Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Figures & data

Table 1 The studies

Study name	Study location	Catalyst investigator(s)	Study focus	Selected citations
Prevention and competing demands in primary care	Nebraska, USA	Crabtree BF, Miller WL	Ethnographic descriptive study of 18 practices to understand variation in quality of care	34
Using Learning Teams for	New Jersey and	Crabtree BF, Miller WL	Practice intervention in 56 primary care	35
Reflective Adaptation (ULTRA)	Pennsylvania, USA		practices using facilitated team building and reflection to enhance quality of care
National Demonstration Project (NDP)	USA	Crabtree BF, Miller WL	Multimethod evaluation of the first major implementation of the Patient-Centered Medical Home in the USA among 36 family medicine practices	25,36,37
Strengthening PHC services through innovative practice networks	Alberta, Canada	Scott C	Three-phase program of research focusing on the impact of context and models of PHC on outcomes. Particular focus on establishment of interprofessional relationships	38
Behind the closed door. Using ethnography to understand family health teams	Ontario, Canada	Russell GM	Team formation and CDM in newly forming large primary care practices	39,40
Comparison of models of PHC in Ontario	Ontario, Canada	Hogg W, Russell GM,	Mixed methods evaluation of four primary care models in Ontario	41,42
Association of PHC service models with perceived health status, utilization of health services, ability for self-care, and perceived quality of services in patients with chronic disease	Québec, Canada	Levesque JF	Organizational models of PHC and their influence on health, utilization, and self-care for chronically ill patients	43
Accessibility and continuity of care: a study of PHC in Québec	Québec, Canada	Levesque JF	Organizational models of PHC and their influence on accessibility and experience of care users	44
Reorganizing the care of depression and related disorders in a primary care setting	Victoria and Tasmania, Australia	Gunn JM	Depression care in Australian general practice	45
Prac-Cap	Five Australian states and one territory	Harris MF	CDM and GP perspectives	46,47
Teamwork	Three Australian states	Harris MF	Cluster randomized trial of intervention to enhance interprofessional teamwork within 40 general practices	48,49
Teamlink: interprofessional teamwork between general practice and allied health services	Sydney, Australia	Harris MF	Quasi-experimental trial of facilitated teamwork between general practice and allied health services in 26 urban practices	24,50

Abbreviations: PHC, primary health care; CDM, chronic disease management; GP, general practitioner; Prac-Cap, practice capacity for chronic disease.

Table 2 Changes to interprofessional teamwork studied in five jurisdictions

Jurisdictions	Studies	Interprofessional teamwork interventions or policies
Australia	Prac-Cap (2001–2004), Teamwork (2005–2008), Team-link (2006–2010), Reorder (2005–2007)	Enhanced primary care: funding episodes of care, interprofessional care plans, Medicare funding for allied health and psychological services
USA	P&CD (1997–1999), ULTRA (2002–2006), NDP (2006–2011)	Staff roles in preventive services delivery, quality improvement, learning teams, Patient- Centered Medical Home
Alberta	CoMPaIR (2007–2011)	Primary care networks: blended payments
Ontario	BCD (2007–2009)	Family health teams, increased capitated payments
Quebec	Primary care models (2005)	Family Medicine Groups: blended payments

Abbreviations: ULTRA, Using Learning Teams for Reflective Adaptation; NDP, National Demonstration Project; P&CD, Prevention and Capacity Demand; CoMPaIR, Contexts and Models in Primary health care and the impact on Interprofessional Relationships; BCD, Behind Closed Doors; Prac-Cap, practice capacity for chronic disease.

