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Casalino LP, Jung HY, Bodenheimer T, Diaz I, Chen MA, Willard-Grace R, Zhang M, Johnson P, Qian Y, O'Donnell EM, Unruh MA. The Association of Teamlets and Teams with Physician Burnout and Patient Outcomes. J Gen Intern Med 2023; 38:1384-1392. [PMID: 36441365 PMCID: PMC10160282 DOI: 10.1007/s11606-022-07894-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary care "teamlets" in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team. OBJECTIVE To determine the prevalence and performance of teamlets and teams. DESIGN Cross-sectional observational study linking survey responses to Medicare claims. PARTICIPANTS Six hundred eighty-eight general internists and family physicians. INTERVENTIONS Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team). MAIN MEASURES Descriptive: percentage of physicians in teamlet/team categories. OUTCOME MEASURES physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending. KEY RESULTS 77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries. CONCLUSIONS Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.
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Affiliation(s)
- Lawrence P Casalino
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA.
| | - Hye-Young Jung
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | | | - Ivan Diaz
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | | | | | - Manyao Zhang
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | - Phyllis Johnson
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | | | - Eloise M O'Donnell
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
| | - Mark A Unruh
- Department of Population Health Sciences, Weill Cornell Medical College, 402 E. 67th St. Room LA 217, New York, NY, 10065-6304, USA
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Hung DY, Truong QA, Liang SY. Implementing Lean Quality Improvement in Primary Care: Impact on Efficiency in Performing Common Clinical Tasks. J Gen Intern Med 2021; 36:274-279. [PMID: 33236228 PMCID: PMC7878610 DOI: 10.1007/s11606-020-06317-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/13/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many primary care practices have adopted Lean techniques to reduce the amount of time spent completing routine tasks. Few studies have evaluated both immediate and sustained impacts of Lean to improve this aspect of primary care work efficiency. OBJECTIVE To examine 3-year impacts of Lean implementation on the amount of time taken for physicians to complete common clinical tasks. DESIGN Non-randomized stepped wedge with segmented regression and interrupted time series analysis (January 2011-December 2016). PARTICIPANTS A total of 317 physician-led teams in 46 primary care departments in a large ambulatory care delivery system. INTERVENTION Lean redesign was initiated in one pilot site followed by system-wide spread across all primary care departments. Redesigns included standardization of exam room equipment and supplies, streamlining of call management processes, care team co-location, and team management of the electronic inbox. MEASURES Time-stamped EHR tracking of physicians' completion time for 4 common tasks: (1) office visit documentation and closure of patient charts; (2) telephone call resolution; (3) prescription refill renewal; and (4) response to electronic patient messages. RESULTS After Lean implementation, we found decreases in the amount of time to complete: office visit documentation (- 29.2% [95% CI: - 44.2, - 10.1]), telephone resolution (- 22.2% [95% CI: - 38.1, - 2.27]), and renewal of prescription refills (- 2.96% per month [95% CI: - 4.21, - 1.78]). These decreases were sustained over several years. Response time to electronic patient messages did not change significantly. CONCLUSIONS Lean redesigns led to improvements in timely completion of 3 out of 4 common clinical tasks. Our findings support the use of Lean techniques to engage teams in routine aspects of patient care. More research is warranted to understand the mechanisms by which Lean promotes quality improvement and effectiveness of care team workflows.
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Affiliation(s)
- Dorothy Y Hung
- Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, CA, USA.
| | - Quan A Truong
- Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, CA, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, CA, USA
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Calderone J, Lopez A, Schwenk S, Yager J, Shore JH. Telepsychiatry and integrated primary care: setting expectations and creating an effective process for success. Mhealth 2020; 6:29. [PMID: 32632367 PMCID: PMC7327290 DOI: 10.21037/mhealth.2020.02.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/07/2020] [Indexed: 12/26/2022] Open
Abstract
Telepsychiatry, especially in the form of live interactive videoconferencing, has greatly advanced the availability and use of specialist psychiatric consultations in primary care settings. Nevertheless, reliance on telepsychiatry, with corresponding decreases in direct face-to-face interaction between primary care providers and psychiatrists, can create unique challenges such as reducing the availability of non-verbal cues, and preventing the informal interactions that are so necessary for clarifying clinical and process details and for building essential team-based trust and rapport. Written from the perspective of an integrated psychiatrist, this article offers recommendations for a formal process to optimize virtual care coordination by setting clear expectations and providing communication tools for an effective and efficient telepsychiatry enabled integrated service.
