The Evolution of Primary Health Care Teams and Integrated Health Services Delivery in Four Canadian Provinces

Nelley D. Oelke
School of Nursing, University of British Columbia, Okanagan; Rural Coordination Centre of British Columbia, British Columbia, Canada

Ashmita Rai
School of Nursing, University of British Columbia, Okanagan, British Columbia, Canada

A Commentary

Improving integrated health services for patients with two or more chronic illnesses is a priority in Canada as our health systems grapple with their complex needs and the services they require (Kirst et al. 2017; Suter et al. 2014). Team-based primary health care (PHC) models have been implemented in diverse ways to improve patient experience and to bet- ter coordinate integrated care to improve population health and reduce the cost of health care (Kirst et al. 2017; Buljac-Samardzic et al. 2010). The structure and composition of interprofessional primary health care (IPHC) models vary across provinces; however, their common goal is to address the four elements of the Quadruple Aim (population health, patient experience, provider experience, and reducing costs) (Bodenheimer and Sinsky 2014). Although research exists on interprofessional teams and health service integration, understanding the effectiveness of the development and implementation of team-based models for patients with two or more chronic illnesses has been challenging. Policymakers, decision-makers, providers, and patient groups have little evidence on what policies and structures facilitate, incentivize, or prevent integrated service delivery, especially for patients with complex needs. This knowledge gap has had an impact on the reform of service integration for patients with complex needs through IPHC teams. A policy analysis was conducted in four Canadian provinces to examine the policies and structures that scaffold such reform, identifying barriers and facilitators to the implementation of PHC teams and integrated health services. This study was carried out in British Columbia (BC), Alberta (AB), Ontario (ON), and Québec (QC) to understand different models implemented in these provinces and to ensure representation of east, west, and central Canada.

Vulnerability refers to the state of populations or individuals in “…a disadvantaged position in social hierarchies defined by wealth, power, and/or prestige, which place them at risk for poor health” (Ashkin 2018, 331). Poor health is the result of precarious living and working conditions and the adoption of risk behaviours, but is also due to limited access to health resources and services (INESSS 2019). Even before the pandemic, people in vulnerable situations, despite their greater needs, had more difficulty accessing primary care services (Waisel 2013; Loignon et al. 2015; Corscadden et al. 2018). Recent studies show that barriers and inequities in access to care and services have increased since the outbreak of the pandemic and that in several countries, including Canada, the provision of services has not been well adapted to these individuals’ specific needs (Bambra et al. 2020; Haggerty et al. 2020; Torous and Keshavan 2020; Spooner et al. 2021). In addition, the social and economic problems caused by the pandemic led to a significant increase in the number of individuals in vulnerable situations, which in turn placed increased pressure on the health system (Ahmed et al. 2020; Bélair-Cirino 2020; Nicola et al. 2020; CMA 2021). Furthermore, individuals in vulnerable situations are at greater risk of both experiencing the psychosocial consequences of the pandemic and contracting COVID-19 (NIHCM 2020; Moghanibashi-Mansourieh 2021; Santé Montréal 2022). It is therefore important to document how primary care services changed due to the pandemic to enable vulnerable individuals to have more equitable access to services that are better adapted to their needs and the complexity of their situation (Ouimet et al. 2015; Ford-Gilboe et al. 2018; Farley et al. 2020; OECD 2021).

An individual case study of provincial and regional level policy documents on PHC teams and integrated service delivery was conducted in each province (Lukey et al. 2022; Montesanti et al. 2022; Donnelly et al. 2023; Wankah et al. 2022). Key PHC policies in BC, AB, ON, and QC were analyzed using the Policy Triangle Framework (Walt and Gilson 1994) and the Ten Key Principles for Successful Health Systems Integration (Suter et al. 2009) with the main focus on the actors involved, policy process, context and content related to IPHC teams and integrated health services. The set of four papers provides details on each of the participating provinces’ primary health care redesign journeys to implement IPHC teams along with current strengths, weaknesses, opportunities, and barriers (threats) to the same. A cross-jurisdictional comparative policy analysis (Lukey et al. 2021) was also conducted to understand the influence of policies and contexts on PHC teams’ integration. In addition, similarities and variations in policies related to IPHC teams and integrated health services were identified across the four provinces during the analysis. The results of this study provide important data on the development and implementation of IPHC models across the four provinces.

Canadian national PHC reform aimed to establish IPHC in the health care system at the beginning of 2000. The First Ministers’ Accord on Health Care Renewal (2003) and A 10-Year Plan to Strengthen Health Care (2004) were introduced to integrate team-based care as a part of health care reform (Health Council of Canada 2009). The federal government created the Primary Health Care Transition Fund to assist provinces in initiating IPHC delivery over a period of six years period (2000-2006). Over the last two decades, new approaches to service delivery models have been introduced for PHC reforms to integrate physicians with interprofessional health care teams and to enhance patient-centred care. Some provinces have more established models (e.g., Family Health Teams in Ontario, Family Medicine Groups in Québec and Primary Care Networks in Alberta), while others have introduced new models in the last few years (Lukey et al. 2021). In British Columbia, Primary Care Networks (PCNs) were introduced in 2018 (Lukey et al. 2022), while PCNs continue to be the focus in AB since 2005 (Montesanti et al. 2022). In Ontario, Family Health Teams have existed for over a decade, and Ontario Health Teams were introduced in 2019 to provide integrated care within local communities (Donnelly et al. 2023). In Québec, Family Medicine Groups are the main model for IPHC in the past two decades; Local Health Networks and Territorial Health Networks were later introduced to enhance interprofessional team collaboration and included social workers and other allied health professionals (Wankah et al. 2022). Since each province is responsible for the implementation and delivery of IPHC, variations in policies related to IPHC can be seen across the provinces. Patient-centred care was highlighted in provincial policies in all provinces. Patient engagement in policy development, implementation, and evaluation is mentioned in several policy documents (Lukey et al. 2021). The health of Indigenous communities has been given a specific focus in BC through the First Nations Health Authority (Lukey et el. 2022). QC has promoted early investment in electronic health records allowing health care providers to access patient health records throughout the province (Wankah et al. 2022). Our policy analyses found there was limited information available on the impact of PHC teams on health service integration (Lukey et al. 2021). Focusing on performance measurement is an opportunity for all provinces to refine policies based on data and to learn from each other’s experience with different IPHC models and their implementation.