Table 3 Impacts of interprofessional team interventions and policies on communication, relationships, roles and satisfaction of PHC providers by jurisdictions

	Alberta	Ontario	Quebec	USA	Australia
Communication	Variable: in some PCNs, communication improved. In others, lack of role clarity resulted in difficult and/or miscommunication	Improved informal communication within and between practices. But variability in form: some never held meetings; others met regularly, actively, organized mentoring and actively reflected on processes of collaboration	Improved communication between providers within practices	Variable improvement. In some practices, communication was fostered especially between front and back office. In others, minimal impact due to conflict and power relationships	Improved communication between GP and nursing staff. However, some practices rarely had staff meetings or separate clinical and administrative meetings. Poor communication with external AHP and psychologists
Professional roles	Variable acceptance of roles related to knowledge and trust in each other’s competence. In some practices, doctors took on new roles (eg, more complex conditions)	Broadening of nurse responsibilities as well as the new role of NP. However, many (AHP and NP) felt they were not working to their scope of practice. Challenged work practices and professionals ideas of their roles. Family practitioners working in the same way they had been prior to the new model	Some tension regarding new roles. A clear division of labor was required but not achieved. Shared professional responsibility was regarded as being limited by the power of the medical profession and professional associations	Staff took on new roles and responsibilities as long as it did not encroach on the physician’s autonomy and role. Positive where there was openness about working and learning involving both medical and nonmedical staff together	Development of new roles for nurses and allied health despite uncertainty by doctors about their competencies and capacity
Relationships	Improved respect. However, assumption that network relationships occur naturally not requiring formal partnership. Behavior within meetings was a strong determinant of participation, collaborative decision making, respectful interactions	Further developed partnerships between PHC and community programs. Confusion about roles created some tension in some practices. Some friction with doctors over role of NP. Some resistance to change especially within established practices	Formal interorganizational relationships improved over time. Personal trust was limited by poor understanding of other roles. Shared professional responsibility opposed by the medical profession and professional associations	Improved relationships and shared decision making within practice in less hierarchical open decision making. Some conflict when power and authority of doctors or practice manager was challenged. Territoriality in team interventions was seen as the FP’s turf	Improved between practice and allied health services. But constrained by lack of knowledge of services. Some conflict over role of doctors and nurses. Doctors retained control over referral
Work satisfaction	Improved satisfaction and retention of nonphysician staff in less hierarchical teams	Generally improved. However, some frustration that expectations were not met. Many nursing and allied health confronted a clash between their expectations of interprofessional care and their experiences. Physicians felt their workload had not decreased	Improved work satisfaction of providers in FMGs	Those able to implement intervention really loved it and felt energized. Others were frustrated with the lack of progress	Improved satisfaction with shared workload and improved patient outcomes. Some GP and AHP dissatisfaction with referral processes, limited exchange of information, bad working relationships

Abbreviations: PHC, primary health care; PCN, primary care network; GP, general practitioner; AHP, allied health professional; NP, nurse practitioner; FP, family physician; FMG, Family Medicine Group.

Table S1 Example of summary matrix used to compare impacts across studies and jurisdictions