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Affiliation(s)
- Jacqueline Calderone
- Department of Family Medicine and Psychiatry, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Amy Lopez
- Department of Family Medicine, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Schwenk
- Department of Family Medicine, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Joel Yager
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jay H. Shore
- Department of Family Medicine and Psychiatry, Helen and Arthur E. Johnson Depression Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Zijl ALV, Vermeeren B, Koster F, Steijn B. Interprofessional teamwork in primary care: the effect of functional heterogeneity on performance and the role of leadership. J Interprof Care 2020; 35:10-20. [PMID: 32053403 DOI: 10.1080/13561820.2020.1715357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study aimed to unravel the complexity of interprofessional teamwork in primary care teams by testing the relationship between functional heterogeneity and team performance through the mediating role of information elaboration, and the moderating roles of directive leadership and participative leadership. The moderated mediation model was validated using survey data from 1105 professionals and 97 supervisors in 143 Dutch primary care teams. The results confirmed the model and showed a significant negative effect of functional heterogeneity on information elaboration, which in turn had a positive effect on team performance. Both directive and participative leadership moderated the negative effect of functional heterogeneity on information elaboration to the extent that the indirect negative effect of functional heterogeneity on team performance became insignificant under high levels of either directive or participative leadership. The theoretical implications of these findings for the literature on healthcare, team diversity, and leadership, as well as the practical implications for policy makers, educationalists and managers of primary care teams, are discussed.
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Affiliation(s)
- Alissa Lysanne van Zijl
- Department of Public Administration and Sociology, Erasmus University Rotterdam , Rotterdam, Netherlands
| | - Brenda Vermeeren
- Department of Public Administration and Sociology, Erasmus University Rotterdam , Rotterdam, Netherlands
| | - Ferry Koster
- Department of Public Administration and Sociology, Erasmus University Rotterdam , Rotterdam, Netherlands
| | - Bram Steijn
- Department of Public Administration and Sociology, Erasmus University Rotterdam , Rotterdam, Netherlands
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Doekhie KD, Strating MMH, Buljac-Samardzic M, van de Bovenkamp HM, Paauwe J. The different perspectives of patients, informal caregivers and professionals on patient involvement in primary care teams. A qualitative study. Health Expect 2018; 21:1171-1182. [PMID: 30221463 PMCID: PMC6250873 DOI: 10.1111/hex.12824] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/18/2018] [Accepted: 07/13/2018] [Indexed: 12/05/2022] Open
Abstract
Background Patient involvement in the decision‐making process, especially for chronically ill elderly patients, has become an important element of patient‐centred primary care in many countries, including the Netherlands. This study openly explores different perspectives of patients, informal caregivers and primary care professionals on patient involvement in primary care team interactions. Methods Sixty‐four qualitative semi‐structured interviews with chronically ill elderly patients, informal caregivers and primary care professionals from various disciplines. Underpinned by a phenomenology approach, this study used conventional content analysis for data analysis. Results Participants have different views of the roles of patients and informal caregivers in the primary care team and thus different expectations of the extent and level of patient involvement. Three challenges impact patient involvement in the team: (a) patients feel misunderstood and less involved that they would like when professionals take control, (b) patients have to balance the conflicting opinions of different professionals and (c) informal caregivers act undesirably as team leaders due to their own view of the level of patient involvement. Discussion and conclusion Patient involvement is formed in complex interactions between patients, informal caregivers and multiple professionals whose perspectives and expectations can be misaligned. Recognizing the value of patients and informal caregivers on the team could help professionals to understand them better and thus limit the likelihood of challenges arising in team interactions.
