Juanitas Final April 29 2007
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- 1. ANALYSIS AND SYNTHESIS REPORT Primary Health
CareInter-professional CollaborationChronic Disease
ManagementHealth Promotion and Disease Prevention Activities,
Processes and Tools Submitted To:Ontario Ministry of Health and
Long Term CareChair, Family Health Team Quality Management
Collaborative Submitted By:Juanita Barrett Submission Date: April
29, 2007 1
- 2. EXECUTIVE SUMMARYIn the fall of 2006, the Ontario Ministry
of Health and Long Term Care (OMHLTC) identified the need to
provide ongoing leadership and direction to assist with the
development and implementation of a quality management strategy
that would support Family Health Teams (FHTs) in delivering
effective Primary Health Care (PHC) programs. A small Quality
Management Collaborative Steering Committee was initiated, and a
Consultant contracted to complete an analysis and synthesis of PHC
activities in all jurisdictions of Canada, with the exception of
Ontario. The focus of the analysis and synthesis was on activities
that supported Interdisciplinary Collaboration (IDC), Chronic
Disease Management (CDM) and/or Chronic Disease Prevention and
Management (CDPM), and Health Promotion and Disease Prevention
(HPDP) changes.The approach to the analysis and synthesis included
review and analysis of current available reports/ documents
regarding processes/ tools from such sources as Health Canada,
Canadian College Family Physicians (CFPC)Toolkit, and Enhancing
Collaborative Inter-professional Practice (EICP) web-sites. A major
part of the approach was a cross country Environmental Scan (with a
number of follow ups with the jurisdictional representatives for
clarity and/or add information) to identify processes and tools
used to facilitate implementation of PHC changes for CDPM, HPDP,
and IPC in PHC teams within jurisdictions. Although time did not
permit the completion of the scan internationally, some information
was obtained from the EICP and CFPC toolkits regarding some of the
processes and tools utilized to support changes in England and New
Zealand. Key findings, trends, lessons (including facilitators and
barriers) of the processes and tools were collated, and
recommendations were developed to support the work of the Quality
Management Collaborative Steering Committee.SUMMARY AND
CONCLUSIONSJurisdictions across Canada have moved PHC changes
forward with a focus on Inter- Professional Collaboration, Chronic
Disease Management and/ or Health Promotion/ Disease Prevention, or
some combination of 2 or 3 of them. Whatever the provincial
direction, inter- professional teams (with a minimum of at least 2
different professional groups one of which was a family physician)
were utilized and supported to provide services to defined
populations, whether it was a geographic population, a specific
physician population or a special needs population. Partnerships
were developed, and included linkages with provincial Associations
(especially Medical Associations), Departments or Ministries of
Health, Non-Governmental organizations, and private sectors (e.g.
Fee-for-Service physicians, pharmacists).There was leadership for
the changes, including frameworks in some jurisdictions, and some
form of provincial plans (supported through the Departments/
Ministries of Health with provincial offices to support policy
direction and implementation) in place in all jurisdictions. Health
Councils or some form of Provincial Advisory Committees, were
evident in most jurisdictions. Family Physician leaders were
generally seen at the provincial and regional/ PHC team area
levels, and both regional and PHC team level administrative leaders
(e.g. Directors at the regional level and Coordinators and/or
Facilitators at the PHC team level) were evident in a number of
jurisdictions. In all jurisdictions there were identified leaders
who facilitated the various changes that occurred.Numerous
processes and tools were developed and utilized to support changes,
with formalized team development a focus for most areas. The Wagner
Model was predominately used if there was provincial direction for
CDM, with a focus on one disease at least initially, and most of
the provinces that did not move in this direction are now looking
to that model as the potential way to move forward with their
provincial initiatives for CDM. Additional processes and tools
utilized in a few jurisdictions to support access and management of
chronic diseases were Advanced or Improved Access, and Stanford
Self-Management workshops. Most jurisdictions used Train-the-
Trainer methods to enhance uptake of changes and to support both
implementation and sustainability of their strategies.2
- 3. Other facilitators of change and barriers to change were
similar across the country, whether there was a focus on
Inter-Professional Collaboration, CDM or HPDP. Some consistent
facilitators identified included electronic health records of some
sort (or some form of communicating electronically), incentives,
physician participation, inter-professional development, voluntary
participation, development of trust, and time to actually make the
changes. Consistent barriers included lack of electronic health
records, lack of alternate payment models for physicians, lack of
integration across governmental areas within the Departments/
Ministries of Health, fear of loss of focus on primary prevention,
turf protection, silos within health care delivery, the acute care
focus of health, and lack of time for changes to occur.There was a
variety of methods, processes and tools developed to evaluate the
initiatives that have been tested through the period of the PHCTF
funds, and they may provide the opportunity for some further PHC
evaluation and/ or research in the future. Early results of
initiative evaluations, regardless of team size/composition,
population served or model utilized, are showing some positive
shifts in providers working together, some changes in adherence to
appropriate Clinical Practice Guidelines for certain diseases, and
also some enhanced self management by clients.Generally funds for
the changes made were supported by the Health Canada PHCTF.
However, a number of jurisdictions did provide for changes in
funding and payment models for physicians, and incentives to
support their participation as team members. As well some
jurisdictions have provided funds for ongoing changes into the
future, including operational support for community development and
CDM.RECOMMENDATIONSThe synthesized information about
inter-professional collaboration, CDM and HPDP can provide the
MOHLTC and the Quality Management Collaborative Steering Committee
with the processes and tools, based on the evaluation completed
across the country, to provide ongoing leadership and direction to
support FHTs in Ontario.It is therefore recommended that:1.
Inter-professional partnerships, based on the professionals in the
FHTs, and includinglinkages and partnering with relevant
Associations, be identified to develop a provincialplan to support
FHTs in delivering effective programs.2. A provincial plan,
building on the frameworks and/ or plans of other jurisdictions,
bedeveloped to support FHTs in delivering effective programs.3.
This provincial plan should include at a minimum:Specifics of
provincial, regional and FHT leadership, and facilitation;Focus of
changes (i.e. inter-professional collaboration, CDM, HDPM);Some
criteria to identify population served;If there is decision to move
to a CDM model, consideration should be given to whichmodel, and if
the Wagner model is used, which elements will be implemented andhow
they will be supported;Consideration should be given to the pursuit
of Advanced Access approaches, andincorporating them into the
plan;Consideration should be given to the Stanford Self-Management
workshops as astand-alone or incorporated into the CDM model
chosen;Identification of the various processes and tools that will
be required to support theplanned changes (team development, scope
of practice shifts, communitydevelopment, support for any changes
in use of electronics); 3
- 4. Identification of the various electronic technologies that
will be used and supported,with associated change management
plans;Clarification and/or confirmation of any physician funding/
payment models andincentives, with associated processes for
accessing and monitoring;Development of an associated overall
implementation plan, with timelines;Development and implementation
of an evaluation process, with baseline data ifpossible and
processes for regular feedback to the FHT teams; andFinancial plan
and budget for implementation and evaluation of the plan,
withidentified reporting mechanisms.4. The time frames associated
with the plan should be appropriate and allow time, at aminimum,
for such things as:The completion of the plan as
outlined;Relationship building with the various
partners;Participation of FHT representatives in the specific plans
for their FHT;Team development and work on scope of practice at the
FHT levels;Adjusting to am electronic environment if that is the
route taken;Monitoring of evaluation and client data provided;
andCase conferencing and team meetings as required. 4
- 5. Table of ContentsEXECUTIVE SUMMARY1.0.
INTRODUCTION1.1.Report Background Information1.2.Approach to
Analysis and Synthesis2.0. PHC CHANGE: General
Information2.1.Frameworks2.2.Planning Supports3.0. PHC CHANGE:
Inter-Professional Collaboration 3.1. NunavutNo information was
provided or accessible. 3.2. North West Territories3.2.1.Service
Changes and Partnerships 3.2.2.Teams 3.2.3.Physician/ Other
Leadership/ Facilitation Support 3.2.4.Processes and Tools 3.2.4.1.
Processes and Tools 3.2.5.Other Facilitators of Innovations
3.2.6.Outstanding Barriers to Innovations 3.2.7.Evaluation
3.2.8.Funding 3.3. YukonSee Chapter 4. 3.4. British ColumbiaSee
Chapters 4 and 5. 3.5. Alberta3.5.1.Service Changes and
Partnerships 3.5.2.Teams 3.5.3.Physician/ Other Leadership/
Facilitation Support 3.5.4.Processes and Tools 3.5.4.1. Processes
and Tools 3.5.5.Other Facilitators of Innovations 3.5.6.Outstanding
Barriers to Innovations 3.5.7.Evaluation 3.5.8.Funding 3.6.
Saskatchewan3.6.1.Service Changes and Partnerships5
- 6. 3.6.2.Teams 3.6.3.Physician/ Other Leadership/ Facilitation
Support 3.6.4.Processes and Tools 3.6.4.1. Processes and Tools
3.6.5.Other Facilitators of Innovations 3.6.6.Outstanding Barriers
to Innovations 3.6.7.Evaluation
3.6.8.Funding3.7.Manitoba3.7.1.Service Changes and Partnerships
3.7.2.Teams 3.7.3.Physician/ Other Leadership/ Facilitation Support
3.7.4.Processes and Tools 3.7.4.1. Processes and Tools 3.7.5.Other
Facilitators of Innovations 3.7.6.Outstanding Barriers to
Innovations 3.7.7.Evaluation 3.7.8.Funding3.8.Quebec3.8.1.Service
Changes and Partnerships 3.8.2.Teams 3.8.3.Physician/ Other
Leadership/ Facilitation Support 3.8.4.Processes and Tools 3.8.4.1.
