Coordinating primary care services: A case of policy layering

Continuity of care during long-term care transitions: a scoping review of the Canadian literature

BACKGROUND

Patients who maintain longitudinal provider-patient relationships experience better overall health outcomes. However, most older adults in Canada lose contact with their family physician when they enter long-term care (LTC) as new providers assume responsibility for their care. There is relatively little known about the contextual factors, processes, knowledge, and health professions education antecedents that promote the benefits of relational, management, and informational care continuity during LTC transitions.

METHODS

Using a rigorous scoping review method, we searched multiple databases systematically to identify and scrutinize peer-reviewed articles pertaining to continuity of care during LTC transitions in Canada. Guided by Transitions Theory, two independent reviewers screened citations and extracted data. A descriptive analytical method was employed to categorize content into themes.

RESULTS

Eight articles met the inclusion criteria. Our findings confirm that instances of relational continuity are very few during LTC transitions, suggesting barriers associated with practice models and the influence of physician characteristics. Notably, the review also highlights that the involvement of interprofessional team members, patients, and their partners-in-care in transition planning could improve informational and management care continuity for patients as they move into LTC.

CONCLUSION

Patient and family involvement, provider training, and practice and funding arrangements are all critical to improving relational, management, and informational care continuity during LTC transition. We recommend more studies to understand processes and policies to optimize informational continuity as a panacea for the often-disrupted relational continuity.

Patient pathways in primary health care - an interview study across various health care personnel in a Canadian and a Norwegian county

BACKGROUND

Due to demographic changes in the Western world governments emphasize the need for viable solutions, e.g. through decentralization of specialist health care services and better coordination within and between health care services. Both Norway and Canada have been through health care reforms and initiatives aiming to improve continuity and coordination of services. Organizational change to primary care in both countries encompasses both team-based service delivery involving allied health professionals, and new blended payment models. The objective of this study was to explore patient pathways in primary healthcare from various health personnel's perspectives, and across various primary care organizations in Norway and Canada.

METHODS

The study had a qualitative design, including interviews with physicians, nurses and managers (n = 19) in primary care, from a county in Norway and a region in Canada. Data were analyzed with a thematic approach, in line with recommendations from Braun & Clarke.

RESULTS

Three themes were identified: 1) Structural challenges, 2) Towards a more specialized primary health care and 3) Dedication could improve continuity. Findings indicate that coordinating health care services was assumed difficult due to different health care levels, funding systems, managements, electronic record systems and organizations. Hospitals were assumed more task oriented, while primary health care services were considered more care oriented, and this challenged the coordination across organizations. Primary care services were perceived to be more and more specialized, also representing a threat for coordination and continuity. Health care personnel in both countries perceived that dedicated personnel for each patient could improve information flow and continuity across services.

CONCLUSIONS

Achieving continuity and coordination of health care services seems challenging. Integration strategies seem essential for reducing silo thinking and fragmentation of health care services.

How regulatory frameworks drive differences in home-care agencies: Results from a national multicenter cross-sectional study in Switzerland

INTRODUCTION

The sustainability and rising costs of the health-care system are of concern. Although health-care reforms impact various areas of care, there is only limited evidence on how regulations affect home-care agencies and health-care delivery.

OBJECTIVES

The primary aim was to explore different financial and regulatory mechanisms and how they drive differences in the organizational structures, processes, and work environment of home-care agencies.

DESIGN AND METHODS

We used data from a national multicenter cross-sectional study of Swiss home care that included a random sample of 88 home-care agencies with a total of 3223 employees. Data was collected in 2021 through agency and personnel questionnaires including geographic characteristics, financial and regulatory mechanisms, service provision, financing, work environment, resources and time allocation, and personnel recruitment. We first conducted a cluster analysis to build agency groups with similar financial and regulatory mechanisms. We then performed Fisher's exact, ANOVA, and Kruskal-Wallis tests to determine group differences in organizational structures, processes, and work environments. Finally, we performed a lasso regression to determine which variables were predictive for the groups.

