In Canada there is a push and a need for primary care transformation to address increasing costs, shortage of primary care providers (PCPs), and changing population needs (1). Calls for transformation are motivated by a desire to achieve the Quadruple Aim as an approach to optimizing health system performance in four areas of focus: improving the health of populations, enhancing patient and provider experience of care, and reducing per capita costs of healthcare (2,3).
There is recognition of the value of team-based primary and community care (TBPCC) (4–8). Evidence suggests that TBPCC practices are able to provide more appropriate care to their patients (8–10) with improved comprehensiveness, coordination, and efficiency of care (10,11), and lower burnout rates for providers (12). Research focused on an assessment of progress in the transition to team-based practice emphasizes key change concepts for practice transformation: empanelment (attachment of patients to primary care providers), continuous and team-based healing relationships, patient-centred interactions, engaged leadership, quality improvement strategy, enhanced access, care coordination, and evidence-based care (13).
The Patient Medical Home (PMH) model is dominant across North America and is a building block of TBPCC in Canada. The College of Family Physicians of Canada defines the PMH as a medical office or clinic where each patient has: her or his own family doctor; other health professionals working as a team with the patient’s doctor; timely appointments for all visits; arrangement and coordination of all other medical services; an electronic medical record; and ongoing evaluation and quality improvement programs (6).
Ontario’s Family Health Team (FHT) model, implemented in 2005, may be Canada’s, if not North America’s, largest example of a jurisdictional model for a PMH. The model is based on multidisciplinary teams and an innovative incentive-based funding system. Nearly 2 million Ontarians are served by 170 FHTs (14). However, health systems transformation is complex (15) and its progress in Canada is varied province by province (16–18).
There are several review articles focused on attributes of TBC in the US and internationally (1,4,8,19–22); however, there is a gap in synthesizing evaluations of TBPCC in Canada. While the Quadruple Aim provides a framework for the assessment of many of the more longitudinal outcomes of TBPCC, the transformation of primary care is a process that occurs over time and requires a focus on formative as well as summative evaluation.
The TBPCC Evaluation Framework
Langton et al., (2016) emphasizes the importance of congruence between “a primary care performance measurement system and accepted conceptual frameworks that articulate important features of high-quality primary care systems” (p. 37). In anticipation of the need for a coordinated approach to evaluation, we developed the TBPCC Evaluation Framework (Figure 1). It is derived from the literature on TBC and was developed through an iterative process including the synthesis of literature and a review process with stakeholders: policymakers, TBC project leaders in communities, and researchers with relevant expertise. The literature was synthesised into a draft framework with a number of dimensions.
The TBPCC Evaluation Framework is situated in the healthcare system, as illustrated by the World Health Organization’s partnership pentagon, which includes key stakeholder groups (23).The framework includes eight dimensions: Relationship Centred Care, Patient Experience, Provider Experience, Team Function, Care Process and Quality, Team Based Care Foundations, Population Health, and Health Care Costs. These incorporate the Quadruple Aim.
Under each dimension, specific aspects have been defined, which were assigned specific measures. Validated and published evaluation tools were collected from the literature for consideration and were mapped to the framework.
Figure 1: TBPCC Evaluation Framework
Table 1: Eight TBPCC Evaluation Framework Dimensions
Relationship Centred Care
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The focus, in TBC, on supporting caring relationships between the patient, family and their providers
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Patient Experience
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Patient and family’s subjective experience of care
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Provider Experience
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Experience of individual providers in doing their work
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Team Function
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How team members interact to contribute to comprehensive, coordinated care
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Care Process and Quality
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Measuring appropriateness, efficiency, and effectiveness of care services provided to patients
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TBC Foundations
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Features of the community, policy, funding, etc. that enable an effective TBC practice
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Population Health
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Assessment of health systems utilization and health outcomes for the population served
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Health Care Costs
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Measurement of the costs of care both within the TBC practice and overall for the population served
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Relationship Centered Care (RCC) assesses the quality and continuity of a therapeutic relationship between the patient and the patient’s providers. RCC includes patient perceptions of provider-patient connection, cultural sensitivity/safety, and relationship continuity.
Patient Experience is the patient and family’s subjective experience of the care they receive. Systematic reviews have shown strong correlation between patient experience of care and clinical safety/ effectiveness (24). This dimension is a component of the Quadruple Aim and includes patient experience of care, team, and clinic-facilities. It includes patient perception of access to care and patient empowerment.
Provider Experience is the subjective experiences of individual providers in the team about their work. This includes the delivery of care to patients, their interactions with their work environment, the impact of policy on TBC and role-definition, and work/life balance. It is also one component of the Quadruple Aim.
Team Function is focused on the structure and operation of a team, the interactions of team members, and the additional supports that contribute to comprehensive, coordinated care. Aspects of team function include team leadership, team composition, team capacity, team communication/coordination, team trust/relationships, and the use of enabling tools (education, IT).
Care Process and Quality assesses services actively provided to patients in contrast to overall care outcomes for the population served (see health of the population dimension). Care Process and Quality includes access, health promotion, preventive care, chronic disease management, and urgent episodic illness.
TBC Foundations are features of the community, TBPCC policies, jurisdictional systems, and the supporting organization(s) that enable an effective TBC practice. In particular, this includes the development of a shared vision of TBC and facilitates the alignment of policy planning to support the implementation of TBC. Aspects of TBC foundations include office space and resources, education and training, policy, scopes of practice, funding models and incentives, community supports, and regional supports.
Health of the Population is the assessment of broader health systems utilization measures and health outcomes for the population that is being supported by the team. In contrast to Care Process and Quality dimension, this includes whether individuals access care or not. The Population Health dimension includes aspects such as attachment, health promotion and preventive care, CDM, episodic illness management, and health system utilization.
Healthcare Costs includes the tracking and analysis of total costs associated with individual patients within a TBPCC practice. This includes consideration of the broader, systems level costs that are influenced by the transition to TBPCC. This dimension includes facility/operational costs, direct service costs, total healthcare spending per person, hospital and ED utilization rates and costs, and medication costs.
Assessing the long-term benefits of systems change requires 5-10 years (25,26); however, shorter-term evaluation is needed to support decision makers, continuous quality improvement, adaptation, and flexibility to ensure process is relevant to specific contexts and communities. To complement the dimensions, the TBPCC framework includes an adoption model (Figure 2), adapted from the Clinical Adoption Meta Model (27). This encourages thinking on the evolution of indicators over time from measuring baseline and early intention to change through to observable behaviour changes to long-term outcomes.
Figure 2: TBPCC Adoption Model
Purpose
The purpose of this paper is threefold: 1. To synthesize peer-reviewed evidence on the outcomes of team-based primary and community care (TBPCC) in Canada on Patient and Provider Experience, Population Health, and Health Care Costs (Quadruple Aim) (3); 2. To introduce the TBPCC Evaluation Framework to address gaps identified in the synthesis; and 3. To extend the critical interpretive synthesis to include the additional four domains from the TBPCC Evaluation Framework (i.e., Relationship Centred Care, Care Process and Quality, Team Function and TBC Foundations).