Processes and Tools 3.8.5.Other Facilitators of Innovations
3.8.6.Outstanding Barriers to Innovations 3.8.7.Evaluation
3.8.8.Funding3.9.New Brunswick3.9.1.Service Changes and
Partnerships 3.9.2.Teams 3.9.3.Physician/ Other Leadership/
Facilitation Support 3.9.4.Processes and Tools 3.9.4.1. Processes
and Tools 3.9.5.Other Facilitators of Innovations 3.9.6.Outstanding
Barriers to Innovations 3.9.7.Evaluation 3.9.8.Funding3.10. Nova
Scotia3.10.1. Service Changes and Partnerships 3.10.2. Teams
3.10.3. Physician/ Other Leadership/ Facilitation Support 3.10.4.
Processes and Tools 3.10.4.1.Processes and Tools 3.10.5. Other
Facilitators of Innovations 3.10.6. Outstanding Barriers to
Innovations 3.10.7. Evaluation 3.10.8. Funding 6
- 7. 3.11. Prince Edward Island 3.11.1. Service Changes and
Partnerships3.11.2. Teams3.11.3. Physician/ Other Leadership/
Facilitation Support3.11.4. Processes and Tools3.11.4.1.Processes
and Tools3.11.5. Other Facilitators of Innovations3.11.6.
Outstanding Barriers to Innovations3.11.7. Evaluation3.11.8.
Funding 3.12. Newfoundland and Labrador 3.12.1. Service Changes and
Partnerships3.12.2. Teams3.12.3. Physician/ Other Leadership/
Facilitation Support3.12.4. Processes and Tools3.12.4.1.Processes
and Tools3.12.5. Other Facilitators of Innovations3.12.6.
Outstanding Barriers to Innovations3.12.7. Evaluation3.12.8.
Funding4.0. PHC CHANGE: Chronic Disease Management/ Chronic Disease
Prevention andManagement 4.1.Nunavut No information was provided or
accessible. 4.2.North West Territories 4.2.1.Service Changes and
Partnerships4.2.2.Teams4.2.3.Physician/ Other Leadership/
Facilitation Support4.2.4.Processes and Tools4.2.4.1. Processes and
Tools4.2.5.Other Facilitators of Innovations4.2.6.Outstanding
Barriers to Innovations4.2.7.Evaluation4.2.8.Funding 4.3.Yukon
4.3.1.Service Changes and Partnerships4.3.2.Teams4.3.3.Physician/
Other Leadership/ Facilitation Support4.3.4.Processes and
Tools4.3.4.1. Processes and Tools4.3.5.Other Facilitators of
Innovations4.3.6.Outstanding Barriers to
Innovations4.3.7.Evaluation4.3.8.Funding 7
- 8. 4.4. British Columbia 4.4.1.Service Changes and
Partnerships4.4.2.Teams4.4.3.Physician/ Other Leadership/
Facilitation Support4.4.4.Processes and Tools4.4.4.1. Processes and
Tools4.4.5.Other Facilitators of Innovations4.4.6.Outstanding
Barriers to Innovations4.4.7.Evaluation4.4.8.Funding4.5. Alberta
4.5.1.Service Changes and Partnerships4.5.2.Teams4.5.3.Physician/
Other Leadership/ Facilitation Support4.5.4.Processes and
Tools4.5.4.1. Processes and Tools4.5.5.Other Facilitators of
Innovations4.5.6.Outstanding Barriers to
Innovations4.5.7.Evaluation4.5.8.Funding4.6. Saskatchewan
4.6.1.Service Changes and Partnerships4.6.2.Teams4.6.3.Physician/
Other Leadership/ Facilitation Support4.6.4.Processes and
Tools4.6.4.1. Processes and Tools4.6.5.Other Facilitators of
Innovations4.6.6.Outstanding Barriers to
Innovations4.6.7.Evaluation4.6.8.Funding4.7. Manitoba No
information was provided or accessible.4.8. Quebec See Chapter
3.4.9. New Brunswick 4.9.1.Service Changes and
Partnerships4.9.2.Teams4.9.3.Physician/ Other Leadership/
Facilitation Support4.9.4.Processes and Tools4.9.4.1. Processes and
Tools4.9.5.Other Facilitators of Innovations4.9.6.Outstanding
Barriers to Innovations4.9.7.Evaluation4.9.8.Funding8
- 9. 4.10. Nova Scotia 4.10.1. Service Changes and
Partnerships4.10.2. Teams4.10.3. Physician/ Other Leadership/
Facilitation Support4.10.4. Processes and Tools4.10.4.1.Processes
and Tools4.10.5. Other Facilitators of Innovations4.10.6.
Outstanding Barriers to Innovations4.10.7. Evaluation4.10.8.
Funding 4.11. Prince Edward Island 4.11.1. Service Changes and
Partnerships4.11.2. Teams4.11.3. Physician/ Other Leadership/
Facilitation Support4.11.4. Processes and Tools4.11.4.1.Processes
and Tools4.11.5. Other Facilitators of Innovations4.11.6.
Outstanding Barriers to Innovations4.11.7. Evaluation4.11.8.
Funding 4.12. Newfoundland and Labrador 4.12.1. Service Changes and
Partnerships4.12.2. Teams4.12.3. Physician/ Other Leadership/
Facilitation Support4.12.4. Processes and Tools4.12.4.1.Processes
and Tools4.12.5. Other Facilitators of Innovations4.12.6.
Outstanding Barriers to Innovations4.12.7. Evaluation4.12.8.
Funding5.0. PHC Change: Health Promotion/ Disease Prevention
5.1.Nunavut No information provided. 5.2.North West Territories
5.2.1.Service Changes and Partnerships5.2.2.Teams5.2.3.Physician/
Other Leadership/ Facilitation Support5.2.4.Processes and
Tools5.2.4.1. Processes and Tools5.2.5.Other Facilitators of
Innovations5.2.6.Outstanding Barriers to
Innovations5.2.7.Evaluation5.2.8.Funding9
- 10. 5.3. Yukon See Chapter 4.5.4. British Columbia
5.4.1.Service Changes and Partnerships5.4.2.Teams5.4.3.Physician/
Other Leadership/ Facilitation Support5.4.4.Processes and
Tools5.4.4.1. Processes and Tools5.4.5.Other Facilitators of
Innovations5.4.6.Outstanding Barriers to
Innovations5.4.7.Evaluation5.4.8.Funding5.5. Alberta 5.5.1.Service
Changes and Partnerships5.5.2.Teams5.5.3.Physician/ Other
Leadership/ Facilitation Support5.5.4.Processes and Tools5.5.4.1.
Processes and Tools5.5.5.Other Facilitators of
Innovations5.5.6.Outstanding Barriers to
Innovations5.5.7.Evaluation5.5.8.Funding5.6. Saskatchewan
5.6.1.Service Changes and Partnerships5.6.2.Teams5.6.3.Physician/
Other Leadership/ Facilitation Support5.6.4.Processes and
Tools5.6.4.1. Processes and Tools5.6.5.Other Facilitators of
Innovations5.6.6.Outstanding Barriers to
Innovations5.6.7.Evaluation5.6.8.Funding5.7. Manitoba 5.7.1.Service
Changes and Partnerships5.7.2.Teams5.7.3.Physician/ Other
Leadership/ Facilitation Support5.7.4.Processes and Tools5.7.4.1.
Processes and Tools5.7.5.Other Facilitators of
Innovations5.7.6.Outstanding Barriers to
Innovations5.7.7.Evaluation5.7.8.Funding5.8. Quebec No information
was provided or accessible.10
- 11. 5.9.New Brunswick 5.9.1.Service Changes and
Partnerships5.9.2.Teams5.9.3.Physician/ Other Leadership/
Facilitation Support5.9.4.Processes and Tools5.9.4.1. Processes and
Tools5.9.5.Other Facilitators of Innovations5.9.6.Outstanding
Barriers to Innovations5.9.7.Evaluation5.9.8.Funding 5.10. Nova
Scotia 5.10.1. Service Changes and Partnerships5.10.2. Teams5.10.3.
Physician/ Other Leadership/ Facilitation Support5.10.4. Processes
and Tools5.10.4.1.Processes and Tools5.10.5. Other Facilitators of
Innovations5.10.6. Outstanding Barriers to Innovations5.10.7.
Evaluation5.10.8. Funding 5.11. Prince Edward Island 5.11.1.
Service Changes and Partnerships5.11.2. Teams5.11.3. Physician/
Other Leadership/ Facilitation Support5.11.4. Processes and
Tools5.11.4.1.Processes and Tools5.11.5. Other Facilitators of
Innovations5.11.6. Outstanding Barriers to Innovations5.11.7.
Evaluation5.11.8. Funding 5.12. Newfoundland and Labrador 5.12.1.
Service Changes and Partnerships5.12.2. Teams5.12.3. Physician/
Other Leadership/ Facilitation Support5.12.4. Processes and
Tools5.12.4.1.Processes and Tools5.12.5. Other Facilitators of
Innovations5.12.6. Outstanding Barriers to Innovations5.12.7.
Evaluation5.12.8. Funding6.0. DISCUSSION: Activities, Processes and
Tools Overview 6.1.General Information 6.2.Inter-professional
Collaboration 6.2.1.Service Changes, Models and
Partners6.2.2.Teams11
- 12. 6.2.3. Physicians/ Other Leadership/ Facilitation Support
6.2.4. Processes and Tools for Facilitation/ Implementation 6.2.5.
Other Facilitators of Innovation 6.2.6. Outstanding Barriers to
Innovations 6.2.7. Evaluation 6.2.8. Funding Sources6.3.Chronic
Disease Prevention and Management6.3.1. Service Changes, Models and
Partners 6.3.2. Teams 6.3.3. Physicians/ Other Leadership/
Facilitation Support 6.3.4. Processes and Tools for Facilitation/
Implementation 6.3.5. Other Facilitators of Innovation 6.3.6.