RESULTS

Four agency groups were built, differing in view of financial and regulatory mechanisms and we found differences in the range and amount of services provided, with regard to employment conditions and cost structures.

DISCUSSION

The most prominent differences were found between agency groups with versus agency groups without a service obligation. Financial incentives must be well aligned with the goal of achieving and maintaining financially sustainable, accessible, and high-quality home care.

The impact of team-based primary care on medication-related outcomes in older adults: A comparative analysis of two Canadian provinces

Objective

To evaluate if access to team-based primary care is related to medication management outcomes for older adults.

Methods

We completed two retrospective cohort studies using administrative health data for older adults (66+) in Ontario (n = 428,852) and Québec (n = 310,198) who were rostered with a family physician (FP) between the 2001/02 and 2017/18 fiscal years. We generated matched comparison groups of older adults rostered to an FP practicing in a team-based model, and older adults rostered to an FP in a non-team model. We compared the following outcomes between these groups: any adverse drug reactions (ADRs), any potentially inappropriate prescription (PIP), and polypharmacy. Average treatment effects of access to team-based care were estimated using a difference-in-differences estimator.

Results

The risk of an ADR was 22 % higher (RR = 1.22, 95 % CI = 1.18, 1.26) for older adults rostered to a team-based FP in Québec and 6 % lower (RR = 0.943, 95 % CI = 0.907, 0.978) in Ontario. However, absolute risk differences were less than 0.5 %. Differences in the risk of polypharmacy were small in Québec (RR = 1.005, 95 % CI = 1.001, 1.009) and Ontario (RR = 1.004, 95 % CI = 1.001, 1.007) and had absolute risk differences of less than 1 % in both provinces. Effects on PIP were not statistically or clinically significant in adjusted models.

Interpretation

We did not find evidence that access to team-based primary care in Ontario or Québec meaningfully improved medication management outcomes for older adults.

Team-based primary care reforms and older adults: a descriptive assessment of sociodemographic trends and prescribing endpoints in two Canadian provinces

BACKGROUND

Team-based primary care reforms aim to improve care coordination by involving multiple interdisciplinary health professionals in patient care. Team-based primary care may support improved medication management for older adults with polypharmacy and multiple points of contact with the healthcare system. However, little is known about this association. This study compares sociodemographic and prescribing trends among older adults in team-based vs. traditional primary care models in Ontario and Quebec.

METHODS

We constructed two provincial cohorts using population-level health administrative data from 2006-2018. Our primary exposure was enrollment in a team-based model of care. Key endpoints included adverse drug events (ADEs), potentially inappropriate prescriptions (PIPs), and polypharmacy. We plotted prescribing trends across the observation period (stratified by model of care) in each province. We used standardized mean differences to compare characteristics of older adults and providers, as well as prescribing endpoints.

RESULTS

Formal patient/physician enrollment increased in both provinces since the time of policy implementation; team-based enrollment among older adults was higher in Quebec (47%) than Ontario (33%) by the end of our observation period. The distribution of sociodemographic characteristics was reasonably comparable between team-based and non-team-based patients in both provinces, aside from a persistently higher share of rural patients in team-based care. Most PIPs assessed either declined or remained relatively steady over time, regardless of model of care and province. Several PIPs were more common among team-based patients than non-team-based patients, particularly in Quebec. We did not detect notable trends in ADEs or polypharmacy in either province.

CONCLUSIONS

Our findings offer encouraging evidence that many PIPs are declining over time in this population, regardless of patients' enrollment in team-based care. Rates of decline appear similar across models of care, suggesting these models may not meaningfully influence prescribing endpoints. Additional efforts are needed to understand the impact of team-based care among older adults and improve primary care prescribing practices.

