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Parsons Leigh J, Moss SJ, Mizen SJ, Sriskandarajah C, FitzGerald EA, Quinn AE, Clement F, Farkas B, Dodds A, Columbus M, Stelfox HT. "We're sinking": a qualitative interview-based study on stakeholder perceptions of structural and process limitations to the Canadian healthcare system. Arch Public Health 2024; 82:56. [PMID: 38664761 PMCID: PMC11044548 DOI: 10.1186/s13690-024-01279-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Despite longstanding efforts and calls for reform, Canada's incremental approach to healthcare changes has left the country lagging behind other OECD nations. Reform to the Canadian healthcare system is essential to develop a higher performing system. This study sought to gain a deeper understanding of the views of Canadian stakeholders on structural and process deficiencies and strategies to improve the Canadian healthcare system substantially and meaningfully. METHODS We conducted individual, ~ 45-minute, semi-structured virtual interviews from May 2022 to August 2022. Using existing contacts and snowball sampling, we targeted one man and one woman from five regions in Canada across four stakeholder groups: (1) public citizens; (2) healthcare leaders; (3) academics; and (4) political decision makers. Interviews centered on participants' perceptions of the state of the current healthcare system, including areas where major improvements are required, and strategies to achieve suggested enhancements; Donabedian's Model (i.e., structure, process, outcomes) was the guiding conceptual framework. Interviews were audio-recorded, transcribed verbatim, and de-identified, and inductive thematic analysis was performed independently and in duplicate according to published methods. RESULTS The data from 31 interviews with 13 (41.9%) public citizens, 10 (32.3%) healthcare leaders, 4 (12.9%) academics, and 4 (12.9%) political decision makers resulted in three themes related to the structure of the healthcare system (1. system reactivity; 2. linkage with the Canadian identity; and 3. political and funding structures), three themes related to healthcare processes (1. staffing shortages; 2. inefficient care; and 3. inconsistent care), and three strategies to improve short- and long-term population health outcomes (1. delineating roles and revising incentives; 2. enhanced health literacy; 3. interdisciplinary and patient-centred care). CONCLUSION Canadians in our sample identified important structural and process limitations to the Canadian healthcare system. Meaningful reforms are needed and will require addressing the link between the Canadian identity and our healthcare system to facilitate effective development and implementation of strategies to improve population health outcomes.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada.
| | - Stephana Julia Moss
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Sara J Mizen
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Cynthia Sriskandarajah
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Emily A FitzGerald
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Amity E Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Fiona Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Brenlea Farkas
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexandra Dodds
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Melanie Columbus
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Henry T Stelfox
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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AGGARWAL MONICA, HUTCHISON BRIAN, ABDELHALIM REHAM, BAKER GROSS. Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?". Milbank Q 2023; 101:1139-1190. [PMID: 37743824 PMCID: PMC10726918 DOI: 10.1111/1468-0009.12674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/29/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. CONTEXT Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems. METHODS A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time. FINDINGS The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. CONCLUSIONS Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.
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Affiliation(s)
| | - BRIAN HUTCHISON
- Centre for Health Economics and Policy AnalysisMcMaster University
| | - REHAM ABDELHALIM
- Institute of Health PolicyManagement and EvaluationUniversity of Toronto
| | - G. ROSS BAKER
- Dalla Lana School of Public HealthUniversity of Toronto
- Institute of Health PolicyManagement and EvaluationUniversity of Toronto
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Breton M, Smithman MA, Lamoureux-Lamarche C, Keely E, Farrell G, Singer A, Dumas Pilon M, Bush PL, Nabelsi V, Gaboury I, Gagnon MP, Steele Gray C, Hudon C, Aubrey-Bassler K, Visca R, Côté-Boileau É, Gagnon J, Deslauriers V, Liddy C. Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces. EVALUATION AND PROGRAM PLANNING 2023; 100:102329. [PMID: 37329836 DOI: 10.1016/j.evalprogplan.2023.102329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/18/2023] [Accepted: 06/07/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada. METHODS We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework. RESULTS The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes. CONCLUSIONS Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.
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Affiliation(s)
- Mylaine Breton
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil Campus, Longueuil, QC, Canada.
| | - Mélanie Ann Smithman
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil Campus, Longueuil, QC, Canada
| | | | - Erin Keely
- Department of Medicine, University of Ottawa, Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
| | - Gerard Farrell
- Department of Family Medicine, Memorial University, St-John, NFL, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Maxine Dumas Pilon
- Collège Québécois des Médecins de Famille, Family Medicine Center, St-Mary's Hospital, McGill University, Montréal, QC, Canada
| | - Paula Louise Bush
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Véronique Nabelsi
- Département des sciences administratives, Université du Québec en Outaouais, Gatineau, QC, Canada
| | - Isabelle Gaboury
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil Campus, Longueuil, QC, Canada
| | | | - Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum, Research Institute, Sinai Health System, University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Catherine Hudon
- Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Regina Visca
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Élizabeth Côté-Boileau
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil Campus, Longueuil, QC, Canada
| | - Justin Gagnon
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Véronique Deslauriers
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil Campus, Longueuil, QC, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, ON, Canada
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Breton M, Lamoureux-Lamarche C, Smithman MA, Keely E, Pilon MD, Singer A, Farrell G, Bush PL, Hudon C, Cooper L, Nabelsi V, Côté-Boileau É, Gagnon J, Gaboury I, Gray CS, Gagnon MP, Visca R, Liddy C. Scaling-Up eConsult: Promising Strategies to Address Enabling Factors in Four Jurisdictions in Canada. Int J Health Policy Manag 2023; 12:7203. [PMID: 38618827 PMCID: PMC10590220 DOI: 10.34172/ijhpm.2023.7203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/18/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Effective healthcare innovations are often not scaled up beyond their initial local context. Lack of practical knowledge on how to move from local innovations to large-system improvement hinders innovation and learning capacity in health systems. Studying scale-up processes can lead to a better understanding of how to facilitate the scale-up of interventions. eConsult is a digital health innovation that aims to connect primary care professionals with specialists through an asynchronous electronic consultation. The recent implementation of eConsult in the public health systems of four Canadian jurisdictions provides a unique opportunity to identify different enabling strategies and related factors that promote the scaling up of eConsult across jurisdictions. METHODS We conducted a narrative case study in four Canadian provinces, Quebec, Ontario, Manitoba, and Newfoundland & Labrador, over a 3-year period (2018-2021). We observed provincial eConsult committee meetings (n=65) and national eConsult forums (n=3), and we reviewed internal documents (n=93). We conducted semi-structured interviews with key actors in each jurisdiction (eg, researchers, primary care professionals, specialists, policy-makers, and patient partners) (n=40). We conducted thematic analysis guided by the literature on factors and strategies used to scale up innovations. RESULTS We identified a total of 31 strategies related to six key enabling factors to scaling up eConsult, including: (1) multi-actor engagement; (2) relative advantage; (3) knowledge transfer; (4) strong evidence base; (5) physician leadership; and (6) resource acquisition (eg, human, material, and financial resources). More commonly used strategies, such as leveraging research infrastructure and bringing together various actors, were used to address multiple enabling factors. CONCLUSION Actors used various strategies to scale up eConsult within their respective contexts, and these helped address six key factors that seemed to be essential to the scale-up of eConsult.