Outstanding Barriers to Innovations 6.3.7. Evaluation 6.3.8.
Funding Sources6.4.Health Promotion and Disease Prevention 6.4.1.
Service Changes, Models and Partners 6.4.2. Teams 6.4.3.
Physicians/ Other Leadership/ Facilitation Support 6.4.4. Processes
and Tools for Facilitation/ Implementation 6.4.5. Other
Facilitators of Innovation 6.4.6. Outstanding Barriers to
Innovations 6.4.7. Evaluation 6.4.8. Funding Sources7.0 CONCLUSIONS
and RECOMMENDATIONS:Application of Activities, Processes and Tools
in Ontario Family Health Teams7.1.Conclusions7.2.Recommendations
REFERENCESAPPENDICES:Appendix A Environmental Scan Templates12
- 13. 1.0.INTRODUCTION1.1. Report Background InformationFamily
Health Teams (FHTs) in Ontario vary in size from 2 or 3 to about 20
Family Practice Physicians, and are located in urban, rural, remote
or northern areas in the province. More than half are led by
physicians, some by community boards and some by a mixed governance
structure. The population served varies from 2,000 in rural and
remote areas to 20,000 to 40,000 or so in large urban areas. All
FHTs are interdisciplinary, with at least one health provider
(nurse, nurse practitioner, social worker, dietitian, and/or
pharmacist) and a physician.In the fall of 2006, the Ontario
Ministry of Health and Long Term Care (OMHLTC) identified the need
to provide ongoing leadership and direction to assist with the
development and implementation of a quality management strategy
that would support FHTs in delivering effective programs. A small
Quality Management Collaborative Steering Committee was initiated,
and a Consultant contracted to support some of the initial work to
assist with this leadership.The mandate of the consultant, based on
direction from OMLTC representatives, was to: Provide a written
report with a synthesis and analysis of the information, including
key findings, trends and lessons (facilitators and barriers), of
processes and tools utilized for implementation of CDPM, HPDP, and
Interdisciplinary Collaboration in PHC settings.1.2.Approach to
Analysis and SynthesisThe approach to the analysis and synthesis
included:Development (and approval by OMHLTC representatives) of a
plan and template for datacollection to focus on Chronic Disease
Prevention and Management (CDPM), HealthPromotion and Disease
Prevention (HPDP), & Interdisciplinary Collaboration
processesand tools;Review and analysis of current available
reports/ documents re processes/ tools acrossCanada (except
Ontario) regarding CDPM, HPDP, & IDC approaches from such
sourcesas Health Canada, Canadian College Family Physicians
(CFPC)Toolkit, and EnhancingCollaborative Inter-professional
Practice (EICP) web-site was completed;Using the developed
templates and jurisdictional linkages, an Environmental Scan (with
anumber of follow ups with the jurisdictional representatives for
clarity and/or addedinformation) was done to identify processes and
tools used to facilitate implementation ofPrimary Heath Care (PHC)
changes for CDPM, HPDP, and Interdisciplinary Collaborationin PHC
teams across the country (except for Ontario);Time did not permit
the completion of the scan internationally; however efforts were
madeto obtain information from England without success, and some
information was obtainedfrom the EICP and CFPC toolkits regarding
some of the processes and tools in England;The key findings,
trends, lessons (including facilitators and barriers) of processes
andtools used to facilitate implementation CDPM, HPDP,
Interdisciplinary Collaboration inPHC settings were drafted;Various
drafts of parts of the report was shared with the OMHLTC
representatives toensure that the information being collected,
analyzed and synthesized was meeting theneeds; andA final draft of
the report was submitted prior to final report submission.13
- 14. 2.0.PHC CHANGE: General Information This chapter provides
information regarding identified frameworks and/or models that
promoted and/or supported PHC changes and the various planning
supports for changes including: Health Councils, scope of practice
joint statements, job descriptions, various associations roles/
descriptions for disciplines, performance management, policies and
procedures, population health approach, information and
communication, regulations, and inter-professional education. It
also integrates any information gathered regarding national and
international initiatives.2.1. FrameworksSome of the jurisdictions
developed frameworks or models to provide direction for PHC
changes.Source:EICP/ CFPC ToolkitNorth West Territories Primary
Community Care Framework: This policy document is guiding the
transition to interdisciplinary team approach through an Integrated
Service Delivery Model for the NWT health and Social Services
System. Both a plain language and detailed versions of this model
are accessible on the public website.
http://www.hlthss.gov.nt.ca/Features/Programs_and_Services/isdm/pcc/primary_community_care
.asp.North West Territories Integrated Service Delivery Model for
the North West Territories Health and Social Services System: This
report provides information on the Integrated Services Delivery
Model, which fulfills Action Item 5.2.1 of the HSS System Action
Plan. It describes the vision and philosophy of the Integrated
Services Delivery Model and the three elements of integrated
service: primary community care, agency integration and core
services.
http://www.hlthss.gov.nt.ca/content/Publications/Reports/ISDM/isdmdetailedmarch2004.pdf.
Also a plain language summary at:
http://www.hlthss.gov.nt.ca/content/Publications/Reports/ISDM/isdmsummarymarch2004.pdfNova
Scotia The Advisory Committee on PHC Renewal, with broad
stakeholder consultation across the jurisdiction, created a vision
for primary health care in Nova Scotia that set the stage for
future renewal of Nova Scotias primary health care system. Reaching
the preferred future conveyed by Nova Scotias Vision for Primary
Health Care required a strategic approach. Consequently, the
Advisory Committee on PHC Renewal proposed the following four
strategic approaches for use of Nova Scotias funding allocation
from the Primary Health Care Transition Fund: Shifting the focus of
primary health care from family physicians in solo or group
practiceto collaborative primary health care teams that involve
many different primary health careproviders offering a defined
range of comprehensive services to a defined population; Developing
a cultural shift among primary health care providers that supports
apopulation health approach, collaboration and an enhanced role for
health promotion; Changing the primary health care funding system
so that primary health careprofessionals are remunerated by means
that are not volume-driven; Preparing the primary health care
system for the future implementation of an electronicpatient record
that easily facilitates sharing of information among primary care
providersand between the primary, secondary and tertiary health
care systems. For more information, contact: Nova Scotia Department
of Health or see framework on www.gov.ns.ca.14
- 15. Newfoundland and Labrador Moving Forward Together:
Mobilizing Primary Health Care: A Framework for Primary Health Care
Renewal in Newfoundland and Labrador This is a framework document
that was developed in 2003 for the province to support
implementation of primary health care renewal. It discusses PHC
renewal though a number of measures including an interdisciplinary
PHC model and promotes the following features to support PHC
change: inter-professional teams, enhanced scope of practice,
wellness and health promotion, chronic disease prevention and
management, enhanced access to services, enhanced communication and
information management, and funding and payment models for family
physicians and other providers. For more information, see
http://www.health.gov.nl.ca/health/publications/pdfiles/Moving%20Forward%20Together%20appl
e.p.Source: EICP and CFPCBarriers and Facilitators to Enhancing
Interdisciplinary Collaboration in Primary Healthcare: The
Enhancing Interdisciplinary Collaboration in Primary Healthcare
(EICP) Initiatives. This document provides information regarding
barriers and challenges to be addressed when enhancing
interdisciplinary collaboration in PHC. It is good for validation
of some of processes and use of tools to ensure success and manage
challenges. For more information, see
http://www.eicp-cis.ca/en/resources/pdfs/Barriers-and-Facilitators-to-
Enhancing-Interdisciplinary-Collaboration-in-Primary-Health-Care.pdf.Implementing
Family Medicine Groups: The Challenge in the Reorganization of
Practice and Interprofessional Collaboration: M-D Beaulieu et al,
Physician Sadok Besrour Chair in Family Medicine, Montreal, April
2006. 5 case studies provided examples of challenges in enhancing
collaboration, advise to administrators, and ethical dimensions.