Policy programs and service delivery models for older adults and their caregivers: Comparing three provinces and two states

Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are being continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends or other unpaid caregivers. Ten dementia care policy programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared deductively using a comparative policy framework originally developed by Richard Rose. One aim of this research was to understand how different jurisdictions have worked to reduce the fragmentation of dementia care. Another aim is to assess, relying on the theory of smart policy layering, the extent to which these policy efforts 'patch' health system structures or add to system redundancies. We find that these programs were introduced in a manner that did not fully consider how to patch current programs and services and thus risk creating further system redundancies. The implementation of these policy programs may have led to policy layers, and potentially to tension among different policies and unintended consequences. One approach to reducing these negative impacts is to implement evaluative efforts that assess 'goodness of fit'. The degree to which these programs have embedded these efforts into an existing policy infrastructure successfully is low, with the possible exception of one program in NY.

Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015

BACKGROUND

Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming.

METHODS

We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.'

RESULTS

Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues.

CONCLUSION

The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

Introduction

Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models.

Methods

We reviewed empirical studies (published 2011-2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada.

Findings

Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models.

Conclusion

This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.

The Delivery of Patient Care in Ontario's Family Health Teams during the First Wave of the COVID-19 Pandemic

OBJECTIVE

The objective of this paper was to identify continuations and changes in care delivery methods in primary care teams during the COVID-19 pandemic.

DESIGN

The study used a cross-sectional, web-based survey comprising close-ended and open-ended questions.

SETTING

The setting comprised family health teams (FHTs) across Ontario, Canada.

PARTICIPANTS

The participants included executive directors of FHTs or designates of their choosing.

SURVEY

Descriptive statistics were derived from responses to close-ended questions, and responses to open-ended questions were coded using thematic analysis.

RESULTS

With 93 participants, the response rate was 48%. Participants reported the continuation of in-person care, the implementation of virtual care across FHTs and collaboration within these teams and their communities.

Customizing a Program for Older Adults Living with Frailty in Primary Care

Coordination of primary care is essential to improving care delivery within health systems, especially for older adults with increased health/social needs. A program jointly funded by the Canadian Foundation for Healthcare Improvement and Canadian Frailty Network, was implemented in a nurse practitioner-led clinic to address the gap in frailty care for older adults. The clinic was situated within a health and social services organization with a mandate to enhance the quality of life of older adults living in the community. Through this program, a frailty assessment pathway and social/clinical prescriptions were implemented with necessary adaptations as a result of COVID-19.

Inequities in the delivery of mental health care: a grounded theory study of the policy context of primary care

BACKGROUND

Strengthening capacity for mental health in primary care improves health outcomes by providing timely access to coordinated and integrated mental health care. The successful integration of mental health in primary care is highly dependent on the foundation of the surrounding policy context. In Ontario, Canada, policy reforms in the early 2000's led to the implementation of a new interprofessional team-model of primary care called Family Health Teams. It is unclear the extent to which the policy context in Ontario influenced the integration of mental health care in Family Health Teams emerging from this period of policy reform. The research question guiding this study was: what were key features of Ontario's policy context that influenced FHTs capacity to provide mental health services for mood and anxiety disorders?

METHODS

A qualitative study informed by constructivist grounded theory. Individual interviews were conducted with executive directors, family physicians, nurse practitioners, nurses, and the range of professionals who provide mental health services in interprofessional primary care teams; community mental health providers; and provincial policy and decision makers. We used an inductive approach to data analysis. The electronic data management programme NVivo11 helped organise the data analysis process.

RESULTS

We conducted 96 interviews with 82 participants. With respect to the contextual factors considered to be important features of Ontario's policy context that influenced primary care teams' capacity to provide mental health services, we identified four key themes: i) lack of strategic direction for mental health, ii) inadequate resourcing for mental health care, iii) rivalry and envy, and, iv) variations across primary care models.

CONCLUSIONS

As the first point of contact for individuals experiencing mental health difficulties, primary care plays an important role in addressing population mental health care needs. In Ontario, the successful integration of mental health in primary care has been hindered by the lack of strategic direction, and inconsistent resourcing for mental health care. Achieving health equity may be stunted by the structural variations for mental health care across Family Health Teams and across primary care models in Ontario.