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Affiliation(s)
- Mylaine Breton
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil, QC, Canada
| | | | - Mélanie Ann Smithman
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil, QC, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
| | - Maxine Dumas Pilon
- Collège québécois des médecins de famille, Family Medicine Center, St-Mary’s Hospital, McGill University, Montréal, QC, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MN, Canada
| | - Gerard Farrell
- Department of Family Medicine, Memorial University, St. John, NL, Canada
| | - Paula Louise Bush
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Catherine Hudon
- Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Lynn Cooper
- Canadian Injured Workers Alliance, Thunder Bay, ON, Canada
| | - Véronique Nabelsi
- Département des sciences administratives, Université du Québec en Outaouais, Gatineau, QC, Canada
| | | | - Justin Gagnon
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Isabelle Gaboury
- Centre de recherche Charles-Le Moyne, Université de Sherbrooke, Longueuil, QC, Canada
| | - Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum, Research Institute, Sinai Health System, University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | | | - Regina Visca
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, ON, Canada
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Peckham A, Saragosa M, King M, Roerig M, Shaw J, Bornstein S, McGrail K, Morris M, Young Y, Papenkov MV, Marchildon G. Policy programs and service delivery models for older adults and their caregivers: Comparing three provinces and two states. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e4264-e4279. [PMID: 35582789 PMCID: PMC10083929 DOI: 10.1111/hsc.13820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 03/14/2022] [Accepted: 04/12/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Allie Peckham
- Edson College of Nursing and Health InnovationArizona State UniversityPhoenixArizonaUSA
- North American Observatory on Health Systems and PoliciesTorontoOntarioCanada
| | - Marianne Saragosa
- Edson College of Nursing and Health InnovationArizona State UniversityPhoenixArizonaUSA
- North American Observatory on Health Systems and PoliciesTorontoOntarioCanada
| | - Madeline King
- North American Observatory on Health Systems and PoliciesTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Monika Roerig
- North American Observatory on Health Systems and PoliciesTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - James Shaw
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
- Department of Physical Therapy, Temerty Faculty of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Stephen Bornstein
- Department of Political Science Memorial UniversitySt. John'sNewfoundland and LabradorCanada
- Community Health and Humanities, Faculty of MedicineMemorial UniversitySt. John'sNewfoundland and LabradorCanada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Madeline Morris
- College of Nursing and Health SciencesUniversity of VermontBurlingtonVermontUSA
| | - Yuchi Young
- School of Public Health, Department of Health Policy, Management & BehaviorState University of New York at AlbanyAlbanyNew YorkUSA
| | - Maksim V. Papenkov
- School of Arts and Sciences, Department of EconomicsState University of New York at AlbanyAlbanyNew YorkUSA
| | - Greg Marchildon
- North American Observatory on Health Systems and PoliciesTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
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McKayMadeleine, Lavergne MR, Prince LeaAmanda, Le M, Grudniewicz A, Blackie D, Goldsmith LJ, Marshall EG, Mathews M, McCracken R, McGrail K, Wong S, Rudoler D. Government policies targeting primary care physician practice from 1998-2018 in three Canadian provinces: A jurisdictional scan. Health Policy 2022; 126:565-575. [DOI: 10.1016/j.healthpol.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 02/22/2022] [Accepted: 03/11/2022] [Indexed: 11/28/2022]
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Smithman MA, Dumas-Pilon M, Campbell MJ, Breton M. Evaluation of a Dragons' Den-inspired symposium to spread primary health care innovations in Quebec, Canada: a mixed-methods study using quality-improvement e-surveys. CMAJ Open 2022; 10:E247-E254. [PMID: 35318248 PMCID: PMC8946644 DOI: 10.9778/cmajo.20200251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND On May 24, 2017, the Quebec College of Family Physicians held an innovation symposium inspired by the television show Dragons' Den, at which innovators pitched their innovations to Dragon-Facilitators (i.e., decision-makers) and academic family medicine clinical leads. We evaluated the effects of the symposium on the spread of primary health care innovations. METHODS We conducted a mixed-methods evaluation of the symposium. We collected data related to Rogers' innovation-decision process using 3 quality-improvement e-surveys (distributed between May 2017 and February 2018). The first survey evaluated spread outputs (innovation discovery, intention to spread, improvements) and was sent to all participants immediately after the symposium. The second evaluated short-term spread outcomes (follow-ups, successes, barriers) and was sent to innovators 3 months after the symposium. The third evaluated medium-term spread outcomes (spread, perceived impact) and was sent to innovators and clinical leads 9 months after the symposium. We analyzed the data using descriptive statistics, content analysis and joint display. RESULTS Fifty-one innovators, 66 clinical leads (representing 42 clinics) and 37 Dragon-Facilitators attended the symposium. The response rates for the surveys were 61% (82/134) for the immediate post-symposium survey of all participants; 68% (21/31) for the 3-month survey of innovators; and 49% (48/97) for the 9-month survey of clinical leads and innovators. Immediately after the symposium, clinical leads and Dragon-Facilitators reported a high likelihood of adopting an innovation (mean ± standard deviation 8.02 ± 1.63 on a 10-point Likert scale) and 87% (53/61) agreed that they had discovered innovations at the symposium. Nearly all innovators (95%, 20/21) intended to follow up with potential adopters. After 3 months, 62% (13/21) of innovators had followed up in some way. After 9 months, 72% of clinical leads (18/25) had implemented at least 1 innovation, and 52% of innovators (12/23) had spread or were in the process of spreading innovations. INTERPRETATION The innovation symposium supported participants in achieving the early stages of spreading primary health care innovations. Replicating such symposia may help spread other health care innovations.
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Affiliation(s)
- Mélanie Ann Smithman
- Faculty of Medicine and Health Sciences (Smithman), Universite de Sherbrooke, Longueuil, Que.; Department of Family Medicine (Dumas-Pilon), McGill University, Montréal, Que.; Collège québécois des médecins de famille (Dumas-Pilon), Québec, Que.; Soutien à la pratique et développement professionnel continu (Campbell), Collège québécois des médecins de famille, Laval, Que.; Département des sciences de la santé communautaire (Breton), Université de Sherbrooke, Sherbrooke, Que.
| | - Maxine Dumas-Pilon
- Faculty of Medicine and Health Sciences (Smithman), Universite de Sherbrooke, Longueuil, Que.; Department of Family Medicine (Dumas-Pilon), McGill University, Montréal, Que.; Collège québécois des médecins de famille (Dumas-Pilon), Québec, Que.; Soutien à la pratique et développement professionnel continu (Campbell), Collège québécois des médecins de famille, Laval, Que.; Département des sciences de la santé communautaire (Breton), Université de Sherbrooke, Sherbrooke, Que
| | - Marie-Josée Campbell
- Faculty of Medicine and Health Sciences (Smithman), Universite de Sherbrooke, Longueuil, Que.; Department of Family Medicine (Dumas-Pilon), McGill University, Montréal, Que.; Collège québécois des médecins de famille (Dumas-Pilon), Québec, Que.; Soutien à la pratique et développement professionnel continu (Campbell), Collège québécois des médecins de famille, Laval, Que.; Département des sciences de la santé communautaire (Breton), Université de Sherbrooke, Sherbrooke, Que
| | - Mylaine Breton
- Faculty of Medicine and Health Sciences (Smithman), Universite de Sherbrooke, Longueuil, Que.; Department of Family Medicine (Dumas-Pilon), McGill University, Montréal, Que.; Collège québécois des médecins de famille (Dumas-Pilon), Québec, Que.; Soutien à la pratique et développement professionnel continu (Campbell), Collège québécois des médecins de famille, Laval, Que.; Département des sciences de la santé communautaire (Breton), Université de Sherbrooke, Sherbrooke, Que
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Leslie M, Khayatzadeh-Mahani A, Birdsell J, Forest PG, Henderson R, Gray RP, Schraeder K, Seidel J, Zwicker J, Green LA. An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change. BMC FAMILY PRACTICE 2020; 21:258. [PMID: 33278880 PMCID: PMC7718828 DOI: 10.1186/s12875-020-01330-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 11/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. METHODS Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. RESULTS Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. CONCLUSIONS Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.
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Affiliation(s)
- Myles Leslie
- School of Public Policy / Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, DTC547 - 906 8th Avenue SW, Calgary, AB, T2P 1H9, Canada.
| | - Akram Khayatzadeh-Mahani
- Saskatchewan Population Health and Evaluation Research Unit, University of Regina, Regina, Canada
| | - Judy Birdsell
- IMAGINE Citizens Collaborating for Health, Calgary, Canada
| | - P G Forest
- School of Public Policy / Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, DTC547 - 906 8th Avenue SW, Calgary, AB, T2P 1H9, Canada
| | - Rita Henderson
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Robin Patricia Gray
- School of Public Policy / Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, DTC547 - 906 8th Avenue SW, Calgary, AB, T2P 1H9, Canada
| | - Kyleigh Schraeder
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Judy Seidel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, Alberta Health Services, Calgary, Canada
| | - Jennifer Zwicker
- School of Public Policy / Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Lee A Green
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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Embrett M, Randall GE, Lavis JN, Dion ML. Conceptualising characteristics of resources withdrawal from medical services: a systematic qualitative synthesis. Health Res Policy Syst 2020; 18:123. [PMID: 33115486 PMCID: PMC7592573 DOI: 10.1186/s12961-020-00630-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Terms used to describe government-led resource withdrawal from ineffective and unsafe medical services, including 'rationing' and 'disinvestment', have tended to be used interchangeably, despite having distinct characteristics. This lack of descriptive precision for arguably distinct terms contributes to the obscurity that hinders effective communication and the achievement of evidence-based decision-making. The objectives of this study are to (1) identify the various terms used to describe resource withdrawal and (2) propose definitions for the key or foundational terms, which includes a clear description of the unique characteristics of each. METHODS This is a systematic qualitative synthesis of characteristics and terms found through a search of the academic and grey literature. This approach involved identifying commonly used resource withdrawal terms, extracting data about resource withdrawal characteristics associated with each term and conducting a comparative analysis by categorising elements as antecedents, attributes or outcomes. RESULTS Findings from an analysis of 106 documents demonstrated that terms used to describe resource withdrawal are inconsistently defined and applied. The characteristics associated with these terms, mainly antecedents and attributes, are used interchangeably by many authors but are differentiated by others. Our analysis resulted in the development of a framework that organises these characteristics to demonstrate the unique attributes associated with each term. To enhance precision, these terms were classified as either policy options or patient health outcomes and refined definitions for rationing and disinvestment were developed. Rationing was defined as resource withdrawal that denies, on average, patient health benefits. Disinvestment was defined as resource withdrawal that results in, on average, improved or no change in health benefits. CONCLUSION Agreement on the definition of various resource withdrawal terms and their key characteristics is required for transparent government decision-making regarding medical service withdrawal. This systematic qualitative synthesis presents the proposed definitions of resource withdrawal terms that will promote consistency, benefit public policy dialogue and enhance the policy-making process for health systems.