For more information, see
www.medfam.umontreal.ca/chaire_sadok_besrour/chaire/chaire.htm.Joint
Statement on Resolving Ethical Conflicts Between Providers of
Healthcare and Persons Receiving Care: This joint statement was
developed by the Alberta Provincial Health Ethics Network, with
statements from the CHA, CMA, CAN and CHAC, and was approved on
June 8, 1998.2.2.Planning SupportsThroughout the review of
information collected, there were a number of planning supports
identified, including general ones (programs or guidelines for
change), Health Councils, job descriptions, performance management
tools, and policies and procedures. This section also includes
initiatives from various national and/ or international
groups.GeneralSource: EICP/ CFPC ToolkitBritish Columbia The
College of Health Disciplines, University of British Columbia The
college is currently being restructured. Various inter-professional
courses are available including a population health approach,
health care team development, health care ethics, etc. For more
information see
http://www.health-disciplines.ubc.ca/index.phpAlbertaAlberta
Medical Association Practice Management Program This program
provides business related advice to family physicians as they
develop Primary Care Networks (PCNs). It specifically provides
information for developing physician leaders,15
- 16. governance structures, mitigating risk (legal, business,
financial, tax), managing change and letters of intent/business
plans. For more information, see www.albertadoctors.org.Source:
CFPC ToolkitPrimary Health Care in Alberta This planning document
overviews Alberta's approach to PHC through local primary care
initiatives and includes indicators for measuring PHC. For more
information see
http://www.health.gov.ab.ca/public/in_primary.pdfSaskatchewanGuidelines
for the Development of a Regional Health Authority Plan for PHC
Services: The purpose of the guidelines is to help with the
implementation of a regional primary health care (PHC) plan. These
guidelines discuss what PHC is, the planning steps required, action
plan including team formation, and implementation. For more
information see
http://www.health.gov.sk.ca/ph_phs_publications/phs_pub_guidelines_%20for_dev.pdf.Saskatchewan's
Action Plan for Primary Health Care Service This document contains
definitional information, roles and responsibilities for various
stakeholders, and approach and strategies for implementation. For
more information see
http://www.health.gov.sk.ca/ph_phs_publications/phs_action_plan_for_primary_health_care.pdfManitoba
Nor'West Co-op Community Health Centre, Winnipeg, Manitoba: It is a
non-profit accredited health agency located in north Winnipeg
established in 1972 by community members as part of a co-operative
community health centre. This community health centre has developed
several working plans, including an environmental, information
management, and human resources plans. Environmental Plan Final
Copy IM PLAN04-07 Overview - IM Plan and Priorities 05-06
HRPlan2006-2009Source: EICP/ CFPC ToolkitCAPC/CPNP People and
Planning: A Human Resources Toolkit for CAPC/CPNP Projects:
Although this is not a primary health care specific, it provides a
very good overview of management and human resources functions,
including strategic planning, evaluation, hiring, orientation,
training, supervision, etc. For more information see
http://www.phac-aspc.gc.ca/dca-
dea/programs-mes/capc-cpnp_pphr_e.html.United States John Hopkins
Adjusted Clinical Group (ACG) Case-Mix System This is a population
based risk adjustment tool developed in the U.S. The ACG System
creates a common language for healthcare analysis and can be used
to: predict high-risk users for inclusion in care management;
determine government- or employer-budgeted payment to health plans;
fairly allocate resources within programs; set capitation payments
for provider groups; evaluate access to care; assess the efficiency
of provider practices; and improve quality and monitor outcomes. It
is used by the British Columbia government. For more information
see http://www.acg.jhsph.edu/United Kingdom National Institute for
Health and Clinical Excellence (NICE) This is an independent
organization responsible for providing national guidance on the
promotion of good health and the prevention and treatment of ill
health. Many tools available on the site from clinical practice
guidelines to cost impact tools. For more information see
http://www.nice.org.uk/16
- 17. New Zealand Resources for Primary Health Care Organizations
This New Zealand Web page contains information on funding
guidelines, service specifications, performance indicators, data
elements, audit protocols, enrolment rules and guidelines, PHO
projects, etc. For more information see
http://www.moh.govt.nz/phoHealth CouncilsSource:EICP/ CFPC
ToolkitAlbertaHealth Sciences Council The mission of the Health
Sciences Council (HSC) is to champion interdisciplinary health
sciences research, education and community service at the
University of Alberta. All Health Science students at the
University of Alberta are required to take a core interdisciplinary
course. This intensive course provides health science students with
an overview of the theory and application of working in teams.
There is also clinical placements of teams. For more information
see http://www.healthscience.ualberta.ca/Source: Facilitation
GuideSaskatchewan Health Quality Council Collaborative (HQCC) (SK)
Borrowing from the British Columbia model, the HQCC in Saskatchewan
has played a lead role in implementing a collaborative focus on
chronic heart disease, diabetes and access. The HQCC takes a
learn-by- doing approach, supports the use of best evidence and
brings a range of practitioners together to share knowledge and
test improvement of ideas. For more information see
www.hcq.sk.caScope of Practice/ Collaborative PracticeSource: EICP
and CFPC ToolkitCMA/CAN/CPA Joint Position Statement on Scopes of
Practice This statement overviews the principles and criteria for
the determination of scopes of practices. For more information see
http://www.cna-
nurses.ca/CNA/documents/pdf/publications/PS66_Scopes_of_practice_June_2003_e.pdfCMPA/CBPA
The Canadian Medical Protective Agency (CMPA) and the Canadian
Nurses Protective Society (CNPS) have developed a joint statement
on liability protection for nurse practitioners and physicians in
collaborative practice. It discusses liability risks, liability
protection and risk management. For more information see
com_joint_statement-e.pdfJob DescriptionsSource: Facilitation
GuideBritish Columbia Expanded Medical Office Assistant Role: As
part of the diabetes collaborative, the role of medical office
assistants was enhanced to include data recording, planning of
office visits and related details of the visit (blood pressures,
height and weight, foot exams and self management). For more
information see contact Debbie.lewis@northernhealth.ca, Northern
Health. 17
- 18. Source: EICP/ CFPC ToolkitBritish ColumbiaMid-Main
Community Health Centre, Vancouver, BC A job description for
primary care nurse clinicians has been developed. For more
information see MMjob description NPMid-Main Community Health
Centre, Vancouver, BC Several documents are highlighted: a form
that clarifies the job descriptions and relationships within the
community, the transferring of function from one discipline to
another; the pharmacist's prescriptive authority, and Warfarin
monitoring physician authorization form that allows the pharmacists
to manage a patient's therapy. For more information see Clarifying
Job Descriptions and Related Tasks Transfer of Function Pharmacist
Prescriptive Authority Warfarin Authorization FormAlberta Calgary
Health Region, Home Care Program This home care program offers a
range of services from nursing, therapy, rehabilitation to personal
care. The program uses behavioral descriptive interview techniques
to recruit new members to its team. Highlighted is the applicant
screening and behavior descriptive interview package for community
care coordinator positions. For more information see 1_BDI-CCC
RNManitoba Nor'West Co-op Community Health Centre, Winnipeg,
Manitoba Job descriptions for the community development
coordinator, family violence counselor, aboriginal health outreach
worker and the primary care registered nurse are highlighted. For
more information see CDCoordinator Position Family Violence
Counselor Position Aboriginal Health Outreach Primary Care
Registered Nurse.Newfoundland and Labrador Dr. Charles L. LeGrow
Health Care Centre, Port aux Basques; A job description has been
developed for the PHC Coordinator. For more information see PHC
Coordinator. Association Role Descriptions Most professional
associations have developed role descriptions for the disciplines
of that asscocation which can be accessed at the below
web-sites.Source: EICP/ CFPC ToolkitCanadian Association of
Occupational Therapists
http://www.otworks.ca/otworks_page.asp?pageid=824Canadian
Association of Social Workers http://www.casw-acts.ca/Canadian
Association of Speech-Language Pathologists and Audiologists
http://www.caslpa.ca/english/careers/careers.aspCanadian Nurses
Association:
http://www.cnaaiic.ca/CNA/nursing/becoming/default_e.aspx Nurse
Practitioner at http://www.cnpi.ca/faq.asp Advanced Nursing
Practice at
http://www.cnaaiic.ca/CNA/documents/pdf/publications/PS60_Advanced_Nursing_Practice_June
_2002_e.pdf Clinical Nurse Specialist at
http://www.cnaaiic.ca/CNA/documents/pdf/publications/PS65_Clinical_Nurse_Specialist_March_2
003_e.pdf 18
- 19. Canadian Pharmacists Association
http://www.pharmacists.ca/content/about_cpha/about_pharmacy_in_can/how_to_become/index.c
fmCanadian Physiotherapy Association
http://www.physiotherapy.ca/whatis.htmCanadian Psychological
Association
http://www.cpa.ca/cpasite/showPage.asp?id=1023&fr=##1
Psychologists and PHCCollege of Family Physicians of Canada
http://www.cfpc.ca/local/files/Communications/Health%20Policy/FAMILY_MEDICINE_IN_CANAD
A_English.pdfDietitians of Canada
http://www.dietitians.ca/news/downloads/role_of_RD_french.pdf
http://www.dietitians.ca/news/downloads/role_of_RD_in_PHC.pdf
Performance ManagementManitoba Klinic Community Health Centre,
Winnipeg, Manitoba Performance appraisals are completes every two
years at the Centre. It developed its own tool that addresses soft
skills such as teamwork, interpersonal conflict, etc. The
performance appraisal process involves team members listing their
roles/responsibilities with the six top tasks that want to be
evaluated on. The process also includes peer review, self
evaluation and includes salaried physicians. For more information
see Performance Appraisal Process Policies and
ProceduresAlbertaChinook Education Menu Booklet: This booklet
includes resources to guide orientation and training as well as to
assist clinics in accessing available educational resources and
supports. These resources are available to family practice team
members, as well as physicians and existing office staff. For more
information see Education-Menu-Booklet-IIManitobaNor'West Co-op
Community Health Centre, Winnipeg, Manitoba This Centre has a
policy that overviews the functioning of the integrated goal sheets
that are developed for each client. For more information see
P&P Integrated Goal Sheet I.pdf. Population Health
ApproachPublic Health Agency of Canada Population Health is an
approach to health that aims to improve the health of the entire
population and to reduce health disparities among population
groups. The Public Health Agency of Canada has identified
population health as a key concept and approach for policy and
program development aimed at improving the health of Canadians. In
order to reach these objectives, the Agency is looking at and
acting upon the broad range of factors and conditions (determinants
of health) that have a strong influence on our health. This website
provides a good overview of the key elements and concepts that
define a population health approach. For more information see
http://www.phac-aspc.gc.ca/ph-sp/phdd/.19
- 20. Information and CommunicationSource: EICP/ CFPC
ToolkitHealth Canada eHealth Toolkit eHealth is the use of
information and communication technologies to support, educate,
inform and connect health care professionals and the people they
serve. Health Canada's eHealth Solutions Unit works to develop
eHealth tools to support the use of health technology in Canada's
First Nations and Inuit communities to be connected, informed, and
ultimately healthier. Their overall aim is to enable front line
health care providers working in First Nations and Inuit
communities to improve people's health through innovative eHealth
partnerships, technologies, tools and services. Tools are available
in areas such as connectivity, telehealth, health information
systems, information for health providers, privacy protection and
standards. For more information see
http://www.hc-sc.gc.ca/fnih-spni/services/ehealth-esante/index_e.htmlCPA
E-Therapeutics, The Canadian Pharmacists Association This will be a
resource for Canadian physicians, pharmacists, nurse practitioners
and other primary health care professionals to help make the right
therapeutic decision. ETherapeutics+ provides a tool set based on
CPhA's Therapeutic Choices and e- CPS plus references to create a
centralized drug resource for drug therapy information. For more
information see
http://etherapeutics.pharmacists.ca/forms/index.asp?