Primary health care reforms continue today in these provinces and across Canada with different models being employed to promote enhanced PHC teams. Implementation of key elements in PHC team policy has the potential to enhance the role of IPHC and facilitate health service integration for better outcomes for patients, providers, and the health system. Further research is required to better understand and evaluate the efficacy of integrated health services through IPHC teams across Canada.

Acknowledgement

The authors would like to thank all team members for their work on this project: Brenda Jagroop, Judy Birdsell, Shana Ooms, Darlene Arsenault, Shannon Berg, Mylaine Breton, Catherine Donnelly, Sharon Johnston, Stephanie Montesanti, Isabelle Gaboury, Lee Green, Karin Maiwald, Sara Mallinson, Peter Hirschkorn, Callie Pritchard, Simone Parniak, and Paul Wankah. Funding for this project was provided by the Canadian Institutes of Health Research, Health Research BC, and the University of British Columbia, Okanagan.

References

A 10-Year Plan to Health Care. 2004. http://www.scics.gc.ca/CMFiles/800042005_e1JXB-342011-6611.pdf.

Bodenheimer T, Sinsky C. 2014. From triple to quadruple aim: care of the patient requires care of the provider. Annals of Family Medicine 12(6): 573-576. https://doi.org/10.1370/afm.1713.

Buljac-Samardzic M, Dekker-van Doorn CM, Van Wijngaarden JDH, van Wijk KP. 2010. Interventions to improve team effectiveness: a systematic review. Health Policy, 94(3): 183-195. https://doi.org/10.1016/j.healthpol.2009.09.015.

Donnelly C, Parniak S, Oelke N, Johnston S. 2023. Analysis of primary health care team and integration policy in Ontario. Health Reform Observer--Observatoire des Réformes de Santé 10(1): 4. https://doi.org/10.13162/hro-ors.v10i1.4728.

First Ministers’ Accord on Health Care Renewal. 2003. http://www.scics.gc.ca/cmfiles/800039004_e1gtc-352011-6102.pdf.

Health Council of Canada. 2009. Teams in action: primary health care teams for Canadians. https://publications.gc.ca/collections/collection_2012/ccs-hcc/H174-32-2009-eng.pdf.

Kirst M, Im J, Burns T, Baker GR, Goldhar J, O’Campo P, Wojtak A, Wodchis WP. 2017. What works in implementation of integrated care programs for older adults with complex needs? A realist review. International Journal for Quality in Health Care 29(5): 612-624. https://doi.org/10.1093/intqhc/mzx095.

Lukey A, Johnston S, Montesanti S, Donnelly C, Wankah P, Breton M, Gaboury I, Parniak S, Pritchard C, Berg S, Maiwald K, Mallinson S, Green LA, Oelke ND. 2021. Facilitating integration through team-based primary healthcare: a cross-case policy analysis of four Canadian provinces. International Journal of Integrated Care 21(4). https://doi.org/10.5334/ijic.5680.

Lukey A, Maiwald K, Wankah Nji P, Breton M, Hirschkorn P, Oelke ND. 2022. Implementing team-based innovation in primary health care in British Columbia. Health Reform Observer--Observatoire des Réformes de Santé 10(1): 3. https://doi.org/10.13162/hro-ors.v10i1.4696.

Montesanti S, Pritchard C, Green LA, Berg S, Mallinson S, Birdsell J. 2022. Implementing primary health care teams and integrated care in Alberta, Canada. Health Reform Observer--Observatoire des Réformes de Santé 10(1): 2. https://doi.org/10.13162/hro-ors.v10i1.4680.

Suter E, Oelke ND, Adair CE, Armitage GD. 2009. Ten key principles for successful health systems integration. Healthcare Quarterly 13(SP1): 16-23. https://doi.org/10.12927/hcq.2009.21092.

Suter E, Misfeldt R, Mallinson S, Wilhelm A, Boakye O, Marchildon G, Kendel D, Nasmith L, Wong S, Lai D. 2014. Comparative review of the policy landscape of team-based primary health care service delivery in Western Canada. Canadian Institutes of Health Research. Alberta Health Services.

Walt G, Gilson L. 1994. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy and Planning 9(4): 353-370. https://doi.org/10.1093/heapol/9.4.353.

Wankah P, Breton M, Lukey A, Gaboury I, Smithman MA, Malo M, Oelke N. 2022. Shaping primary health care teams and integrated care in Québec: an overview of policies (2000-2020). Health Reform Observer--Observatoire des Réformes de Santé 10(1): 1. https://doi.org/10.13162/hro-ors.v10i1.4691.

Health Reform Observer - Observatoire des Réformes de Santé, Volume 10 | Issue 1 | Article 5 https://doi.org/10.13162/hro-ors.v10i1.4694.