A Review and Synthesis of TBPCC Evaluation in Canada: Looking Beyond the Quadruple Aim

Background The objectives of this article are: 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); 2. To introduce the TBPCC Evaluation Framework; 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). We conducted a review of the following databases: Medline (OVID and PubMed), CINAHL, Embase, SportDiscus, and PsycINFO as well as an advanced search with Google Scholar (Title only) with the words “Canada AND primary AND team”. Review concepts included: population (patients), intervention (team-based primary health care), comparator (usual care, single practitioner delivery mode), outcome (patient and provider experience, population health, and health care costs), time (2000-present), and type (randomized controlled trials, controlled trials, quasi-experimental designs, and implementation studies/evaluations). We excluded reviews, opinion papers, laboratory-based studies, and studies based outside of Canada.

provider experience, team function, and the quality of care. By encouraging a focus on formative as well as summative evaluation, the TBPCC Evaluation Framework provides a comprehensive approach to assessing the evidence needed to support actionable improvements for TBPCC in Canada.

Trial Registration
To identify peer-reviewed literature, we followed standard review methodology and reporting guidelines as established by PRISMA. We registered our review on PROSPERO (2018 CRD42018091086).

Background
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)(5)(6)(7)(8). Evidence suggests that TBPCC practices are able to provide more appropriate care to their patients (8)(9)(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). 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)(17)(18).
There are several review articles focused on attributes of TBC in the US and internationally (1,4,8,(19)(20)(21)(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 (Fig. 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 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. 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, shorterterm 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 (Fig. 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 longterm outcomes.

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,  Table 2), neither of which are explicitly reflected in the Quadruple Aim.

West Coast
There were no included studies identified from this region.

Prairie Provinces
Four of the seven studies from the Prairie Provinces (Alberta = 6, Manitoba = 1) mapped to the Quadruple Aim. Two studies reported on patient experience (33,34), one on population health (35), and one on provider experience (36). Three of seven studies reported on team collaboration and function as important components of transitioning to TBC (36)(37)(38). Emerging themes from the studies were patient needs regarding respect, support, and advocacy, and improved knowledge, independence, care received, ability to make decisions, and overall health. Other related themes included: provider and patient experience with overall delivery and quality of care (33)(34)(35)39), provider remuneration, and support for information technology, leadership, and education (38).
There was discordance for the two studies that focused on perceptions of access to care. One study emphasized that while the respect, support, and community advocacy provided to patients as a result of a TBC model was appreciated, accessibility continued to be a barrier for patients (33). Another study reported a perceived benefit improvement in access to care (34). One study noted increased job satisfaction for providers (36).
Central Canada 18 of the 34 studies from Central Canada (Quebec = 2, Ontario = 32) mapped to the Quadruple Aim.

Atlantic Canada
There was one study from Atlantic Canada (Nova Scotia = 1), which did not map to the Quadruple Aim but reported on team function and ongoing interprofessional education to address issues of respect for health professions (67).

Territories and Nunavut
There were no included studies from this region.

Pan-Canadian Studies
There were three Pan-Canadian studies, with one study mapping to patient experience (24). All studies reported on access to care and included process and outcome indicators that were perceived positively in TBC setting such as: patient centeredness, comprehensiveness, and continuity of care (67,68,69).  Table 3 Number The gap in literature from Nunavut and the territories was more surprising. A targeted search resulted in a number of articles that describe team-based practices in the North, the use of telehealth and paraprofessionals to support team-based practice, and the challenges facing teams where positions are filled with temporary rotating staff and turnover is high (70,71). This suggests a more targeted exploration of the evaluation of TBPCC in Northern and in rural and remote communities as an area for future research.
All articles included in the integrative synthesis are aligned with at least one dimension of the TBPCC Evaluation Framework. System transformation in primary care is complex and is a process that occurs over time. Because many provinces are early in this transition, the longitudinal assessment required to assess most elements of the Quadruple Aim are not yet possible or published, which is likely part of the reason why only 51% of studies mapped to the Quadruple Aim. The TBPCC Evaluation Framework intentionally has a broader scope supporting formative and summative evaluation. Next, we provide further contextualization of the eight dimensions of the framework and why these are important to measure.