dsp=template&act=view3&template_id=39&lang=eREGULATION
(Professional Organizations)Source: EICP/ CFPC ToolkitsAccess to
information regarding regulations for some professional
organizations are cited below.Social Work National Scopes of
Practice Statement www.caswacts.caCanadian Pharmacy
AssociationPharmacists
http://www.pharmacists.ca/content/about_cpha/about_pharmacy_in_can/
how_to _become/index.cfmPhysiotherapyCompetency Profile: Essential
Competencies of Physiotherapy Support Workers
http://www.physiotherapy.ca/compprofile.htm 20
- 21. Occupational Therapy Essential Competencies of Practice for
Occupational Therapists in Canada
http://www.cotm.ca/publications.html.
http://www.otworks.ca/otworks_page.asp?pageid=824Occupational
Therapy Practice Guidelines for Occupational Therapists: Consulting
to Third Parties: Assist occupational therapists in recognizing and
managing issues which arise when the occupational therapist agrees
to provide an assessment of a client to a third party.
http://www.cotm.ca/publications.html.Occupational Therapy AAROT
Guidelines for the Assignment/Delegation of Occupational Therapy
Services to Support Personnel
http://www.acot.ca/files/Support_Personnel_Guideline_
June_22.05_ACOT_VERSION_Final_Document.pdf.Psychology Integration
of Psychologists in Family Health Teams IPEM - FHT tool
kit-NOV24th2005.pdf.Canadian Nurses AssociationStandards and Best
Practices for Nurses
http://www.cna-nurses.ca/CNA/practice/standards/default_e.aspx.
Other useful links include: a description of Nurse practitioner see
http://www.cnpi.ca/faq.asp a description of advanced nursing
practice see
http://www.cna-aiic.ca/CNA/documents/pdf/publications/PS60_Advanced_Nursing_Practice_June_2002_e.pdf
a position description of Clinical Nurse Specialist
http://www.cna-aiic.ca/CNA/documents/pdf/publications/PS65_Clinical_Nurse_Specialist_March_2003_e.pdf
a statement about Registered Nurses and where they work at
http://www.cna-aiic.ca/CNA/nursing/becoming/default_e.aspx.Interprofessional
EducationMcMaster University The Nursing and Health Care leadership
courses/Management Distance Education Program provides courses for
nurses that include: Leadership/Management; Conflict Management;
Leading Effective Teams in Health Organizations; Decentralized
Budgeting and Total Quality Management. For more information see
www.fhs.mcmaster.ca/nursing/distance/distance.htmCentre for Health
Sciences Interprofessional Education (USA) The Center for Health
Sciences Interprofessional Education is dedicated to creating an
atmosphere of openness and commitment to interprofessional practice
for the next century. It offers courses on interprofessional
competencies, issues in interdisciplinary health care,
interprofessional collaborative teams, etc. For more information
see http://interprofessional.washington.edu/about.aspCentre for
Interprofessional Practice (UK) The centre is part of the Institute
of Health at the University of East Anglia, Norwich, which is a
joint initiative across the Schools of Health to deliver teaching
and research on interprofessional learning. The Centre has
team-based education packages that have been developed to support
active health/social care teams in enhancing their team working
skills and improving their understanding of the different
professional roles involved in patient/client care. For more
information see http://www.uea.ac.uk/cipp/. 21
- 22. Interdisciplinary Health Care Team Practice This is a
learning module for students (and others) from the District of
Columbia AHEC (Area Health Education Centre). It is a resource
linked to the U.S. Department of Health and Human Services site.
The module contains learning on: Interdisciplinary Team Case
Historical Background Models Of Team Practice The Interdisciplinary
Teamwork System Model Interdisciplinary Team Building Members of
the Health Care Team For more information see
http://dcahec.gwumc.edu/education/session3/.The United Kingdom
Centre for the Advancement of Interprofessional Education (CAIPE)
CAIPE's focus is on ways of enabling professions, in the university
and the workplace, to learn from and about each other, foster
mutual respect, overcome barriers to collaboration and engender
action. It promotes interprofessional learning which actively
involves service users and local communities as essential partners.
For more information see http://www.caipe.org.uk.22
- 23. 3.0.PHC CHANGE:Inter-Professional Collaboration This
chapter provides an overview of PHC inter-professional
collaboration processes and tools in most jurisdictions, with some
exceptions and limitations: Nunavut was unable to provide any
information at this time nor could information regarding their
activities be identified on any of the websites or documents
reviewed; Information for Manitoba is restricted to information
gathered from the EICP/ CFPC toolkits or Facilitation Guide as the
environmental scan was not completed; Information regarding British
Columbia regarding inter-professional collaboration is included in
the chapter on CDPM; There is some information areas missing for
the Saskatchewan and Quebec sections; and Ontario information is
being completed by that jurisdiction.3.1.NunavutNo information was
provided.3.2.North West Territories3.2.1. Service Changes and
PartnershipsServices in the North West Territories are provided
around six core service areas: diagnostic and curative;
rehabilitation services; mental health and addictions services;
promotion and prevention services; protection services and
continuing care services. Services provided reflect the needs of
the client or family living within the team area.The Department and
Authorities work with other government departments such as: RCMP,
Justice, Education Culture and Employment, Housing and Municipal
and Community Affairs to address issues of common concern.
Interagency Committees meet regularly in communities to provide a
forum to address intersectoral issues and concerns.The eight health
and social services authorities (HSSA or Authorities) and the
Department of Health and Social Services (DHSS or the Department)
were involved in the development of the Integrated Service Delivery
Model (ISDM) for the Northwest Territories health and social
services system, which is based upon a Primary Community Care (PCC)
approach. This model is one of horizontal and vertical integration
around the six core service areas as identified earlier. PCC
providers deliver core services to clients at the primary level.The
ISDM includes PCC teams at the primary level, regional support
teams at the regional level, and territorial health and social
services caregivers with a mandate to serve the whole NWT. A
client's first point of contact is usually a member of the PCC
team. Within the primary community care team, care givers work in
many different disciplines: physicians, nurse practitioners,
community health nurses, licensed practical nurses, midwives,
social workers, mental health and addictions counselors, community
wellness workers, community health workers, and community health
representatives. They are supported by regional support teams
(radiology, fluoroscopy, rehabilitation, health promotion
specialists, etc.), and territorial support teams that provide
specialized procedures and services (surgery, intensive care,
psychiatric care; CT scan, chemotherapy, etc.) and coordinate out
of territory transfers.Regional teams either travel to communities
to provide service, or PCC providers arrange client referrals to
regional centres. PCC providers also coordinate referrals to
Territorial services for secondary or tertiary care services. More
complex services not available in the NWT are provided through Out
of Territory referrals.23
- 24. To work effectively on behalf of their clients, PCC
providers collaborate with providers across the horizontal levels,
or up to the vertical levels of the HSSA system. They work with
other health and social services providers, and agencies and other
sectors (Justice; Municipal and Community Affairs; and Education
Culture and Employment, etc.). The make up of the team is
reflective of the needs of the client.Progress toward
implementation of the ISDM varies from region to region. Primary
Health Care Transition Fund (PHCTF) projects have helped to create
some momentum, and the lessons learned will benefit others as the
NWTs move toward full implementation of ISDM.The following is a
summary of Primary Health Care and PCC Teams within the PHCTF
funded projects:YHSSA, Great Slave Community Health Clinic (GSLHC):
The PCC team includes physicians, nurse practitioner, public health
nurse, licensed practical nurse, client advocate, mental health
worker, and support staff. The Authority will soon add a midwife.
The GSCHC partners with the Tree of Peace (a non-governmental
organization) for addiction counseling and support services. The
YHSSA GSCHC, TCSA, Integrated Wellness Centre, and FSHSSA,
Introducing Midwifery Services project, and BDHSSA Beaufort Delta
Wellness Teams are all co-located.TCSA, Integrated Wellness Centre:
The PCC team includes mental health counsellors, addictions
counsellors, social workers, and a public health nurse. They work
closely with the teachers in the two local schools, and the nurse
practitioner and community health nurses in the Marie Adele Bishop
Health Centre in Behchoko (formerly Fort Rae).FSHSSA, Introducing
Midwifery Services project: The midwives work with the nurse
practitioner, physicians, general duty nurses, and public health
nurses to provide prenatal and postnatal care for women in the
community. They also are linked to the Obstetricians and the
Coordinator of the STHA Northern Womens Health Program.STHA,
Northern Womens Health Program: The team includes the nurse
coordinator, physicians, an Obstetrician and a midwife who provide
prenatal services for women, and support PCC providers throughout
the NWT involved in the provisions of prenatal care services for
women. Stanton Territorial Health Authority (STHA) Northern Womens
Health Program provides coordination and support to PCC providers
through a 1-800 call line and bi-monthly tele-health
sessions.3.2.2. Teams and ServicesAll community care providers are
part of the quot;teamquot;, with the client and family as part of
the team and the central focus. Primary Community Care (PCC) teams
work with other agencies and groups to address problems and create
healthy communities.The number of clients served is unknown.