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Affiliation(s)
- Mark Embrett
- Faculty of Health, School of Nursing, Dalhouise University, 5869 University Avenue, PO BOX 15000, Halifax, Nova Scotia, B3H 4R2, Canada. .,St. Francis Xavier University, 4130 University Avenue, Antigonish, Nova Scotia, B2G2W5, Canada.
| | - Glen E Randall
- Health Policy and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, L8S4M4, Canada.,McMaster University, DSB-229, 1280 Main Street West, Hamilton, Ontario, L8S 4M4, Canada
| | - John N Lavis
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8S4L6, Canada.,McMaster Health Forum, MML-417, 1280 Main St. West, Hamilton, Ontario, L8S4L6, Canada
| | - Michelle L Dion
- Department of Political Science, McMaster University, Hamilton, Ontario, L8S4L6, Canada.,Kenneth Taylor Hall (KTH) 533, 1280 Main St. West, Hamilton, Ontario, L8S4L6, Canada
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Evolution of the determinants of unmet health care needs in a universal health care system: Canada, 2001-2014. HEALTH ECONOMICS POLICY AND LAW 2020; 16:400-423. [PMID: 32807251 DOI: 10.1017/s1744133120000250] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
While ensuring adequate access to care is a central concern in countries with universal health care coverage, unmet health care needs remain prevalent. However, subjective unmet health care needs (SUN) can arise from features of a health care system (system reasons) or from health care users' choices or constraints (personal reasons). Furthermore, investigating the evolution of SUN within a health care system has rarely been carried out. We investigate whether health needs, predisposing factors and enabling factors differentially affect SUN for system reasons and SUN for personal reasons, and whether these influences are stable over time, using representative data from the Canadian Community Health Surveys from 2001 to 2014. While SUN slightly decreased overall during our period of observation, the share of SUN for system reasons increased. Some key determinants appear to consistently increase SUN reporting over all our observation periods, in particular being a woman, younger, in poorer health or not having a regular doctor. The distinction between personal and system reasons is important to better understand individual experiences. Notably, women report more SUN for system reasons and less for personal reasons, and reporting system reasons increases with age. Given this stability over time, our results may inform health policymakers on which subpopulations to target to ensure access to health care is universal.
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Mansfield E, Sandercock J, Dowedoff P, Martel S, Marcinow M, Shulman R, Parks S, Peters ML, Versloot J, Kerr J, Zenlea I. Implementing integrated care pilot projects in hospital settings – an exploration of disruptive practices. JOURNAL OF INTEGRATED CARE 2020. [DOI: 10.1108/jica-12-2019-0051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeIn Canada, integrated care pilot projects are often implemented as a local reform strategy to improve the quality of patient care and system efficiencies. In the qualitative study reported here, the authors explored the experiences of healthcare professionals when first implementing integrated care pilot projects, bringing together physical and mental health services, in a community hospital setting.Design/methodology/approachEngaging a qualitative descriptive study design, semi-structured interviews were conducted with 24 healthcare professionals who discussed their experiences with implementing three integrated care pilot projects one year following project launch. The thematic analysis captured early implementation issues and was informed by an institutional logics framework.FindingsThree themes highlight disruptions to established logics reported by healthcare professionals during the early implementation phase: (1) integrated care practices increased workload and impacted clinical workflows; (2) integrating mental and physical health services altered patient and healthcare provider relationships; and (3) the introduction of integrated care practices disrupted healthcare team relations.Originality/valueStudy findings highlight the importance of considering existing logics in healthcare settings when planning integrated care initiatives. While integrated care pilot projects can contribute to organizational, team and individual practice changes, the priorities of healthcare stakeholders, relational work required and limited project resources can create significant implementation barriers.
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Scaling up eConsult for access to specialists in primary healthcare across four Canadian provinces: study protocol of a multiple case study. Health Res Policy Syst 2019; 17:83. [PMID: 31511008 PMCID: PMC6739985 DOI: 10.1186/s12961-019-0483-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Canada has been referred to as the land of 'perpetual pilot projects'. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times - one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients' medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. METHODS We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). DISCUSSION This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.
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Rudoler D, Peckham A, Grudniewicz A, Marchildon G. Coordinating primary care services: A case of policy layering. Health Policy 2018; 123:215-221. [PMID: 30583803 DOI: 10.1016/j.healthpol.2018.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 11/04/2018] [Accepted: 12/08/2018] [Indexed: 11/29/2022]
Abstract
In this paper, we discuss the processes of policy layering as they relate to health care reform. We focus on efforts to achieve systems of coordinated primary care, and demonstrate that material change can be achieved through processes of incremental policy layering. Such processes also have a high potential for unintended consequences. Thus, we propose new principles of 'smart' policy layering to guide decision-makers to do incrementalism better. We then apply these principles to recent primary care reforms in Ontario, Canada. This paper conceptualizes 'smart' policy layering as a mechanism to achieve productive policy change in contexts with strong institutional barriers to reform.
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Affiliation(s)
- David Rudoler
- Faculty of Health Sciences, University of Ontario Institute of Technology, Canada; Institute of Mental Health Policy Research, Centre for Addiction and Mental Health, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada.
| | - Allie Peckham
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; North American Observatory on Health Systems and Policies, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, Canada; Institut du-savoir Montfort, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Greg Marchildon
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; North American Observatory on Health Systems and Policies, Canada
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Peckham A, Morton-Chang F, Williams AP, Miller FA. Rebalancing health systems toward community-based care: The role of subsectoral politics. Health Policy 2018; 122:1260-1265. [PMID: 30278991 DOI: 10.1016/j.healthpol.2018.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/16/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
There has been increased policy discourse urging a "rebalancing" of health systems from institutionally-based to community-based approaches. This paper offers an analysis of the subsectoral dynamics that condition opportunities to strengthen community-based care relative to acute care. We report on the results of a policy study in Ontario, Canada that explored factors impacting on the capacity to expand community-based care. In so doing, we highlight the challenges associated with the community subsector's ability to develop 'critical' status and challenge the dominance of the acute subsector. We conclude that attempts to rebalance health systems toward community-based care should begin by understanding that health care is not a monolithic policy sector, but rather a collection of proximate policy sub-sectors, inclusive of community care, acute care, and institutional care, each with their own internal characteristics and dynamics that impact sectoral directions.
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Affiliation(s)
- Allie Peckham
- Institute of Health Policy, Management and Evaluation, University of Toronto College St, Suite 425, Toronto, Ontario M5T 3M6, Canada; North American Observatory on Health Systems and Policies College St, Suite 425, Toronto, Ontario M5T 3M6, Canada.
| | - Frances Morton-Chang
- Institute of Health Policy, Management and Evaluation, University of Toronto College St, Suite 425, Toronto, Ontario M5T 3M6, Canada.
| | - A Paul Williams
- Institute of Health Policy, Management and Evaluation, University of Toronto College St, Suite 425, Toronto, Ontario M5T 3M6, Canada.
| | - Fiona A Miller
- Institute of Health Policy, Management and Evaluation, University of Toronto College St, Suite 425, Toronto, Ontario M5T 3M6, Canada.
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Perceptions of the effectiveness of Advanced Practice Nurses on a neurosurgery unit in a Canadian Tertiary Care Centre: A pre-and-post implementation design. Int J Nurs Sci 2018; 5:138-143. [PMID: 31406815 PMCID: PMC6626254 DOI: 10.1016/j.ijnss.2018.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/31/2018] [Accepted: 03/27/2018] [Indexed: 11/30/2022] Open
Abstract
Objectives A framework for the advanced practice nurse (APN) role was developed in our Canadian Tertiary Care Centre, delineating five domains of advanced nursing practice: clinical practice, consultation, research, education and leadership. The goal of this study was to evaluate perceptions of the effectiveness of the implementation of an innovative APN role on an in-patient Neurosurgery unit. Methods A pre-and-post implementation design, incorporating both qualitative and quantitative data, was utilized. An innovative APN role was implemented within the Neurosurgery program focusing on the clinical domain and required the successful candidates to be NP prepared. This APN role was designed to improve patient flow, documentation, communication and patient and staff satisfaction. Three primary outcomes were measured: pre-implementation questionnaire (nurses), post-implementation questionnaire (nurses and residents) and number of pages to the on-call resident. Results Survey scores by nurses and residents indicated improvement across all aspects studied. Average scores increased from 1.1 to 2.6, reflecting an overall statistically significant increase. The number of pages to the on-call resident also showed a decrease. Conclusion Perceptions of patient care delivery and professional collaboration improved following implementation of the APN role. Responses indicated that APNs significantly impacted patient care and improved nurses and residents' job satisfaction.
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Mansfield E, Bhattacharyya O, Christian J, Naglie G, Steriopoulos V, Webster F. Physicians’ accounts of frontline tensions when implementing pilot projects to improve primary care. J Health Organ Manag 2018; 32:39-55. [DOI: 10.1108/jhom-01-2017-0013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Canada’s primary care system has been described as “a culture of pilot projects” with little evidence of converting successful initiatives into funded, permanent programs or sharing project outcomes and insights across jurisdictions. Health services pilot projects are advocated as an effective strategy for identifying promising models of care and building integrated care partnerships in local settings. In the qualitative study reported here, the purpose of this paper is to investigate the strengths and challenges of this approach.
Design/methodology/approach
Semi-structured interviews were conducted with 34 primary care physicians who discussed their experiences as pilot project leads. Following thematic analysis methods, broad system issues were captured as well as individual project information.
Findings
While participants often portrayed themselves as advocates for vulnerable patients, mobilizing healthcare organizations and providers to support new models of care was discussed as challenging. Competition between local healthcare providers and initiatives could impact pilot project success. Participants also reported tensions between their clinical, project management and research roles with additional time demands and skill requirements interfering with the work of implementing and evaluating service innovations.
