COVID-19 – an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

Abstract

Background COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. Methods We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. Results We identified and analyzed six organizational innovations. Four of these – centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. Conclusion COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Enfrentamento da Covid-19 na Atenção Primaria à Saúde: documentos normativos e mortalidade

“…No Canadá, médicos de família identificaram como um fator positivo para a readequação dos cuidados primários durante a pandemia a descentralização das tomadas de decisões para se adaptar às necessidades locais. Esse fato contribuiu para que as respostas às necessidades de acesso emergentes durante a pandemia acelerassem a propagação de inovações já existentes, e para a criação de novas ações específicas para atender as demandas da população (Breton, et al, 2022).…”

“…Adoção de medidas não farmacológicas como o distanciamento físico, reorganização dos fluxos de atendimento de pacientes Covid e não Covid (Sigurdsson, et al, 2020;Dias & Ribeiro, 2020), adoção de unidades de atendimento específicos para pacientes sintomáticos respiratórios (Breton, et al, 2022;Jacobson, et al, 2020) e o atendimento por telemedicina (Kaufman-Shriqui, et al, 2022;Gao, et al, 2022;Morreel, et al, 2020), foram medidas adotadas que permitiram a continuidade da prestação de serviços e acesso dos usuários aos serviços da APS.…”

Challenges and impacts from wait times for specialist care identified by primary care providers: Results from the MAAP study cross-sectional survey

“…More research is needed to identify challenges posed by the pandemic, and implications across the Quintuple Aim. 20 Fortunately, several innovations were introduced during the pandemic to support patient access to primary care 39 and to facilitate consultations between PCPs and specialists. 40 These initiatives should be evaluated to ascertain their usefulness across the Quintuple Aim.…”

Evaluation of the implementation of single points of access for unattached patients in primary care and their effects: a study protocol

“…29 In response to unattached patients’ challenges accessing primary care services, one region in Québec developed a project called Accès Réseau Pertinence . 30 This pilot project processed 11 500 requests for consultations, among which more than half were answered by health providers or resources other than a general practitioner. 31 Based on the promising results observed in terms of improved use of health system resources and better adaptation to patients’ needs, the Ministry of Health and Social Services mandated all 18 health regions to establish points of access for unattached patients ( Guichets d’accès première ligne (GAPs)) within their respective regions.…”

“…Currently in Québec (Canada), over 1 million patients are registered on a CWL for unattached patients ( Guichets d'accès aux médecins de famille ),28 which represents more than 12% of the Québec population 29. In response to unattached patients’ challenges accessing primary care services, one region in Québec developed a project called Accès Réseau Pertinence 30. This pilot project processed 11 500 requests for consultations, among which more than half were answered by health providers or resources other than a general practitioner 31.…”