Comparing public policies impacting prescribing and medication management in primary care in two Canadian provinces

The challenges of polypharmacy and inappropriate prescribing are recognized internationally. This study synthesizes and compares the policies related to these issues introduced in Canada's two most populous provinces - Ontario and Quebec - over the first two decades of the 21st century. Drawing on policy documents and consultations with experts, we found that while medication management to address polypharmacy and inappropriate prescribing has not been an explicit and consistent policy target in either province, some policy changes sought to directly or indirectly impact medication management. These changes include the introduction of primary care teams that include pharmacists, the introduction of a medication review performed by pharmacists (in Ontario), increased emphasis on quality improvement with some attention to potentially inappropriate medications (specifically opioids in Ontario), and investments in information technology to improve communication across providers and move toward electronic prescribing to improve medication safety and appropriateness. Despite growing evidence of the problem of polypharmacy and inappropriate prescribing, there has been limited policy attention targeting these problems directly, and policy changes with potential to improve prescribing and medication management may not have been fully realized. Further research to evaluate the impact of these changes on provider behaviours, and on patient outcomes, warrants attention.

Factors associated with homecare coordination and quality of care: a research protocol for a national multi-center cross-sectional study

INTRODUCTION

The persistent fragmentation of home healthcare reflects inadequate coordination between care providers. Still, while factors at the system (e.g., regulations) and organisational (e.g., work environment) levels crucially influence homecare organisation, coordination and ultimately quality, knowledge of these factors and their relationships in homecare settings remains limited.

OBJECTIVES

This study has three aims: [1] to explore how system-level regulations lead to disparities between homecare agencies' structures, processes and work environments; [2] to explore how system- and organisation-level factors affect agency-level homecare coordination; and [3] to explore how agency-level care coordination is related to patient-level quality of care.

DESIGN AND METHODS

This study focuses on a national multi-center cross-sectional survey in Swiss homecare settings. It will target 100 homecare agencies, their employees and clients for recruitment, with data collection period planned from January to June 2021. We will assess regulations and financing mechanisms (via public records), agency characteristics (via agency questionnaire data) and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care (via questionnaires for homecare employees, clients and informal caregivers). All collected data will be subjected to descriptive and multi-level analyses.

DISCUSSION

The first results are expected by December 2021. Knowledge of factors linked to quality of care is essential to plan and implement quality improvement strategies. This study will help to identify modifiable factors at multiple health system levels that might serve as access points to improve coordination and quality of care.

Integrated Care Programs for People with Multimorbidity in European Countries: eHealth Adoption in Health Systems

INTRODUCTION

eHealth applications have the potential to provide new integrated care services to patients with multimorbidity (MM), also supporting multidisciplinary care. The aim of this paper is to explore how widely eHealth tools have been currently adopted in integrated care programs for (older) people with MM in European countries, including benefits and barriers concerning their adoption, according to some basic health system characteristics.

MATERIALS AND METHODS

In 2014, in the framework of the ICARE4EU project, expert organizations in 24 European countries identified 101 integrated care programs. Managers of the selected programs completed an online questionnaire on several dimensions, including the use of eHealth. We analyzed data from this questionnaire, in addition to qualitative information from six innovative programs which were studied in depth through case study methodology, according to characteristics of national health systems: a national health model (financing system), overall strength of primary care (PC) (structure/service delivery process), and level of (de)centralization of health system (executive powers in a country).

RESULTS

85 programs (out of 101) adopted at least one eHealth tool, and 42 of these targeted explicitly older people. In most cases, Electronic Health Records (EHRs) were used and some benefits emerged like improved care management and integration, although inadequate funding mechanisms represented a major barrier. The analysis by health system characteristics showed a greater adoption of eHealth applications in decentralized countries, in countries with a National Health Service (NHS) model, and in countries with a strong/medium level of PC development.

CONCLUSIONS

Although in the light of some limitations, findings indicate a relation between implementation of care programs using eHealth tools and basic characteristics of health systems, with decentralization of a health system, NHS model, and strong/medium PC having a key role. However adaptations of European health systems seem necessary, in order to provide a more innovative and integrated care.