and Bodenheimer, 2017, Halcomb et al, 2014, Merrick et al, 2014. Current models of general practice remain reactive, GP led care (Russell, 2018) with lack of role clarity, suboptimal collaboration and funding mechanisms contributing to the under-utilisation of nurses (Bauer andBodenheimer, 2017, McInnes et al, 2015). Emerging evidence demonstrates nurse-led chronic disease management to be feasible and highly acceptable to consumers (Halcomb et al, 2015a, Halcomb et al, 2015b, Mahomed et al, 2012, Stephen et al, 2018a, Stephen et al, 2018b.…”

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory

“…As seen in the current study, time and space resources were required to ensure team collaboration. This has long been supported by research that shows financial support for team activities has a positive effect on team performance [12,23]. Despite the need for resources to support team activities, results showed that teams and patients perceived that HT was valuable, embedded well into the clinic environment, and worth maintaining.…”

“…Researchers have found mixed levels of buy-in for interdisciplinary working by certain team members (i.e., physicians, pharmacists and nurses) with a tendency of physicians to resist collaborative teamwork, giving preference to working independently [23]. Primary care researchers explored contextual factors influencing team performance in five jurisdictions in three countries and found that despite moving to collaborative teams, primary care clinicians still tended to work in parallel, infrequently using team approaches to solve clinical problems [12]. They also found that team-based primary care was enhanced when direct physician involvement was not required in care provision.…”

“…Given that older adults experience multiple co-morbidities [8,9] they can benefit from person-focused, wellness-oriented, tailored approaches to care [10] to support them to age in place. Interventions to address older adults' needs as well as manage chronic diseases typically require the adoption of models of care that support interprofessional team-and community-based primary care for older adults [11,12]. This paper examines the implementation of an innovative team-based primary care model to address the needs of this population.…”