Originality/value
Study findings highlight the complexity of pilot project implementation, which encompasses physician commitment to addressing care for vulnerable populations through to the need for additional skill set requirements and the impact of local project environments. The current pilot project approach could be strengthened by including more multidisciplinary collaboration and providing infrastructure supports to enhance the design, implementation and evaluation of health services improvement initiatives.
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Cookson R, Mondor L, Asaria M, Kringos DS, Klazinga NS, Wodchis WP. Primary care and health inequality: Difference-in-difference study comparing England and Ontario. PLoS One 2017; 12:e0188560. [PMID: 29182652 PMCID: PMC5705159 DOI: 10.1371/journal.pone.0188560] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 11/09/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions-one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada). METHODS We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions. RESULTS Inequality trends were comparable in both jurisdictions from 2004-6 but diverged from 2007-11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004-6 and 2007-11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods. DISCUSSION In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms.
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Affiliation(s)
- Richard Cookson
- Centre for Health Economics, University of York, York, United Kingdom
| | - Luke Mondor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Health System Performance Research Network, Toronto, Ontario, Canada
| | - Miqdad Asaria
- Centre for Health Economics, University of York, York, United Kingdom
| | - Dionne S. Kringos
- Academic Medical Centre, University of Amsterdam, Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Niek S. Klazinga
- Academic Medical Centre, University of Amsterdam, Department of Public Health, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter P. Wodchis
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Health System Performance Research Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- * E-mail:
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18
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Harnagea H, Couturier Y, Shrivastava R, Girard F, Lamothe L, Bedos CP, Emami E. Barriers and facilitators in the integration of oral health into primary care: a scoping review. BMJ Open 2017; 7:e016078. [PMID: 28951405 PMCID: PMC5623507 DOI: 10.1136/bmjopen-2017-016078] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This scoping study has been conducted to map the literature and provide a descriptive synthesis on the barriers and facilitators of the integration of oral health into primary care. METHODS Grounded in the Rainbow conceptual model and using the Levac et al six-stage framework, we performed a systematic search of electronic databases, organisational websites and grey literature from 1978 to April 2016. All publications with a focus on the integration of oral health into primary care were included except commentaries and editorials. Thematic analyses were performed to synthesise the results. RESULTS From a total of 1619 citations, 58 publications were included in the review. Barrier-related themes included: lack of political leadership and healthcare policies; implementation challenges; discipline-oriented education; lack of continuity of care and services and patients' oral healthcare needs. The facilitators of integration were supportive policies and resources allocation, interdisciplinary education, collaborative practices between dental and other healthcare professionals, presence of local strategic leaders and geographical proximity. DISCUSSION AND PUBLIC HEALTH IMPLICATIONS This work has advanced the knowledge on the barriers and facilitators at each integration domain and level, which may be helpful if the healthcare organisations decide to integrate oral health and dental services into primary care. The scoping review findings could be useful for both dental and medical workforce and allied primary healthcare providers. They could also guide the development of healthcare policies that support collaborative practices and patient-centred care in the field of primary care.
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Affiliation(s)
- Hermina Harnagea
- School of Public Health, Université de Montréal, Montréal, Québec, Canada
| | - Yves Couturier
- School of Social Work, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Richa Shrivastava
- Faculty of Dental Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Felix Girard
- Faculty of Dental Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Lise Lamothe
- School of Public Health, Université de Montréal, Montréal, Québec, Canada
- Public Health Research Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Elham Emami
- School of Public Health, Université de Montréal, Montréal, Québec, Canada
- Faculty of Dental Medicine, Université de Montréal, Montréal, Québec, Canada
- Public Health Research Institute, Université de Montréal, Montréal, Québec, Canada
- Faculty of Dentistry, McGill University, Montréal, Québec, Canada
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Leck V, Randall GE. The rise and fall of dental therapy in Canada: a policy analysis and assessment of equity of access to oral health care for Inuit and First Nations communities. Int J Equity Health 2017; 16:131. [PMID: 28728554 PMCID: PMC5520332 DOI: 10.1186/s12939-017-0631-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/17/2017] [Indexed: 11/14/2022] Open
Abstract
Background Inequality between most Canadians and those from Inuit and First Nations communities, in terms of both access to oral health care services and related health outcomes, has been a long-standing problem. Efforts to close this equity gap led to the creation of dental therapy training programs. These programs were designed to produce graduates who would provide services in rural and northern communities. The closure of the last dental therapy program in late 2011 has ended the supply of dental therapists and governments do not appear to have any alternative solutions to the growing gap in access to oral health care services between most Canadians and those from Inuit and First Nations communities. Methods A policy analysis of the rise and fall of the dental therapy profession in Canada was conducted using historical and policy documents. The analysis is framed within Kingdon’s agenda-setting framework and considers why dental therapy was originally pursued as an option to ensure equitable access to oral health care for Inuit and First Nations communities and why this policy has now been abandoned with the closure of Canada’s last dental therapy training school. Results The closure of the last dental therapy program in Canada has the potential to further reduce access to dental care in some Inuit and First Nations communities. Overlaps between federal and provincial jurisdiction have contributed to the absence of a coordinated policy approach to address the equity gap in access to dental care which will exacerbate the inequalities in comparison to the general population. The analysis suggests that while a technically feasible policy solution is available there continues to be no politically acceptable solution and thus it remains unlikely that a window of opportunity for policy change will open any time soon. Conclusion In the absence of federal government leadership, the most viable option forward may be incremental policy change. Provincial governments could expand the scope of practice for dental hygienists in the hope that it may support enhanced access, consumer choice, and efficiency in the delivery of oral health care to Inuit and First Nations communities in Canada.
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Affiliation(s)
- Victoria Leck
- Health Policy and Management, DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4M4, Canada
| | - Glen E Randall
- Health Policy and Management, DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4M4, Canada.
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Laberge M, Wodchis WP, Barnsley J, Laporte A. Efficiency of Ontario primary care physicians across payment models: a stochastic frontier analysis. HEALTH ECONOMICS REVIEW 2016; 6:22. [PMID: 27271177 PMCID: PMC4894855 DOI: 10.1186/s13561-016-0101-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 06/01/2016] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The study examines the relationship between the primary care model that a physician belongs to and the efficiency of the primary care physician in Ontario, Canada. METHODS Survey data were collected from 183 self-selected physicians and linked to administrative databases to capture the provision of services to the patients served for the 12 month period ending June 30, 2013, and the characteristics of the patients at the beginning of the study period. Two stochastic frontier regression models were used to estimate efficiency scores and parameters for two separate outputs: the number of distinct patients seen and the number of visits. RESULTS Because of missing data, only 165 physicians were included in the analyses. The average efficiency was 0.72 for both outputs with scores varying from 4 % to 93 % for the visits and 5 % to 94 % for the number of patients seen. We observed that there were both very low and very high efficiency scores within each model. These variations were larger than variations in average scores across models.
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Affiliation(s)
- Maude Laberge
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, 1225 Center Dr, Room 3111, Gainesville, FL, 32610, USA.
- Canadian Centre for Health Economics, Toronto, Canada.
| | - Walter P Wodchis
- Canadian Centre for Health Economics, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Toronto Rehabilitation Institute, Toronto, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Audrey Laporte
- Canadian Centre for Health Economics, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
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Emami E, Harnagea H, Girard F, Charbonneau A, Voyer R, Bedos CP, Chartier M, Wootton J, Couturier Y. Integration of oral health into primary care: a scoping review protocol. BMJ Open 2016; 6:e013807. [PMID: 27798039 PMCID: PMC5073498 DOI: 10.1136/bmjopen-2016-013807] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Integrated care has been introduced as a means of improving health outcomes and access to care, and reducing the cost of healthcare. Despite its importance, the integration of oral health into primary care is still an emerging healthcare pathway. This scoping review protocol has been developed and funded by the Canadian Institutes of Health Research to provide an evidence-based synthesis on a primary oral healthcare approach and its effectiveness in improving oral health outcomes. METHODS AND ANALYSIS The 6-stage framework developed by Levac et al underpins this scoping review. We will identify relevant existing theories, programmes and original research through a comprehensive and systematic search of electronic databases such as OVID (MEDLINE, EMBASE, Cochrane databases), NCBI (PubMed), EBSCOhost (CINAHL), ProQuest, Databases in Public Health, Databases of the National Institutes of Health (health management and health technology) and relevant organisational websites and other sources of grey literature. All types of studies from 1978 to May 2016 in the French and English languages will be included. Using the Rainbow conceptual model of integrative primary care, a qualitative descriptive approach and thematic analysis will be used to synthesise the literature. Implementing novel healthcare models necessitates identifying barriers, sharing knowledge and delivering information. The integration of oral healthcare into primary care is an approach that promotes breaking the boundaries separating oral healthcare professionals and primary care. It creates opportunities for the dental workforce to become more involved in community-based practice and to assume shared responsibility with healthcare professionals to address the unmet oral health needs of those experiencing vulnerability and marginalisation. ETHICS AND DISSEMINATION The scoping study has received approval from the Université de Montréal's Institutional Review Board (#14-097-CERES-D). The findings will be disseminated through publications and presentations in provincial, national and international research symposiums and professional meetings.