Populations served are those within the mandate of the regional
health and social services authority boundaries. Authorities use
information from a variety of sources to identify the health and
social services needs of residents (health assessments, health
status reports, etc).Within the NWT, inter-professional teams are
located in 29 of 33 communities, consisting of 2 to 3 disciplines
working together. The teams also include paraprofessionals such as
community health representatives, community health workers and
community wellness workers.In the NWT, PCC providers are deployed
in teams located in the 31 communities across the Territory. The
teams range in size and number according to the size of the
community. The following teams have emerged through the NWT PHCTF
initiative:24
- 25. BDHSSA, Beafort Delta Wellness Teams includes three teams
working with clients around 3 specific issues (rural); YHSSA,
Yellowknife Community Health Clinic have assembled one
interdisciplinary team of providers; however, at times, smaller
teams within the larger team work together to case manage for
complex clients (urban); TCSA, Integrated Wellness Centre project
has one team; however, at times, smaller teams within the larger
team work together to case manage for complex clients (rural);
FSHSSA, Introducing Midwifery Services project: the midwives work
with other members of the PCC team and STHA Northern Womens Health
Program to provide reproductive health services for women
(rural).3.2.3. Physician/ Other Leadership/ Facilitation SupportThe
NWT is early into the implementation of the ISDM, which is led by
the Joint Senior Management Committee (Authority Chief Executive
Officers, DHSS Directors, Assistant Deputy Ministers (2), and
Deputy Minister).The Department was able to make some progress
through the PHCTF initiative to develop a plan to support PCC
providers with the transition toward ISDM. It has been unsuccessful
in efforts to find specific funding for facilitation. The
authorities continue in their efforts to move forward with
leadership and support to staff.Some authorities are establishing
positions to lead implementation of ISDM and/or ISDM Implementation
Committees to sort out the issues related to roles and
responsibilities and scopes of practice. Of the eight authorities,
there are four that have identified staff to lead implementation of
ISDM.3.2.4.Processes and Tools for Facilitation/
ImplementationMultidisciplinary, inter-professional conferences (4
territorial and 1 regional) were held, with change management
workshops at the regional level, and teams of professionals have
been used to design and implement the new service delivery model.
Resources and research has been shared with authorities that have
ISDM leads.Project communications involved both formal and informal
sharing networks to provide information and get feedback. Project
coordinators recognized that change takes time, and that staff are
more likely to support and maintain a change if they have input
into the decision making and feel their opinions are listened to,
valued, and respected. Some specific examples include: YHSSA had
facilitated team building sessions for all staff, and a separate
session for thetransition team tasked with establishing the Great
Slave Community Health Clinic. Theyalso held a symposium for staff
and stakeholders to get input. They will continue to orientnew
staff to the NWT ISDM, emphasizing the PCC approach, and provide
ongoingtraining at the clinic. BDHSSA held team building ISDM
workshops in all communities in the region; andprovided managers
with training on ISDM and interdisciplinary practice. In the
FSHSSA, the midwives gave presentations to staff on their roles
andresponsibilities and scope of practice; and provided second
attendant training to preparenurses to participate in deliveries.
The Authority established an interdisciplinary maternitycare
working group which has transitioned to a Maternity Care Committee.
They haverecently established an ISDM Committee to clarify the
roles, responsibilities, andrelationships of PCC Team Members in
the provision of integrated services. The TCSA, Integrated Wellness
Project identified their biggest challenges as lack of
trust.Clients needed reassurance that the personal issues they
discussed during counselingsessions at the Integrated Wellness
Centre would not be disclosed in the community. 25
- 26. Significant strides have been made in building trust with
clients, as evidenced by the increasing number of clients accessing
the services. Likewise, the staff at the Integrated Wellness Centre
needed to build trusting relationships with other service
providers. A strength of this project was the ongoing and frequent
communication between service providers, with communication working
together with persistence and commitment to build interdisciplinary
teamwork.Challenges stemmed from staff and service providers
difficulties with adjusting to change, limitations on human
resources, the need for clear and effective communication, and
finally, shifting paradigms from an illness-centered approach to a
wellness-centered one.Some authorities have provided training for
employees on change management, conflict resolution, and verbal
judo. Committees have been tasked with addressing scope of practice
issues (e.g. Nurse Practitioner Implementation Committee, Midwifery
Implementation Committee).Information has been shared regarding the
web-based learning provided through the Atlantic team training
modules (Building a Better Tomorrow modules). A workshop on the
Facilitation Guide was facilitated in Yellowknife, with a few of
the authorities sending participants. The Guide will be distributed
to HSSA authorities when the DHSS receives copies.STHAs project
coordinator encountered resistance from physicians who felt they
were the only providers that can look after prenatal patients. This
was overcome by working closely with the physicians and allowing
them to observe the care that women were receiving.3.2.4.1.
Processes and ToolsThe characteristics, philosophy, principles, and
approach are described in the NWT's Integrated Service Delivery
Model (ISPM).Tools used to ID population served include: Authority
designed Client Needs Surveys NWT Client Satisfaction Survey DHSS
The NWT Health Status Report 2005 Epi North Newsletters DHSS
special reports on Cancer, Injuries, Addictions Strategic
Directions reports addressing specific issues such as Sexually
Transmitted Infections, and Respite Care. NWT Bureau of Statistics
demographic reports.For more information see
http://www.hlthss.gov.nt.ca/Features/Programs_and_Services/isdm/default.aspSee
the Nova Scotia section regarding BBTI modules.See the NL section
re Facilitation Guide.3.2.5. Other FacilitatorsTo further support
changes, the strategic plan and action plan are based on ISDM (key
components are collaboration and integration), and physician
contracts reflect expectations for collaboration. Electronic
Medical Records (EMR) pilots are interdisciplinary (for Family
Physicians and Nurse Practitioners). In addition, internet services
are available in all communities.YHSSA reported that with
co-location, providers are able to access each other and consult on
client cases in a more personal and often more timely basis.
Co-location has also resulted in an26
- 27. increased understanding, appreciation, and respect for
professional scopes of practice which promotes collaborative
practice and has given occasion to discuss common concerns with
respect to shared care, e.g. confidentiality and liability
issues.3.2.6. Outstanding Barriers to InnovationsRecruitment and
retention of professionals are outstanding barriers. Job ads,
information regarding bursaries, orientation materials and support
programs for competency development are on the website to help
manage this challenge.3.2.7. EvaluationInformation regarding
evaluation is not available at this time.3.2.8. Funding SourcesHSSA
has used internal operational funding (present staff within the
Authority). Most physicians are remunerated by salary (not fee for
service) through a negotiated contract. All other providers are
Government of NWT employees.3.3.YukonSee Chapter 4.3.4.British
ColumbiaSee Chapters 4 and 5.3.5.Alberta3.5.1. Service Changes and
PartnershipsBy dispersing money to third party organizations to
develop and implement innovative primary health care initiatives,
projects funded through the PHCTF were diverse in scope. Most
initiatives were involved to some extent in the development of
teams of health care providers working collaboratively.There were 9
Capacity Building Fund initiatives funded that encompassed either
regional service changes or changes within individual clinics.The
key vehicle driving primary health care renewal in Alberta is the
Primary Care Initiative (PCI), which was negotiated as part of the
Tri-lateral Master Agreement between the Alberta Medical
Association, the Regional Health Authorities (RHAs) and Alberta
Health and Wellness as equal partners in the agreement. The primary
mechanism for implementing the PCI is the Primary Care Network
(PCN). PCN's are formal (contractual) arrangements between
physicians and RHAs, and are created for the purpose of providing
comprehensive primary care services to a defined population of
patients. PCNs serve the general population, but implement other
programs and services that are needed by their patient
populations.Agencies involved in inter-professional collaboration
(IPC) for change were Capital Health, Calgary Health Region,
Chinook Regional Health Authority, Palliser Health Authority, David
Thompson Regional Health Authority, East Central Health, Aspen
Regional Health Authority, Peace County Health, Northern Lights
Health Region, the Associate Clinic of Pincher Creek, and various
Primary Care Networks.27
- 28. Projects funded through the PHCTF were diverse in scope.
Some projects (e.g. Health First Strathcona, an after-hours primary
care clinic) were based on needs assessments for the general
population in a specific geographical area.3.5.2. TeamsOne of the
goals that Albertas Primary Care Networks work to achieve is to
foster a team approach to providing primary health care.Teams
include participants from many different health disciplines. Roles
and functions are divided according to the skills and scope of
practice associated with each discipline or profession.PCNs serve
diverse population groups in rural and urban areas across the
province. The team comprises of between 80 and 90 staff members,
including physicians, registered nurses, occupation therapists,
public health nurses, lab technicians and mental health workers.
The size and scope of teams in PCNs vary depending on patient needs
and programs currently being implemented. Individual initiatives
identified team numbers and composition.Some specific initiatives
include:Interdisciplinary Primary Health Care Team Initiative: The
team serves the general population. An average of 858 patients
visits the Centre each month.Health First Strathcona: The Centre is
staffed by rotating physicians who work 1 or 2 shifts per month, a
registered nurse, a licensed practical nurse, a respiratory
therapist and an orthopaedic technician.Pincher Creek Rural Primary
Care Initiative: The team is comprised of a registered nurse,
registered dietician, clinical pharmacist, registered social worker
and the patients physician. The extended surgical team is comprised
of two visiting surgeons from Calgary, one local surgeon, three
local physicians providing anesthesiology services, family
physicians and operating room staff.Taber: There is a regional
population of 160,000. Examples of client groups served include: 4%
of population are participating in the Diabetes program, referrals
are accepted from the Home Care program and physician offices, and
350 clients per year are supported by the Palliative Care program.