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Affiliation(s)
- Kirti D Doekhie
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Mathilde M H Strating
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Martina Buljac-Samardzic
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Hester M van de Bovenkamp
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jaap Paauwe
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Rotterdam, The Netherlands.,Department of Applied Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Department of Human Resource Studies, Tilburg University, Tilburg, The Netherlands
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Abstract
OBJECTIVE We assessed fidelity of implementation (FOI) to the intended features of a primary care team redesign that integrated registered nurse care managers and patient health coaches onto existing care teams. The relation of FOI ranking and improvements in intermediate outcomes of diabetes care was examined. DESIGN We assessed FOI by interviewing frontline primary care team members (n = 20). We explored the relation of FOI and outcomes of diabetes care (n = 10 206 patients) over a 3-year period (2010-12). Multilevel, multivariate regression estimated the relation of FOI and improvements in outcomes of diabetes care. SETTING Five primary care practices in greater Los Angeles, CA, USA. PARTICIPANTS Ten thousand, two hundred and six adult patients with diabetes; 20 frontline primary care clinicians and staff. MAIN OUTCOME MEASURES Blood pressure, hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) control among adult diabetic patients. RESULTS All practices improved diabetic patients' LDL-C control over time. In adjusted analyses, the practice with the highest FOI achieved the largest improvement in blood pressure and HbA1c control among diabetic patients. In contrast, the practice with the lowest FOI had the least improvements in blood pressure, HbA1c and LDL-C control. FOI was an inconsistent predictor of intermediate outcomes of diabetes care for other practices. CONCLUSIONS FOI assessment can be useful for identifying low FOI to a redesign so that technical assistance and resources can be provided to improve team functioning and patient outcomes. High FOI can enable greater improvements in patient outcomes in the context of primary care practice redesign.
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Affiliation(s)
- Sherry M Grace
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Drive South, Los Angeles, CA 90095, USA
| | - Jeremy Rich
- HealthCare Partners Institute for Applied Research and Education, 19191 South Vermont Avenue, Suite 200, Torrance, CA 90502, USA
| | - William Chin
- HealthCare Partners Medial Group and Affiliated Physicians, 19191 South Vermont Avenue, Suite 200, Torrance, CA 90502, USA
| | - Hector P Rodriguez
- Division of Health Policy and Management, University of California, Berkeley School of Public Health, 50 University Hall, Room 245, Berkeley, CA 94720, USA
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Rodriguez HP, Giannitrapani KF, Stockdale S, Hamilton AB, Yano EM, Rubenstein LV. Teamlet structure and early experiences of medical home implementation for veterans. J Gen Intern Med 2014; 29 Suppl 2:S623-31. [PMID: 24715392 DOI: 10.1007/s11606-013-2680-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND High functioning interdisciplinary primary care teams are a critical component of the patient-centered medical home. In 2010, the Veterans Administration (VA) implemented a medical home model termed the Patient Aligned Care Teams (PACT), with reorganization of staff into small teams ("teamlets") as a core feature. OBJECTIVE To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets. DESIGN Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012. PARTICIPANTS We interviewed 41 frontline teamlet members (i.e., primary care physicians and staff) from three practices that were part of a PACT demonstration laboratory and examined clinician and staff survey data from 22 practices. MAIN MEASURES Semi-structured interview guide and clinician and staff survey questions covering the following domains: teamlet formation and structure, within-teamlet communication, cross-coverage, role changes, teamlet training, impact on Veterans, and leadership facilitation and support. KEY RESULTS Respondents had limited input into teamlet structure and indicated limited training on the PACT initiative. Guidelines delineating each teamlet member's roles and responsibilities were emphasized as important needs. Chronic understaffing also contributed to implementation challenges and territorial attitudes surfaced when cross-coverage was not clear. In addition, several core features of VA's medical home transformation were not fully implemented by teamlet members. Most also reported limited guidance and feedback from leadership. Despite these challenges, teamlet-based care was perceived to have a positive impact on Veterans' experiences of primary care and also resulted in improved communication among staff. CONCLUSIONS The PACT teamlet model holds much promise for improving primary care at the VA. However, more comprehensive training, improving the stability of teamlets, developing clear cross-coverage policies, and better defined teamlet member responsibilities are important areas in need of attention by VA leadership.