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Affiliation(s)
- Elham Emami
- Faculty of Dentistry, School of Public Health, Université de Montréal, McGill University, Montreal, Quebec, Canada
| | - Hermina Harnagea
- École de santé publique, Université de Montréal, Montréal, Québec, Canada
| | - Felix Girard
- Faculté de médecine dentaire, Université de Montréal, Montréal, Québec, Canada
| | - Anne Charbonneau
- Faculté de médecine dentaire, Université de Montréal, Montréal, Québec, Canada
| | - René Voyer
- Faculté de médecine dentaire, Université de Montréal, Montréal, Québec, Canada
| | | | | | - John Wootton
- Department of Family Medicine, Gatineau Integrated Center of Health and Social Services, Shawville, Québec, Canada
| | - Yves Couturier
- École de travail social, Université de Sherbrooke, Sherbrooke, Québec, Canada
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Johnson A, Nguyen H, Groth M, Wang K, Ng JL. Time to change: a review of organisational culture change in health care organisations. JOURNAL OF ORGANIZATIONAL EFFECTIVENESS-PEOPLE AND PERFORMANCE 2016. [DOI: 10.1108/joepp-06-2016-0040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The culture of an organization shapes the attitudes and behaviors of employees and plays a key role in driving organizational outcomes. Yet, it is enormously challenging to manage or change. The purpose of this paper is to review the recent literature on culture change interventions in health care organizations to identify the common themes underpinning these interventions.
Design/methodology/approach
The paper is developed from an extensive review of the literature on culture change interventions in health care from 2005 to 2015, building on previous reviews and highlighting examples of good practice.
Findings
All culture change interventions included in the review used processes and techniques that can be classified into Lewin’s (1951) three stage model of change. These include providing evidence for the need for change through data, a range of successful change strategies, and strategies for embedding the culture change into business as usual.
Practical implications
There is no “one size fits all” recipe for culture change. Rather, attention to context with key features including diagnosis and evaluation of culture, a combination of support from leaders and others in the organization, and strategies to embed the culture change are important for the change process to happen.
Originality/value
The authors provide an important insight into the key principles and features of culture change interventions to provide practitioners with guidance on the process within health care and other organizations.
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Mulvale G, Embrett M, Razavi SD. 'Gearing Up' to improve interprofessional collaboration in primary care: a systematic review and conceptual framework. BMC FAMILY PRACTICE 2016; 17:83. [PMID: 27440181 PMCID: PMC4955241 DOI: 10.1186/s12875-016-0492-1] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 07/13/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Interprofessional Primary Care Teams (IPCTs) have been shown to benefit health systems and patients, particularly those patients with complex care needs. The literature suggests a wide range of factors that may influence collaboration in IPCTs, however the evidence base is unclear for many of these factors. To target improvement efforts, we identify studies that demonstrate an association between suggested factors and collaborative processes in IPCTs. METHODS A systematic review of 25 years of peer-review literature was conducted to identify studies that test associations between policy, organizational, care team and individual factors, and collaboration in IPCTs. We searched Medline, ProQuest subject, ProQuest abstract, CINAHL, HealthSTAR, and Embase electronic databases between January 1990 to June 2015 and hand-searched reference lists of identified articles. RESULTS The electronic searches identified 1421 articles, nine of which met inclusion criteria. Eighteen factors were significantly associated with collaboration in at least one article. We present the findings within a proposed conceptual model of interrelated 'gears'. The model offers a taxonomy of factors that policy makers (macro gear), organizational managers (meso gear), care teams (micro gear) and health professionals (individual gear) can adjust to improve interprofessional collaboration in IPC teams. Thirteen of the eighteen identified factors were within the micro gear, or team level of decision-making. These pertained to formal processes such as quality audits and group problem-solving; social processes such as open communication and supportive colleagues; team attitudes such as feeling part of the team; and team structure such as team size and having a collaboration champion or facilitator. Fewer policy (eg governance), organizational (eg information systems, organizational culture) or individual (eg belief in interprofessional collaboration care and personal flexibility) level factors were identified. CONCLUSIONS The findings suggest that individual IPCTs have opportunities to improve collaboration regardless of the organizational or policy context within which they operate. Evidence supports the importance of having a team vision and shared goals, formal quality processes, information systems, and professionals feeling part of the team. Few studies assessed associations between collaboration and macro and meso factors, or between factors across levels, which are priorities for future research.
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Affiliation(s)
- Gillian Mulvale
- />DeGroote School of Business, McMaster University, 4350 South Service Road, Rm 421, Burlington, ON Canada L7L 5R8
| | - Mark Embrett
- />Faculty of Health Sciences, McMaster University, CRL Bulding 282, 1280 Main Street West, Hamilton, ON Canada L8S 4K1
| | - Shaghayegh Donya Razavi
- />Faculty of Health Sciences, McMaster University, CRL Bulding 282, 1280 Main Street West, Hamilton, ON Canada L8S 4K1
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Abstract
Access to health care services in Canada has been identified as an urgent priority, and chronic disease has been suggested as the most pressing health concern facing Canadians. Access to services for Canadians living with chronic disease, however, has received little emphasis in the research literature or in health policy reform documents. A systematic review of research into factors impeding or facilitating access to formal health services for people in Canada living with chronic illness is presented. The review includes 31 studies of Canadian populations published between 1990 and 2002; main results were analyzed for facilitators and barriers to access for people experiencing chronic disease. An underlying organizing construct of symmetry between consumers, providers, and the larger Canadian system is suggested as a relevant lens from which to view the findings. Finally, a discussion of the relationship between identified factors and the principles of primary health care is offered.
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Marchildon GP, Hutchison B. Primary care in Ontario, Canada: New proposals after 15 years of reform. Health Policy 2016; 120:732-8. [PMID: 27160481 DOI: 10.1016/j.healthpol.2016.04.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 04/13/2016] [Accepted: 04/15/2016] [Indexed: 11/26/2022]
Abstract
Primary care has proven to be extremely difficult to reform in Canada because of the original social compact between the state and physicians that led to the introduction of universal medical care insurance in the 1960s. However, in the past decade, the provincial government of Ontario has led the way in Canada in funding a suite of primary care practice models, some of which differ substantially from traditional solo and group physician practices based on fee-for-service payment. Independent evaluations show some positive improvements in patient care. Nonetheless, the Ontario government's large investment in the reform combined with high expectations concerning improved performance and the deteriorating fiscal position of the province's finances have led to major conflict with organized medicine over physician budgets and the government's consideration of an even more radical restructuring of the system of primary care in the province.
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Affiliation(s)
- Gregory P Marchildon
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada.
| | - Brian Hutchison
- Departments of Family Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Canada.
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Wang C, Li Q, Sweetman A, Hurley J. Mandatory universal drug plan, access to health care and health: Evidence from Canada. JOURNAL OF HEALTH ECONOMICS 2015; 44:80-96. [PMID: 26410422 DOI: 10.1016/j.jhealeco.2015.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 05/12/2015] [Accepted: 08/11/2015] [Indexed: 06/05/2023]
Abstract
This paper examines the impacts of a mandatory, universal prescription drug insurance program on health care utilization and health outcomes in a public health care system with free physician and hospital services. Using the Canadian National Population Health Survey from 1994 to 2003 and implementing a difference-in-differences estimation strategy, we find that the mandatory program substantially increased drug coverage among the general population. The program also increased medication use and general practitioner visits but had little effect on specialist visits and hospitalization. Findings from quantile regressions suggest that there was a large improvement in the health status of less healthy individuals. Further analysis by pre-policy drug insurance status and the presence of chronic conditions reveals a marked increase in the probability of taking medication and visiting a general practitioner among the previously uninsured and those with a chronic condition.
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Affiliation(s)
- Chao Wang
- International School of Economics and Management, Capital University of Economics and Business, Beijing 100070, PR China.
| | - Qing Li
- International School of Economics and Management, Capital University of Economics and Business, Beijing 100070, PR China.
| | - Arthur Sweetman
- Department of Economics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4M4; Centre for Health Economics and Policy (CHEPA), McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4K1.
| | - Jeremiah Hurley
- Department of Economics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4M4; Centre for Health Economics and Policy (CHEPA), McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4K1.
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A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future? BMC Health Serv Res 2015. [PMID: 26216103 PMCID: PMC4515922 DOI: 10.1186/s12913-015-0955-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background In North America and other industrialized countries, heart failure (HF) has become a national public health priority. Studies indicate there is significant heterogeneity in approaches to treat and manage HF and suggest targeted changes in health care delivery are needed to reduce unnecessary health care utilization and to optimize patient outcomes. Most recent published studies have reported on the care of HF patients in tertiary care hospitals and the perspective of non-specialist stakeholders on HF management, such as general practitioners and clinics or hospital administrators is rarely considered. This study explores the current state of community-based HF care in Canada as experienced by various healthcare stakeholders providing or coordinating care to HF patients. Methods This study employed a qualitative exploratory research design consisting of semi-structured telephone interviews conducted with health care providers and health care administrators working outside of tertiary care in the four most populous Canadian provinces. A modified thematic analysis process was used and the different data sources were triangulated. Findings were collectively interpreted by the authors. Results Twenty-eight participants were recruited in the study: eight cardiologists, five general practitioners/family physicians, eight nurse practitioners/registered nurses, four hospital pharmacists and three health care administrators/directors. Participants reported a lack of stakeholder engagement throughout the continuum of care, which hinders the implementation of a coordinated approach to quality HF care. Four substantive themes emerged that indicated challenges and gaps in the optimal treatment and management of HF in community settings: 1) challenges in the risk assessment and early diagnosis of HF, 2) challenges in ensuring efficient and consistent transition from acute care setting to the community, 3) challenges of primary care providers to optimally treat and manage HF patients, and 4) challenges in promoting a holistic approach in HF management. Conclusions As health systems evolve from tertiary-based care to community-based outpatient services for the management of chronic diseases, this study’s findings pinpoint challenges that have been observed in the Canadian context and can stimulate and orient dialogue toward solutions for a more coordinated approach to improve the care of HF patients and reduce pressure on the healthcare system.