Family Practice Teams (FPTs) focus around the patient roster of
each physician. Program service teams (Geriatrics and Palliative
Care) teams focus on assisting Family Practices and Home Care
nursing with complex cases. FPTs in the clinic revolve around pods
of 4 Family Physicians each. They include 4 medical office
assistants (for rooming pts, ordering labs, etc), 2 Licensed
Practical Nurses (managing disease prevention screening and chronic
disease surveillance), 1 Registered Nurse (managing complex disease
surveillance), and 1 Nurse Practitioner (managing Family Physician
patients when each physician is on holidays).3.5.3. Physician/
Other Leadership/ Facilitation SupportPrimary Care
Interdisciplinary Initiative: The initiative is governed by a
Steering Committee that comprises of all organizations and agencies
involved in the project. An Interdisciplinary Working Group,
including representation from the different professionals that are
part of the interdisciplinary team, is involved in the planning
process and provides leadership for the development of
interdisciplinary teams.Health First Strathcona: A Strategic
Steering Committee comprised of Capital Health staff meet to
discuss new practices, protocols and roles. Participating
physicians and other clinical staff often meet with the Committee
for these discussions. 28
- 29. Pincher Creek Rural Primary Care Initiative: This
initiative is led by a group of eight physicians at the Associated
Medical Clinic in Pincher Creek. One physician is lead liaison with
the project staff.Taber: Physician leaders are involved in a
Governance Committee, and a Local Improvement Committee (LIC). A
Clinical Care Coordinator (Masters of Nursing) was hired for the
clinic.3.5.4. Processes and ToolsDifferent strategies were used in
each project to facilitate the implementation of teams. Some
projects, such as the Primary Care Interdisciplinary Initiative at
Okotoks, developed an orientation manual for staff, held an
orientation session and carried out monthly sharing sessions. The
Capacity Building Fund has demonstrated that co-location, when
possible, is an important strategy to help build effective health
care teams.Two general categories of tools were developed for the
implementation of health care teams. First, tools were developed
for providers, such as orientation manuals and clinical guides. As
well, one project developed an interdisciplinary training manual
for health care providers involved in Albertas Primary Care
Networks. Second, tools were developed to assist patients during
the implementation and use of health teams, such as personal
logbooks for patients to identify which providers are involved in
their care and health trackers to manage healthy living.The
Interdisciplinary Training program developed a training manual for
the development of teams in PCNs. As well, the Office Improvement
Project is assisting PCNs to establish teams to implement a more
integrated approach to the delivery of primary care services in
physicians offices and to determine what team members are
appropriate for physicians patient populations.A Practice Needs
Assessment is available for clinics who are interested in projects
for Advanced Access. 3.5.4.1. Processes and ToolsTaber: A community
needs assessment was completed to identify the population needs.The
Local Improvement Committee includes participation from clinic and
reception staff, as well as physicians.Championship Teams, a
process presented by the Institute of Healthcare Improvement, were
formed. Championship Teams modules were completed, and provided
support for the Advanced Access initiatives in the area.The Family
Practice teams have been developed using Work Flow Mapping process,
facilitated by a department at the Alberta Medical Association
called Toward Optimized Practice (TOP). A Program Budget and
Marginal Analysis (PBMA), which is a priority setting framework
developed by economists at the University of Calgary (Cam Donaldson
and Craig Mitton), was used to prioritize needs and programs.For
more information regarding any of the above see
http://www.health.gov.ab.ca/key/phc.html.Source: Facilitation
ManualEngaging PCN Teams in Change: A workshop, held in June 2006,
supported by Alberta Health and Wellness, for leaders from health
regions and Primary Care Networks, with significant participation
from primary care physicians, gave a boost to team development.
On-going support to PCN teams is offered through the Alberta
Medical Association program Towards Optimized29
- 30. Practice. For further information, contact:
doug.stich@topalbertadoctors.org Toward Optimized Practice.Team
Development in Primary Care Networks: Supported by Alberta Health
and Wellness, Capital Health and Calgary Health Regions hosted a
project to develop a manual which supports interdisciplinary
teamwork in Primary Care Networks across Alberta. It includes
learning activities and resources on system context, using
evidence, building teams, collaboration and scope of practice and
sustaining team facilitators. For further information contact:
Kelly.Holmes@gov.ab.ca, Alberta Health and Wellness.Source: EICPA
Joint Statement on Resolving Ethical Conflicts Between Providers of
Healthcare and Persons Receiving Care, was developed by the Alberta
Provincial Health Ethics Network, statement from the CHA, CMA, CAN
and CHAC, June 8, 1998. For further information see
http://www.phen.ab.ca/pcons/jsrc.html.Chinook Primary Care Network
Communications Plan: The Chinook Health Region in southwestern
Alberta has prepared a comprehensive communications plan to get its
messages about primary health care out to multiple stakeholder
groups. For further information see CPCN comm plan 2006.Chinook
Primary Care Network Evaluation Workplan:The Chinook Health Region
in southwestern Alberta has prepared a service evaluation plan to
assess effectiveness in five key PHC areas. For further information
see CPCN Evaluation Workplan.3.5.5. Other Facilitators of
InnovationsHealth First Strathcona has implemented e-triage that is
used by all Emergency Departments in the region to ensure more
accurate reporting.Pincher Creek Rural Health Care Initiative has
integrated the clinics electronic medical record. The medical
record includes electronic access to radiology reports and
electronic lab results. Also, the initiative has created a registry
to track chronic disease patients and electronic reminders for
physicians about patients in the medical record.Taber: Data support
for decision making was obtained from the local clinic Electronic
Medical Record, regional Medi-Tech, and provincial AHW data.3.5.6.
Outstanding Barriers to InnovationsLearnings from Capacity Building
Fund (CBF) projects show that developing a multidisciplinary team
is a slow process. Furthermore, delays in facility construction and
limited office space often provided barriers to co-location. In
developing multi-disciplinary teams, it is important that all team
members have a common understanding of who the members of their
team are, particularly for those who are members of more than one
team. Learnings from Capacity Building Fund initiatives suggest
that the more intense the interaction between team members on a
daily basis the quicker they will feel as part of a team. Most
importantly, teams take time to develop. Potential strategies to
build a team include co-location, unstructured opportunities to
relationship build (coffee breaks, etc), mutual dependency in
providing effective patient care, and a stable team
membership.Taber: Regional programs sometimes feel their turf is
infringed upon, and their professional roles are being usurped,
leading to suspicion and obstruction at management levels. The
silos and acute care focus remains a major issue to manage. 30
- 31. 3.5.7. EvaluationA Team Functioning survey was developed by
external evaluators to assess team processes in Capacity Building
Fund initiatives, including communication, orientation, leadership,
feedback and coordination. The evaluation determined that
facilitators to team satisfaction are good communication,
co-location, knowledge and respect for others abilities, shared
vision and values, strong leadership and mutual trust. On the other
hand, barriers to team satisfaction included lack of structured and
unstructured opportunities to work together, lack of role clarity,
forced team participation, and lack of stability in team
membership.3.5.8. Funding sourcesThe Capacity Building Fund
provided support for the development of multidisciplinary teams in
the various initiatives. Regional Health Authorities fund the
operation of teams and most often pay providers salaries. As well,
other sources of funding have been used, such as the Medical
Services Delivery Fund that provides funding for alternate payment
plans for physicians.Physicians involved in these teams are largely
paid by fee for service billing for the health services they
provide. In Health First Strathcona, the physicians are on an
alternate payment plan rather than fee for service. In other
projects, including the Chronic Disease Prevention and Management
Network, PHC Chronic Disease Management, the Shared Mental Health
Care Network, physicians receive payment through an alternate
payment plan in addition to fee for service to cover other services
for the initiative, such as planning or tool development. Other
team members, such as nurses, are paid a salary by the
initiatives.Health Link Alberta, Capacity Building Fund initiatives
and other provincial coordination activities were funded through
the PHCTF, Health Canada.PCNs are funded through the Primary Care
Initiative Agreement.The Physician Office Support Program (POSP)
was part of the last negotiation between government and the Alberta
Medical Association, providing funding for hardware and software in
physician offices. It was responsible for the 65%+ computerization
of physician offices in the province.3.6.Saskatchewan3.6.1. Service
Changes and PartnershipsSaskatchewans Action Plan for Primary
Health Care (PHC) is an integrated system of health services
available on a 24-hour, 7-day-a-week basis through Regional Health
Authority (RHA) managed networks and teams of health care
providers. The goal of the plan is to have networks and teams
established in all regions with accessibility to 100% of the
population by the end of 10 years. It is based on a collaborative,
interdisciplinary team approach to service planning and
delivery.Each Regional Health Authority (RHA) is mandated to
develop a network of care provider teams to deliver primary health
care services, and to provide case management to coordinate
services. Primary health care networks throughout the province will
offer a full range of core primary health care services.A network
within a Health Region consists of all the teams that interact with
each other. This may include program teams, central teams,
satellite and visiting teams. RHAs will generally be a network as
specialized program teams may service the whole region.31
- 32. The team extends to include representatives from the
community and other human service sectors such as Education, Social
Services, Justice and Municipal Government, as well as the
public.3.6.2. TeamsClients who live within the PHC team area, or
within a physician practice, are provided service by the
team.Primary health care networks and team structures vary
depending on the geographic or social needs of the population.
Teams vary in size and complement depending upon the assessed needs
of the community and availability of resources.Program TeamsProgram
teams form part of the network. There may be one or several of each
program team in a Health Region depending on the population served.