Themes	Jurisdiction: Ontario
	Study: # 2 (Behind closed doors)
Care processes and referral	Reutilization of community resources: Reasonable partnerships in CHCs. Cooperation with other CHCs and some FPs in particular, but more because of the model of care not team orientation. The FHTs are weak in this regard; most that do use community resources limit referrals to other health care resources. Two FHTs made some early attempts to build partnerships and integrate community resources more, but in light of a general lack of orientation to this model, one discontinued the practice because it was inconvenient (despite positive patient feedback). In contrast, the CHC excelled in this area. Re-referrals: referrals are internal in the FHTs and do not assume a partnership orientation.
Communication	+ Informal communication seemed regular (modified by space and culture) and ± Great deal of variability between practices, some never held meetings, others, like the most “mature” FHT, which met regularly, actively organized mentoring, and actively reflected on processes of collaboration. Social workers were relatively isolated.
Trust/relationship	± Evolution of trust over time with regard to the work of NPs and less trust in those FHTs where certain professionals had specialty training to work with specific subpopulations (eg, an NP who is specialized in care of patients with complicated diabetes).
Task/role realignment	Significant in most FHTs with new professionals. However, mostly old routines persisted in the early years of the model. The competing demands (see later) affected this. Yet, some innovative routines evolved in the best led FHTs.
Power, decision making	− Governance varied significantly. Most decisions in the physician owned FHTs were made by physicians, more complex structures in a well-embedded FHT. In one FHT, all decisions made by a group of FHT owners, this FHT never held meetings between administrative and clinical staff. + Powerful, consistent, and clear leadership increased resilience among individuals and the team, mediating the negativity of the challenges experienced as they worked to develop new working relationships. − Clinical leadership was sometimes surprisingly absent. Much dysfunction found in an academic FHT could be traced back to a vacuum in clinical leadership. The FHT was characterized by a sense of disempowerment and with little encouragement for members to participate in decision making and the proposal of new ideas or exploration of new roles or modes of collaboration. Therefore, higher incidences of staff feeling undervalued, underutilized, and dissatisfied with the current situation.
Adoption and acceptance	+ In terms of integration of specialist expertise in primary care, FPs viewed their colleagues and FHT’s pharmacists as a trusted, regular source of quality evidence. Nurse practitioners, allied health providers, and nurses will utilize the above and each other for decision support, recognizing their expertise. − The distinct philosophy, scope of practice, and different ways that NPs engage with their work all interact to generate some common problems with integration of the NP. − Dieticians/pharmacists expressed desire to do more “… they kind of have almost preconceived notions about what dieticians can see. You know, like diabetes, and weight management, and high cholesterol. And then a lot of times they don’t think outside of that … [Registered Dietician] and work in different ways in different FHTs.
Work satisfaction	− Many found their skills exceed their tasks, led to dissatisfaction. − Many FHT members confronted by a clash between their expectations of interprofessional care and their experiences. Also different expectations of what moving into a FHT model would mean for them, their role, and their way of practicing. − Especially, a problem for NPs. For FPs in general, the changes were positive in terms of work satisfaction.
Practice size	The impact of a FHT (the Ontario model of PHC team). Increased practice size considerably, however, in networked models the individual practices often stayed the same in size. More commonly, there was coalescence of practices into a larger body.
Colocation	± FHTs increased the likelihood of colocation. − Non colocated team members were rarely integrated.
Space	− Physical space is a pervasive problem in FHTs. Lack of space limited hiring in some and a constant preoccupation for FHT managers. Indeed, many of the real teams existed at a site rather than at FHT level. ± Where someone sits in the FHT has much to do with feelings of being part of the team. Physically isolated providers found it hard to integrate with their colleagues and were less able to give others an idea of their skills and potential contributions.
Workload and workforce	− Some physicians thought the FHT model would mean that they would not have to see as many patients. However, 2 years after the transformation, the majority of family practitioners were working in much the same way they had been prior to the integration of the new model.
Scope of responsibility	± Many (AHP and NP especially) felt they were not working to their scope of practice. However, compared to normal practices there was a definite broadening of nurse responsibilities and new role of NP.
Leadership (decision making)	± The team led to the demand for leadership. A balance between clinical and nonclinical leadership seemed necessary. While each role required different skills sets, the “organic” nature of FHTs meant that physicians (in smaller FHTs especially) frequently took on operational roles, while in other sites administrators found themselves managing practitioners with whose clinical roles they are not familiar. In a number of FHTs a collaborative leadership role between clinical and nonclinical did not exist. The CHC was led by a physician who suggested: For me, it’s a good personal fit. I think for a manager, I think it really helps if you’ve got a clinical background. I hear that a lot. I hear from my other fellow CHCs, particularly when they have non-clinical managers. Sometimes the clinicians feel like their concerns are not understood, or are not given the import that they wish that they would be given.
Financial model (business)	− We found an inherent barrier to interprofessional care generated by existing physician-oriented incentive structures. It has become more and more of an issue. The team itself raised the problem, but the financial structure generated it.
Concurrent change (competing demands)	± Team care added the demands on (and requirements for efficient leadership and management). Other demands came from the model requirement to optimize access and increase the quality of chronic disease care. These in themselves generated a need for effective teamwork.

Note: + indicates a positive impact, − indicates a negative impact, ± indicates a variable impact.

Abbreviations: CHC, Community Health Center; FP, family physician; FHT, family health team; NP, nurse practitioner; AHP, allied health professional; PHC, primary health care.