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Zygmunt A, Asada Y, Burge F. Is Team-Based Primary Care Associated with Less Access Problems and Self-Reported Unmet Need in Canada? INTERNATIONAL JOURNAL OF HEALTH SERVICES 2015; 47:725-751. [PMID: 26182942 DOI: 10.1177/0020731415595547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As in many jurisdictions, the delivery of primary care in Canada is being transformed from solo practice to team-based care. In Canada, team-based primary care involves general practitioners working with nurses or other health care providers, and it is expected to improve equity in access to care. This study examined whether team-based care is associated with fewer access problems and less unmet need and whether socioeconomic gradients in access problems and unmet need are smaller in team-based care than in non-team-based care. Data came from the 2008 Canadian Survey of Experiences with Primary Health Care (sample size: 10,858). We measured primary care type as team-based or non-team-based and socioeconomic status by income and education. We created four access problem variables and four unmet need variables (overall and three specific components). For each, we ran separate logistic regression models to examine their associations with primary care type. We examined socioeconomic gradients in access problems and unmet need stratified by primary care type. Primary care type had no statistically significant, independent associations with access problems or unmet need. Among those with non-team-based care, a statistically significant education gradient for overall access problems existed, whereas among those with team-based care, no statistically significant socioeconomic gradients existed.
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Affiliation(s)
- Austin Zygmunt
- 1 Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Yukiko Asada
- 2 Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Frederick Burge
- 3 Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Berg S, Barer M, Sheps S, MacNab YC, McGregor M, Wong ST. Bridging Silos. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2015. [DOI: 10.1177/1084822315572114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Canadian family physicians (FPs) and home health staff (HHS) experience significant barriers to collaboration regarding patients whose needs are complex. This study used mixed methods to examine whether pre-scheduled, structured audio-conferencing could improve patient-related collaboration between physicians and HHS. The number of shared patients and contacts was collected across three phases: baseline, pre-intervention, and intervention. Interviews with FPs and focus groups with HHS were conducted post-intervention. Mixed effects Poisson regressions for count data, and content analysis for interview and focus group data, were used. No statistically significant “intervention” effect was observed in either the number of shared patients or the average patient contacts. Physicians participating in at least one audio-conference had a lower patient contact rate than the rest of the intervention group and controls. Qualitative data suggested that audio-conferences led to fewer contacts due to more efficient communication.
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Affiliation(s)
- Shannon Berg
- Vancouver Coastal Health Research Institute, British Columbia, Canada
- University of British Columbia, Vancouver, Canada
| | - Morris Barer
- University of British Columbia, Vancouver, Canada
- Center for Health Services and Policy Research, Vancouver, Canada
| | - Sam Sheps
- University of British Columbia, Vancouver, Canada
| | | | - Margaret McGregor
- Vancouver Coastal Health Research Institute, British Columbia, Canada
- University of British Columbia, Vancouver, Canada
| | - Sabrina T. Wong
- University of British Columbia, Vancouver, Canada
- Center for Health Services and Policy Research, Vancouver, Canada
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Effectiveness of Health System Services and Programs for Youth to Adult Transitions in Mental Health Care: A Systematic Review of Academic Literature. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2015; 43:259-69. [DOI: 10.1007/s10488-015-0638-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tamblyn R, Ernst P, Winslade N, Huang A, Grad R, Platt RW, Ahmed S, Moraga T, Eguale T. Evaluating the impact of an integrated computer-based decision support with person-centered analytics for the management of asthma in primary care: a randomized controlled trial. J Am Med Inform Assoc 2015; 22:773-83. [PMID: 25670755 PMCID: PMC4482273 DOI: 10.1093/jamia/ocu009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/23/2014] [Indexed: 11/28/2022] Open
Abstract
Background Computer-based decision support has been effective in providing alerts for preventive care. Our objective was to determine whether a personalized asthma management computer-based decision support increases the quality of asthma management and reduces the rate of out-of-control episodes. Methods A cluster-randomized trial was conducted in Quebec, Canada among 81 primary care physicians and 4447 of their asthmatic patients. Patients were followed from the first visit for 3–33 months. The physician control group used the Medical Office of the 21st century (MOXXI) system, an integrated electronic health record. A custom-developed asthma decision support system was integrated within MOXXI and was activated for physicians in the intervention group. Results At the first visit, 9.8% (intervention) to 12.9% (control) of patients had out-of-control asthma, which was defined as a patient having had an emergency room visit or hospitalization for respiratory-related problems and/or more than 250 doses of fast-acting β-agonist (FABA) dispensed in the past 3 months. By the end of the trial, there was a significant increase in the ratio of doses of inhaled corticosteroid use to fast-acting β-agonist (0.93 vs. 0.69: difference: 0.27; 95% CI: 0.02–0.51; P = 0.03) in the intervention group. The overall out-of-control asthma rate was 54.7 (control) and 46.2 (intervention) per 100 patients per year (100 PY), a non-significant rate difference of −8.7 (95% CI: −24.7, 7.3; P = 0.29). The intervention’s effect was greater for patients with out-of-control asthma at the beginning of the study, a group who accounted for 44.7% of the 5597 out-of-control asthma events during follow-up, as there was a reduction in the event rate of −28.4 per 100 PY (95% CI: −55.6, −1.2; P = 0.04) compared to patients with in-control asthma at the beginning of the study (−0.08 [95% CI: −10.3, 8.6; P = 0.86]). Discussion This study evaluated the effectiveness of a novel computer-assisted ADS system that facilitates systematic monitoring of asthma control status, follow-up of patients with out of control asthma, and evidence-based, patient-specific treatment recommendations. We found that physicians were more likely to use ADS for out-of-control patients, that in the majority of these patients, they were advised to add an inhaled corticosteroid or a leukotriene inhibitor to the patient s treatment regimen, and the intervention significantly increased the mean ratio of inhaled corticosteroids to FABA during follow-up. It also reduced the rate of out-of-control episodes during follow up among patients whose asthma was out-of-control at the time of study entry. Future research should assess whether coupling patient-specific treatment recommendations, automated follow-up, and home care with comparative feedback on quality and outcomes of care can improve guideline adoption and care outcomes. Conclusions A primary care-personalized asthma management system reduced the rate of out-of-control asthma episodes among patients whose asthma was poorly controlled at the study’s onset. Trial Registration Clinicaltrials.gov Identifier: NCT00170248 http://clinicaltrials.gov/ct2/show/NCT00170248?term=Asthma&spons=McGill+University&state1=NA%3ACA%3AQC&rank=2
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Affiliation(s)
- Robyn Tamblyn
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Pierre Ernst
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Nancy Winslade
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Allen Huang
- Division of Geriatric Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Roland Grad
- Herzl Family Practice Centre, Jewish General Hospital, Montreal, QC, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Sara Ahmed
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC, Canada Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
| | - Tewodros Eguale
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada
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Social determinants of health and health equity policy research: Exploring the use, misuse, and nonuse of policy analysis theory. Soc Sci Med 2014; 108:147-55. [DOI: 10.1016/j.socscimed.2014.03.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 02/12/2014] [Accepted: 03/06/2014] [Indexed: 12/25/2022]
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Moreira LMDC, Alves CRL, Belisário SA, Bueno MDC, Moraes ÉFD. Das diretrizes à prática: avaliação da atenção pediátrica prestada por um serviço de referência secundária no norte de Minas Gerais. CIENCIA & SAUDE COLETIVA 2013. [DOI: 10.1590/s1413-81232013000600029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A coexistência de condições agudas e crônicas demanda a reorganização do sistema de saúde vigente. O Programa Viva Vida é a estratégia de Minas Gerais para enfrentamento dos problemas na área da saúde da criança. Uma de suas ações é a implantação de Centros Viva Vida de Referência Secundária (CVVRS). O objetivo do estudo foi avaliar a atenção pediátrica prestada por um CVVRS, tendo como referência as diretrizes pactuadas para sua implantação. Foi adotada abordagem quanti-qualitativa, incluindo estudo transversal com amostra aleatória e estratificada de 385 prontuários de crianças inscritas de 2007 a 2009, e análise de grupos focais com atores estratégicos da iniciativa. Houve divergência entre o perfil dos usuários e o público-alvo previsto em relação à idade, município de origem e características clínicas. O acesso e o uso do serviço são heterogêneos entre os municípios da região devido a entraves como desconhecimento da proposta, dificuldade de transporte e fragilidades da rede. A implantação do centro é identificada como iniciativa inovadora e importante para expansão e organização da rede, entretanto, a lógica planejada não se verifica na prática. Intervenções voltadas para a articulação entre os serviços da rede e a adequação das diretrizes pactuadas às peculiaridades regionais são necessárias.