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Krause J, Agarwal S, Bodicoat DH, Ring A, Shepherd D, Rogers S, Wensing M, Baker R. Evaluation of a tailored intervention to improve management of overweight and obesity in primary care: study protocol of a cluster randomised controlled trial. Trials 2014; 15:82. [PMID: 24641767 PMCID: PMC3973828 DOI: 10.1186/1745-6215-15-82] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 02/27/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND In the UK around 22% of men and 24% of women are obese, and there are varying but worrying levels in other European countries. Obesity is a chronic condition that carries an important health risk. National guidelines, for use in England, on the management of people who are overweight or obese have been published by the National Institute for Health and Clinical Excellence (NICE, 2006). NICE recommendations for primary care teams are: determine the degree of overweight and obesity; assess lifestyle, comorbidities and willingness to change; offer multicomponent management of overweight and obesity; referral to external services when appropriate. This study investigates a tailored intervention to improve the implementation of these recommendations by primary care teams. METHODS/DESIGN The study is a cluster randomised controlled trial. Primary care teams will be recruited from the East Midlands of England, and randomised into two study arms: 1) the study group, in which primary care teams are offered a set of tailored interventions to help implement the NICE guidelines for overweight and obesity; or 2) the control group in which primary care teams continue to practice usual care. The primary outcome is the proportion of overweight or obese patients for whom the primary care team adheres to the NICE guidelines. Secondary outcomes include the proportion of patients with a record of lifestyle assessment, referral to external weight loss services, the proportion of obese patients who lose weight during the intervention period, and the mean weight change over the same period. DISCUSSION Although often recommended, the methods of tailoring implementation interventions to account for the determinants of practice are not well developed. This study is part of a programme of studies seeking to develop the methods of tailored implementation. TRIAL REGISTRATION Current Controlled Trials ISRCTN07457585. Registered 09/08/2013. Randomisation commenced 30/08/2013.
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Affiliation(s)
- Jane Krause
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, 22-28 Princess Road West, LE1 6TP Leicester, UK
| | - Shona Agarwal
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, 22-28 Princess Road West, LE1 6TP Leicester, UK
| | - Danielle H Bodicoat
- Diabetes Research Centre, College of Medicine, Biological Sciences and Psychology, Leicester General Hospital, Leicester LE5 4PW, UK
- Leicester Clinical Trials Unit, College of Medicine, Biological Sciences and Psychology, Leicester General Hospital, Leicester LE5 4PW, UK
| | - Arne Ring
- Leicester Clinical Trials Unit, College of Medicine, Biological Sciences and Psychology, Leicester General Hospital, Leicester LE5 4PW, UK
- Department of Mathematical Statistics and Actuarial Sciences,, University of the Free State, P.O. Box 339, Bloemfontein 9300, South Africa
| | - David Shepherd
- Saffron Group Practice, 509 Saffron Lane, Leicester LE2 6UL, UK
| | - Stephen Rogers
- Public Health Department, Guildhall Road, Northampton NN1 5DN, UK
| | - Michel Wensing
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Postbus 9101, 6500 HB Nijmegen, Netherlands
| | - Richard Baker
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, 22-28 Princess Road West, LE1 6TP Leicester, UK
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Ryan D, Barnett R, Cott C, Dalziel W, Gutmanis I, Jewell D, Kelley ML, Liu B, Puxty J. Geriatrics, interprofessional practice, and interorganizational collaboration: a knowledge-to-practice intervention for primary care teams. J Contin Educ Health Prof 2013; 33:180-189. [PMID: 24078366 DOI: 10.1002/chp.21183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Caring for frail seniors requires health professionals with skills and knowledge in 3 core competencies: geriatrics, interprofessional practice, and interorganizational collaboration. Despite a growing population of frail seniors in all developed countries, significant gaps exist in preparation of health professionals in these skills. To help close these gaps, a knowledge-to-practice (KTP) process was undertaken to increase the capacity of newly created family health teams and longer standing Community Health Centers in the Province of Ontario, Canada. METHODS Each team identified a staff member to become its facilitator in the 3 core skill sets. Guided by a KTP framework, a set of training modules were created, compiled into a digital toolkit for transfer into practice, translated in a multimethods workshop, and implemented using a variety of strategies to optimize practice change. RESULTS Staff from 82% of the targeted primary care teams learned to use the toolkit in a train-the-facilitator process that was highly valued, and prompted a range of changes in personal and team practice. A digital toolkit for primary care teams remains an enduring and often used resource. DISCUSSION Closing the knowledge gap in the core competencies for frailty focused care is complex. A KTP framework helped guide a staged multimethod process that produced both individual and team practice change and on online toolkit that has a continuing influence.
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Affiliation(s)
- David Ryan
- Director of Education & Knowledge Processes, Regional Geriatric Program of Toronto, Assistant Professor, Faculty of Medicine University of Toronto.
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