Canadian TBPCC Evaluation -Across the TBPCC Framework Dimensions
Relationship Centred Care (RCC): In our review, studies demonstrated associations between RCC and improved patient outcomes with emphasis on the importance of communication and collaboration (37,40). There is evidence that skills and behaviours related to collaboration are most likely to show significant effects on patient outcomes (37). Evaluation of RCC is important as relationships can be disrupted in poorly functioning teams.
Patient Experience: From our review, there is considerable evidence that TBPCC can enhance patient experience of care through strategies related to accessibility, respectful supportive relationships, enhanced opportunities for knowledge sharing, self-management, and community advocacy (24,33,34,40). The availability of enhanced case management or specialized support roles also positively influences patient experience (44,45,72). These benefits are particularly salient for more vulnerable populations (47,65), who feel they are given the chance to 'tell their story and be heard' in team-based settings (48).
Provider Experience: The review suggests that providers can find working in a team very useful, particularly for complex patients (36,57). Providers perceive there is improved access, continuity of care, and patientcentered-ness in TBC (5,44). Communication and shared understanding of roles contributes to enhanced provider experience (35,36,44,57) as does the availability of providers with specific expertise (e.g. mental health/counselling or CDM) (39,55).  (36)(37)(38)73). Common barriers to collaboration and team function include the time it takes to build relationships, the lack of opportunities for co-location, and challenges with role definition (59,64,66). Despite some studies that suggest only moderate success in the context of interdisciplinary collaboration (63,74), there is ample evidence of the importance of working to develop shared values in primary care teams and the value of efforts to improve group dynamics to support higher levels of interdisciplinary collaboration (5,44,(74)(75)(76). Working to build understanding of roles and shared leadership is also widely attributed to enhancing collaboration (58,60,61,65). There is also evidence of the value of interprofessional education (67,77). Intentional, team-focused activities, including formal meetings, professional development programs, social activities, and retreats, are essential to sustaining and building relationships needed for highly functioning teams (75,78).

Care Process and Quality:
A number of studies included in our review suggest that TBC leads to improvements in patients' perceptions of quality of care, accessibility of care, knowledge of medical conditions, and their ability to self-manage (24,34,40,44,50,53,72,79). Providers' perceptions of capacity can be enhanced through shared care models and opportunities for interprofessional collaboration (39,48,52,61).
However, other studies suggest the accessibility of care is still an issue, even in highly-functioning team-based practices (33,43,46). A pan-Canadian study found that the likelihood of reporting access issues or unmet needs was not significantly different in TBC vs. non-TBC settings (68). However, there is evidence that quality of care, particularly for CDM, is better in team-based practices and particularly in community health centres or practices with blended capitation models (62,69,80).

TBC Foundations:
The most salient issues for teams that emerged from our synthesis are physician remuneration, colocation, interoperable electronic health records, visionary leadership, and educational support (38,39,52,56,62). Larger numbers of physicians on teams and the distribution of teams across sites has been negatively associated with team performance (42,56,59); there is evidence that smaller, colocated teams are more likely to collaborate effectively (66).The physical layout of a space, the presence of coordinator or team management roles, and the use of alternative funding models have been highlighted as foundational to success (56,62,80).
Health of the Population: TBPCC can improve outcomes in population health (e.g. fewer Emergency Room visits for low acuity) (81,82). Some studies highlight early indicators of improvement in population health through TBPCC (35). For example, one study found that increased accessibility to dietitians resulted in increased likelihood of PCPs discussing nutrition for weight management (52). Another study discovered improved CDM and preventive care in TBPCC (53). An addiction shared care program also showed early success (54).

Health Care Costs:
Physician remuneration is an important issue for interprofessional teams across Canada and is a frequent stumbling block (38). Due to the longitudinal nature of cost savings related to longer-term, expected outcomes, there is a paucity of evidence in this dimension. A study focused on the cost effectiveness of a team-based prevention program for complex patients found that it was both more expensive and more effective than other programs (50). There is also evidence that the integration of new team members becomes more cost effective over time (51).

Limitations
The systematic search strategy limited our initial searches to academic literature only, missing publications in the grey literature. There were no results for Western Canada or Nunavut and the Territories, and only limited results in Atlantic Canada. However, we are aware that at the practice level TBC innovations in primary care are being implemented in these regions. A more extensive search that includes a focus on grey literature and government publications could address some of the regional gaps highlighted in this synthesis.  PRISMA2009checklist.doc