Some examples of these teams may be mental health, specialized
programs, public health (population based i.e. Medical Health
Officer, nutritionist, etc.), emergency response teams, and chronic
disease management teams (e.g. diabetic management team). These
teams would link to all teams in the network.Teams would exist in
institutions as well. Much of what happens in a hospital or
Emergency Room is considered primary health care. The management of
many medical conditions involves some time in hospital. The
hospital and emergency room teams must be linked to the community
teams. Further, most of the health care needs that are being met in
special care homes are primary health care services. Teams that
provide service in special care homes should function on primary
health care principles.Central TeamA central team is envisioned to
have at a minimum a group of 3 - 4 physicians and a primary care
nurse practitioner serving a population of approximately 5,000
including satellite and visiting locations. In urban areas
physician groups may be larger, with 5 - 10 physicians and with 1
or 2 primary care nurse practitioners, and therefore serve a larger
population. Although co-location may be desirable for all team
members in most cases, this may not be immediately attainable. At a
minimum, the nurse practitioner should be co-located with the
physician group.An urban centre may have many central teams serving
different communities within the urban boundaries.A central team
may provide visiting services to satellite and visiting locations
and provide needed support to smaller teams.An urban centre may
have several central locations and team members may be by way of a
virtual team. The key idea is the core team members know each other
well and can share the responsibilities of clinical management,
proactive care, or health promotion and injury prevention.Satellite
TeamsThe satellite team will be connected to a central team and
receive visiting services from the central team. A satellite
location is envisioned as a community where resident staff or
visiting staff offers health promotion and prevention services,
clinical services and access to emergency services. A range of
basic services is delivered to meet the health needs of the
individual, family 32
- 33. and community closer to home.A satellite location will at a
minimum have the following services on site: a primary care nurse
practitioner; and a primary care physician (visiting).The following
services would be offered by visiting staff:laboratory (specimen
collection abilities) visiting or part time services;public
health;home care;therapies; and/ oremergency services based on
geographic needs.The client/ patient would generally need to travel
for other services.3.6.3. Physician/ Other Leadership/ Facilitation
SupportThere are Directors of PHC in all of the regions, and
Facilitators in place to support changes in the PHC team
areas.3.6.4. Processes and ToolsThere were formalized processes and
tools developed to support PHC changes in the team areas including:
Focus groups were held to determine potential facilitators and
barriers to team development; Train the trainer sessions for formal
Facilitators were held in the team areas; Team workshops were
delivered by the Facilitators to team members in their areas;
Guidelines were provided for the development of RHA plans;
andProvincial PHC Services Branch was established with the
following objectives:o to support and facilitate the process of
implementing Saskatchewans Action Plan for Primary Health Care;o to
develop the policy framework for Regional Health Authorities (RHAs)
to plan and organize their primary health care service delivery
within regions; ando to develop a strategy to control diabetes
across the province.In 2005 the University of Saskatchewan was
successful in a submission to Health Canada for a 3-year $1.196 M
project entitled, quot;Patient-Centred Inter-professional Team
Experiencesquot;. For more information see (P-CITE).
http://www.pcite.ca/The overall goal of the P-CITE Program is to
improve the health of communities, families and individuals across
the province through engagement of communities and academic
institutions in implementing and evaluating inter-professional
teams for patient-centred health care.The objectives are to:
develop innovative inter-professional patient-centred education
programs and settings and evaluate their benefits; stimulate spread
of best approaches to inter-professional patient-centred education;
and increase health professionals exposure to inter-professional
patient-centred education. 33
- 34. 3.6.4.1. Processes and ToolsSource: Facilitation GuideTeam
Facilitator Training: This training has been developed to support
the development of team facilitators in Saskatchewan. For more
information see www.health.gov.sk.ca/ph_br_phs.html.Facilitator
Network: This provincial forum supports the work of provincial team
facilitators through quarterly meetings guided by a
systems-thinking approach. It offers support with orientation of
new facilitators, continuing education, information and resource
sharing, regional and provincial updates, and updates on
facilitation work/initiatives in other areas of the country. For
more information, contact Primary Health Services Branch,
Saskatchewan Health or gary.n@pnrh.ca, Saskatchewan
Health.Comprehensive Community Information System (CCIS): CCIS is
an innovative vehicle for sharing resources, information, tools and
knowledge, for sparking curiosity, identifying key wellness issues
and determining priorities. It also promotes evidence-based
research, programming, policy development and evaluation. CCIS is
also a community-based tool that fosters empowerment through the
sharing of information and through a collaborative, holistic and
humanistic approach to the ongoing process of community wellness.
For more information, visit http://ccis.cronustech.com.Source:
EICP/ CFPC Tool-kitsPilot Project in PHC Team Development:
Saskatchewan Health, through a partnership with Med-Emerg
International and the Centre for Strategic Management (CSM),
developed a pilot project on interdisciplinary primary health care
teams. It contains team effectiveness tools, team charter
templates, and team facilitator workshops. As a result of team
development project there were also funded team facilitators in
each of RHAs. The team focus developed in Saskatchewan was based on
systems thinking. CSM uses a five step approach quot;ABCDEquot;
model to lead organizations through change and team development.
For more information see
http://www.health.gov.sk.ca/ps_phs_teamdev.pdf.Team Charters: A
team charter (team mandate or terms of reference) is a working
document that defines the team and its scope of work. The charter
is a useful foundation document that supports a team discussion on
purpose, roles and elements of team functioning. For more
information contact the Saskatoon Health Region.Facilitationforum:
To support the sharing of information between colleagues, an
internet-based group page has been established where facilitators
can dialogue about their work. Facilitationforum has been set up
through Yahoo! Groups, a free service that offers a convenient way
to connect with others who share the same interests and ideas. For
more information contact: saskatoonhealthregion.ca, Saskatoon
Health Region.Team Facilitator Training: This training has been
developed to support the development of team facilitators in
Saskatchewan. For more information see
www.health.gov.sk.ca/ph_br_phs.html3.6.5. Other Facilitators of
InnovationsNo information is available at this time.3.6.6.
Outstanding Barriers to InnovationsNo information is available at
this time. 34
- 35. 3.6.7. EvaluationThere was a formal evaluation completed
for the team development process.3.6.8. FundingThe PHCTF provided
funds for some of the change activities, and team
development.3.7.Manitoba3.7.1. Service Changes and PartnershipsNo
information is available at this time.3.7.2. TeamsNo information is
available at this time.3.7.3. Physician/ Other Leadership/
Facilitation SupportNo information is available at this time.3.7.4.
Processes and ToolsThe processes and tolls included were identified
through the Facilitation Guide. 3.7.4.1. Processes and ToolsPrimary
Health Care Lens: This easy-to-use tool encourages reflection on
the degree to which PHC is integrated into providers work. It has
been used with communities and staff as a means to evaluate
existing programs and design new ones so that they are aligned with
the principles of PHC. For more information, contact:
bkozak@arha.ca, Assiniboine Regional Health Authority.Move to PHC:
The NOR-MAN RHA has facilitated a PHC change process focused on
building capacity, encouraging collaboration, working within a
common vision and using communication processes to validate change.
By providing a clear, collective and individual understanding of
PHC concepts imperative to success, this process changed the way
NOR-MAN RHA operates. For more information, contact:
mgray@normanrha.mb.ca, NOR-MAN Regional Health Authority.Change
Management Workshop: It is crucial to recognize that staff members
are at different points in the change cycle. As part of their
move-to-PHC plan, NOR/MAN RHA, staff collaborated to offer a
session to assist staff with the change process. For more
information, contact: mgray@normanrha.mb.ca, NOR-MAN Regional
Health Authority.One Window Approach: This tool was developed to
provide a continuum of service among service providers (within the
health care system and with community partners). It is both a tool
and a process to assess current programs and create a plan for
action to make necessary improvements in: collaborative work,
information sharing and referrals, aligning resources, capacity
building, assessment, tracking, monitoring and evaluation and
communication and connections. For more information, contact:
bkozak@arha.ca, Assiniboine Regional Health Authority.3.7.5. Other
Facilitators of InnovationsNo information is available at this
time. 35
- 36. 3.7.6. Outstanding Barriers to InnovationsNo information is
available at this time.3.7.7. EvaluationNo information is available
at this time.3.7.8. FundingNo information is available at this
time.3.8.Quebec3.8.1. Service Changes and PartnershipsOne of the
models that has been given priority for the integration of health
care is the introduction and development of the Family Medicine
Groups (FMGs) over the next few years. Patient management, which
involves both continuity and accessibility, requires the creation
of medical teams that include nurses. A formal agreement is signed
with a local health and social services network development (CSSSs)
agency. The FMGs offer of services must comply with the regional
plan for the organization of general medical services, as assessed
by the regional department of general medicine.In exchange, this
agreement with the agency calls for technical and financial support
to be provided to support the organization of FMS services
proportional to the number of individuals who are registered (9
000, 12 000, 15 000, 19 000, 24 000 or 30 000 individuals).
Technical support includes the computerization of the FMGs, in
particular, access to test results and data on medications.
Computerization of the FMGs is done in compliance with the
Ministrys general plan for the computerization of the health care
network.The agency is also responsible for supporting the FMGs and
the CSSSs in their efforts to establish functional links, thereby
promoting access to diagnostic services and specialized
services.The FMG is defined as an organization made up of family
physicians who work as a group, in close cooperation with nurses
and other professionals such as pharmacists and social workers. The
FMG offers a range of primary care services with an adapted 24/7
service for patients who voluntarily register with a physician who
is a member of the FMG. The FMG enters into agreements with other
partners (e.g. CSSSs, pharmacists, etc.) in order to provide a
complete range of services. These activities must be a part of the
agencys regional plan for the organization of general medical
services (RPOS).The FMG primarily provides a structure for the
family physicians primary care activities, in the office on an
appointment or drop-in basis, or in the home for individuals whose
mobility is severely limited, during business hours on weekdays and
on a drop-in basis on weekends. The physicians also work in several
other settings (emergency care, long-term hospital care, short-
term hospital care, palliative care, etc.) that do not fall within
the scope of the FMG but with which integration objectives are
being pursued.3.8.2. TeamsIn June 2004, 1995 local service networks
were created across the province to bring services to the
population and to enhance service accessibility, coordination, and
continuity. To achieve the objectives of accessibility, continuity,
and quality, all of the CSSSs, with partners in their local 36