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Sangster-Gormley E, Martin-Misener R, Burge F. A case study of nurse practitioner role implementation in primary care: what happens when new roles are introduced? BMC Nurs 2013; 12:1. [PMID: 23343534 PMCID: PMC3562226 DOI: 10.1186/1472-6955-12-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 01/18/2013] [Indexed: 11/20/2022] Open
Abstract
Background At the time of this study (2009) the role of the nurse practitioner was new to the province of British Columbia. The provincial government gave the responsibility for implementing the role to health authorities. Managers of health authorities, many of whom were unfamiliar with the role, were responsible for identifying the need for the NP role, determining how the NP would function, and gaining team members’ acceptance for the new role. Method The purpose of the study was to explain the process of nurse practitioner role implementation as it was occurring and to identify factors that could enhance the implementation process. An explanatory, single case study with embedded units of analysis was used. The technique of explanation building was used in data analysis. Three primary health care settings in one health authority in British Columbia were purposively selected. Data sources included semi-structured interviews with participants (n=16) and key documents. Results The results demonstrate the complexity of implementing a new role in settings unfamiliar with it. The findings suggest that early in the implementation process and after the nurse practitioner was hired, team members needed to clarify intentions for the role and they looked to senior health authority managers for assistance. Acceptance of the nurse practitioner was facilitated by team members’ prior knowledge of either the role or the individual nurse practitioner. Community health care providers needed to be involved in the implementation process and their acceptance developed as they gained knowledge and understanding of the role. Conclusion The findings suggest that the interconnectedness of the concepts of intention, involvement and acceptance influences the implementation process and how the nurse practitioner is able to function in the setting. Without any one of the three concepts not only is implementation difficult, but it is also challenging for the nurse practitioner to fulfill role expectations. Implications for research, policy, practice and education are discussed.
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Affiliation(s)
- Esther Sangster-Gormley
- School of Nursing, University of Victoria, PO Box 1700, STN CSC, Victoria, British Columbia, V8W 2Y2, Canada.
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DeMiglio L, Williams A. Shared care: the barriers encountered by community-based palliative care teams in Ontario, Canada. HEALTH & SOCIAL CARE IN THE COMMUNITY 2012; 20:420-429. [PMID: 22469189 DOI: 10.1111/j.1365-2524.2012.01060.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
To meet the complex needs of patients requiring palliative care and to deliver holistic end-of-life care to patients and their families, an interprofessional team approach is recommended. Expert palliative care teams work to improve the quality of life of patients and families through pain and symptom management, and psychosocial spiritual and bereavement support. By establishing shared care models in the community setting, teams support primary healthcare providers such as family physicians and community nurses who often have little exposure to palliative care in their training. As a result, palliative care teams strive to improve not only the end-of-life experience of patients and families, but also the palliative care capacity of primary healthcare providers. The aim of this qualitative study was to explore the views and experiences of community-based palliative care team members and key-informants about the barriers involved using a shared care model to provide care in the community. A thematic analysis approach was used to analyse interviews with five community-based palliative care teams and six key-informants, which took place between December 2010 and March 2011. Using the 3-I framework, this study explores the impacts of Institution-related barriers (i.e. the healthcare system), Interest-related barriers (i.e. motivations of stakeholders) and Idea-related barriers (i.e. values of stakeholders and information/research), on community-based palliative care teams in Ontario, Canada. On the basis of the perspective of team members and key-informants, it is suggested that palliative care teams experience sociopolitical barriers in an effort to establish shared care in the community setting. It is important to examine the barriers encountered by palliative care teams to address how to better develop and sustain them in the community.
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Affiliation(s)
- Lily DeMiglio
- School of Geography & Earth Sciences, McMaster University, Hamilton, ON, Canada.
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Lineker SC, Husted JA, Brown KS. Influence of discipline of provider and model of care on an arthritis educational intervention in primary care. Arthritis Care Res (Hoboken) 2012; 64:424-33. [DOI: 10.1002/acr.20694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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A scoping literature review of collaboration between primary care and public health. Prim Health Care Res Dev 2012; 13:327-46. [PMID: 22353204 DOI: 10.1017/s1463423611000491] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AIM The purpose of this scoping literature review was to determine what is known about: 1) structures and processes required to build successful collaborations between primary care (PC) and public health (PH); 2) outcomes of such collaborations; and 3) markers of their success. BACKGROUND Collaboration between PC and PH is believed to enable more effective individual and population services than what might be achieved by either alone. METHODS The study followed established methods for a scoping literature review and was guided by a framework that identifies systemic, organizational and interactional determinants for collaboration. The review was restricted to articles published between 1988 and 2008. Published quantitative and qualitative primary studies, evaluation research, systematic and other types of reviews, as well as descriptive accounts without an explicit research design, were included if they addressed either the structures or processes to build collaboration or the outcomes or markers of such collaboration, and were published in English. FINDINGS The combined search strategy yielded 6125 articles of which 114 were included. Systemic-level factors influencing collaboration included: government involvement, policy and fit with local needs; funding and resource factors, power and control issues; and education and training. Lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing were influential at the organizational level. Interpersonal factors included having a shared purpose; philosophy and beliefs; clear roles and positive relationships; and effective communication and decision-making strategies. Reported benefits of collaboration included: improved chronic disease management; communicable disease control; and maternal child health. More research is needed to explore the conditions and contexts in which collaboration between PC and PH makes most sense and potential gains outweigh the associated risks and costs.
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Daw JR, Morgan SG. Stitching the gaps in the Canadian public drug coverage patchwork?: a review of provincial pharmacare policy changes from 2000 to 2010. Health Policy 2011; 104:19-26. [PMID: 21978939 DOI: 10.1016/j.healthpol.2011.08.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 07/19/2011] [Accepted: 08/31/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To describe recent changes and identify emergent trends in public drug benefit policies in Canada from 2000 to 2010. METHODS For each province, we tracked pharmacare design (namely eligibility, premiums, and patient cost-sharing) over time for three beneficiary groups: social assistance recipients, seniors, and the general non-senior population. We assess which plan designs are emerging as a national standard, where the gaps in public coverage remain, and implications for progress towards national pharmacare. RESULTS Expansion of public drug coverage has been limited. For social assistance recipients, first-dollar coverage is the standard. Seniors coverage remains varied, though means testing of eligibility or cost-sharing is common. Seniors benefits were significantly expanded in only one province. As of 2010, six provinces have embraced age irrelevant catastrophic income-based coverage, in some, resulting in the elimination of seniors drug benefits. CONCLUSIONS Universal income-based catastrophic coverage appears to be emerging as an implicit national standard for provincial pharmacare. However, due to the variation and high level of patient cost-sharing required under these programs, convergence on this model does not equate to substantial progress towards expanding coverage or reducing interprovincial disparities. Leverage of federal spending power to promote standards for public drug coverage is necessary to uniformly protect Canadians against high drug costs.
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Affiliation(s)
- Jamie R Daw
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada.
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Abstract
CONTEXT During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. METHODS This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. FINDINGS Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. CONCLUSIONS Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert.
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Gray BH. In This Issue. Milbank Q 2011. [DOI: 10.1111/j.1468-0009.2011.00631.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Sangster-Gormley E, Martin-Misener R, Downe-Wamboldt B, DiCenso A. Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. J Adv Nurs 2011; 67:1178-90. [DOI: 10.1111/j.1365-2648.2010.05571.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
INTRODUCTION The paper highlights key trajectories and outcomes of the recent policy developments toward integrated health care delivery systems in Quebec and Ontario in the primary care sector and in the development of regional networks of health and social services. It particularly explores how policy legacies, interests and cultures may be mitigated to develop and sustain different models of integrated health care that are pertinent to the local contexts. POLICY DEVELOPMENTS In Quebec, three decades of iterative developments in health and social services evolved in 2005 into integrated centres for health and social services at the local levels (CSSSs). Four integrated university-based health care networks provide ultra-specialised services. Family Medicine Groups and network clinics are designed to enhance access and continuity of care. Ontario's Family Health Teams (2004) constitute an innovative public funding for private delivery model that is set up to enhance the capacity of primary care and to facilitate patient-based care. Ontario's Local Health Integration Networks (LHINs) with autonomous boards of provider organisations are intended to coordinate and integrate care. CONCLUSION Integration strategies in Quebec and Ontario yield clinical autonomy and power to physicians while simultaneously making them key partners in change. Contextual factors combined with increased and varied forms of physician remunerations and incentives mitigated some of the challenges from policy legacies, interests and cultures. Virtual partnerships and accountability agreements between providers promise positive but gradual movement toward integrated health service systems.
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Affiliation(s)
- Izzat Jiwani
- Health Policy Researcher and Management Consultant, IMJ Management Inc. Suite 2801-78 Harrison Garden Boulevard, North York, Ontario, M2N 7E2, Canada
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Wranik D, Durier-Copp M. Framework for the design of physician remuneration methods in primary health care. SOCIAL WORK IN PUBLIC HEALTH 2011; 26:231-259. [PMID: 21534123 DOI: 10.1080/19371911003748968] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Economists have generated a large body of theoretical and empirical knowledge with respect to the design of physician remuneration methods (PRM). This knowledge is difficult to use for a policy maker, because of its technical nature and its fragmentation. The article brings together the scattered elements of theory and evidence into a structured framework that adds practical use value to economic theory, useful in the applied practice of policy development, design, implementation, and evaluation. The article argues that the optimal choice of PRM depends on the goals of the health care system, and on external contextual factors. Fee-for-service payments are best when the goals are quantity of care and risk acceptance. Capitation is best when the goals are collaboration between providers and delivery of preventive services and health promotion. Salaries are best when population density is low, and the goal is to recruit physicians to rural and remote areas. Blended payment models are recommended for the achievement of multiple goals. As a demonstration of use value, the framework is applied to the assessment of Canadian PRM.
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Affiliation(s)
- Dominika Wranik
- School of Public Administration, Dalhousie University, Halifax, Nova Scotia, Canada.
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Integrating psychologists into the Canadian health care system: the example of Australia. Canadian Journal of Public Health 2010. [PMID: 19839293 DOI: 10.1007/bf03405525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Canada and Australia share many similarities in terms of demographics and the structure of their health systems; however, there has been a divergence in policy approaches to public funding of psychological care. Recent policy reforms in Australia have substantially increased community access to psychologists for evidence-based treatment for high prevalence disorders. In Canada, access remains limited with the vast majority of consultations occurring in the private sector, which is beyond the reach of many individuals due to cost considerations. With the recent launch of the Mental Health Commission of Canada, it is timely to reflect on the context of the current Canadian and Australian systems of psychological care. We argue that integrating psychologists into the publicly-funded primary care system in Canada would be feasible, beneficial for consumers, and cost-effective.
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Williams AM, Crooks VA, Whitfield K, Kelley ML, Richards JL, DeMiglio L, Dykeman S. Tracking the evolution of hospice palliative care in Canada: a comparative case study analysis of seven provinces. BMC Health Serv Res 2010; 10:147. [PMID: 20515491 PMCID: PMC2898768 DOI: 10.1186/1472-6963-10-147] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 06/01/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An aging population, rise in chronic illnesses, increase in life expectancy and shift towards care being provided at the community level are trends that are collectively creating an urgency to advance hospice palliative care (HPC) planning and provision in Canada. The purpose of this study was to analyze the evolution of HPC in seven provinces in Canada so as to inform such planning and provision elsewhere. We have endeavoured to undertake this research out of awareness that good future planning for health and social care, such as HPC, typically requires us to first look backwards before moving forward. METHODS To identify key policy and practice events in HPC in Canada, as well as describe facilitators of and barriers to progress, a qualitative comparative case study design was used. Specifically, the evolution and development of HCP in 7 strategically selected provinces is compared. After choosing the case study provinces, the grey literature was searched to create a preliminary timeline for each that described the evolution of HPC beginning in 1970. Key informants (n = 42) were then interviewed to verify the content of each provincial timeline and to discuss barriers and facilitators to the development of HPC. Upon completion of the primary data collection, a face-to-face meeting of the research team was then held so as to conduct a comparative study analysis that focused on provincial commonalities and differences. RESULTS Findings point to the fact that HPC continues to remain at the margins of the health care system. The development of HPC has encountered structural inheritances that have both sped up progress as well as slowed it down. These structural inheritances are: (1) foundational health policies (e.g., the Canada Health Act); (2) service structures and planning (e.g., the dominance of urban-focused initiatives); and (3) health system decisions (e.g., regionalization). As a response to these inheritances, circumventions of the established system of care were taken, often out of necessity. Three kinds of circumventions were identified from the data: (1) interventions to shift the system (e.g., the role of advocacy); (2) service innovations (e.g., educational initiatives); and (3) new alternative structures (e.g., the establishment of independent hospice organizations). Overall, the evolution of HPC across the case study provinces has been markedly slow, but steady and continuous. CONCLUSIONS HPC in Canada remains at the margins of the health care system. Its integration into the primary health care system may ensure dedicated and ongoing funding, enhanced access, quality and service responsiveness. Though demographics are expected to influence HPC demand in Canada, our study confirms that concerned citizens, advocacy organizations and local champions will continue to be the agents of change that make the necessary and lasting impacts on HPC in Canada.
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Affiliation(s)
- Allison M Williams
- School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Valorie A Crooks
- Department of Geography, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kyle Whitfield
- Faculty of Extension, University of Alberta, Edmonton, Alberta, Canada
| | - Mary-Lou Kelley
- School of Social Work and Northern Ontario School of Medicine, Lakehead University, Thunder Bay, Canada
| | - Judy-Lynn Richards
- Department of Sociology and Anthropology, University of Prince Edward Island, Charlottetown, Canada
| | - Lily DeMiglio
- School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Dykeman
- School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
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Affiliation(s)
- C Simms
- Dalhousie University, Faculty of Health, School of Health Administration, Halifax, Nova Scotia, Canada.
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Rodríguez C, Pozzebon M. The implementation evaluation of primary care groups of practice: a focus on organizational identity. BMC FAMILY PRACTICE 2010; 11:15. [PMID: 20175911 PMCID: PMC2841653 DOI: 10.1186/1471-2296-11-15] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 02/22/2010] [Indexed: 11/10/2022]
Abstract
Background Since 2002 the Health Ministry of Québec (Canada) has been implementing a primary care organizational innovation called 'family medicine groups'. This is occurring in a political context in which the reorganization of primary care is considered necessary to improve health care system performance. More specifically, the purpose of this reform has been to overcome systemic deficiencies in terms of accessibility and continuity of care. This paper examines the first years of implementation of the family medicine group program, with a focus on the emergence of the organizational identity of one of the pilot groups located in the urban area of Montreal. Methods An in-depth longitudinal case study was conducted over two and a half years. Face to face individual interviews with key informants from the family medicine group under study were conducted over the research period considered. Data was gathered throuhg observations and documentary analysis. The data was analyzed using temporal bracketing and Fairclough's three-dimensional critical discourse analytical techniques. Results Three different phases were identified over the period under study. During the first phase, which corresponded to the official start-up of the family medicine group program, new resources and staff were only available at the end of the period, and no changes occurred in medical practices. Power struggles between physicians and nurses characterized the second phase, resulting in a very difficult integration of advanced nurse practitioners into the group. Indeed, the last phase was portrayed by initial collaborative practices associated with a sensegiving process prompted by a new family medicine group director. Conclusions The creation of a primary care team is a very challenging process that goes beyond the normative policy definitions of who is on the team or what the team has to do. To fulfil expectations of quality improvement through team-based care, health care professionals who are required to work together need shared time/space contexts to communicate; to overcome interprofessional and interpersonal conflicts; and to make sense of and define who they collectively are and what they do as a clinical team.
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Affiliation(s)
- Charo Rodríguez
- Area of Health Services and Policy Research, Department of Family Medicine, McGill University, Montreal, Québec, Canada.
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Touati N, Pineault R, Champagne F, Denis JL, Brousselle A, Contandriopoulos AP, Geneau R. Evaluating Service Organization Models: The Relevance and Methodological Challenges of a Configurational Approach. EVALUATION (LONDON, ENGLAND : 1995) 2009; 15:375-401. [PMID: 27274682 PMCID: PMC4889425 DOI: 10.1177/1356389009341729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Based on the example of the evaluation of service organization models, this article shows how a configurational approach overcomes the limits of traditional methods which for the most part have studied the individual components of various models considered independently of one another. These traditional methods have led to results (observed effects) that are difficult to interpret. The configurational approach, in contrast, is based on the hypothesis that effects are associated with a set of internally coherent model features that form various configurations. These configurations, like their effects, are context-dependent. We explore the theoretical basis of the configuration approach in order to emphasize its relevance, and discuss the methodological challenges inherent in the application of this approach through an in-depth analysis of the scientific literature. We also propose methodological solutions to these challenges. We illustrate from an example how a configurational approach has been used to evaluate primary care models. Finally, we begin a discussion on the implications of this new evaluation approach for the scientific and decision-making communities.
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Affiliation(s)
- Nassera Touati
- École Nationale d'Administration Publique, Groupe de Recherche Interdisciplinaire en Santé (GRIS), Canada
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Reeves S. Collaborating in Canada. J Interprof Care 2009. [DOI: 10.1080/13561820601035129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dobson RT, Taylor JG, Henry CJ, Lachaine J, Zello GA, Keegan DL, Forbes DA. Taking the lead: community pharmacists' perception of their role potential within the primary care team. Res Social Adm Pharm 2009; 5:327-36. [PMID: 19962676 DOI: 10.1016/j.sapharm.2008.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 11/25/2008] [Accepted: 11/26/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patient-focused care provided by an interprofessional team has long been presented as the preferred method of primary care delivery. Community pharmacists should and can provide leadership for many clinical and managerial activities within the primary care team. OBJECTIVE To determine the extent to which community pharmacists are prepared to be members of the health care team, and to assess their support for general expansion of clinical responsibilities. METHODS A mail questionnaire (in either English or French) was sent to 1500 community pharmacists between February and April 2004. Respondents were asked to indicate the necessity of pharmacy leadership for a range of clinical and managerial services associated with a primary care team. Respondents were also asked to indicate the extent to which they should be more involved in drug therapy selection and monitoring, as well as assuming greater responsibility for treating both minor and chronic illnesses. RESULTS The response rate was 35.2% (470/1337) with the highest response rate in the Prairie provinces (40.6%) and the lowest in Quebec (24.4%). Most pharmacists in the study did not advocate a strong leadership role for non-discipline-specific clinical and managerial activities. Most of them indicated that community pharmacists should be more involved in selecting (69.9%) and monitoring (81.0%) drug therapy, and be more responsible for treating minor illnesses (72.0%). Support for more responsibility declined to 50% for chronic illnesses. CONCLUSIONS The findings of the study suggest substantial variability among pharmacists in their perception of the need for pharmacy leadership across 16 clinical and managerial activities.
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Affiliation(s)
- Roy T Dobson
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7 N 5C9, Canada.
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