If you have any questions or comments regarding the accessibility of this publication, please contact us at accessible parl. On March 11, , the House of Commons Standing Committee on Health passed a motion agreeing to undertake a study to examine the elevated rates of tuberculosis TB infection in First Nations and Inuit communities and report its conclusion, including recommendations towards a national strategy to eradicate this disease. The Committee held one meeting examining this topic on April 20, , where they heard from a wide range of witnesses, including: government officials, First Nations and Inuit organizations and communities, public health organizations, and experts in TB prevention and control. This report provides relevant background regarding tuberculosis in First Nations and Inuit communities, including the federal government's role in this area and highlights the issues raised by witnesses during the course of the hearing.
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A multiple case-study approach involving 14 FHTs was employed. Thirty-two semistructured interviews were conducted and data were analyzed by employing an inductive thematic approach. A member-checking technique was also undertaken to enhance the validity of the findings. Five main themes are reported: rethinking traditional roles and scopes of practice, management and leadership, time and space, interprofessional initiatives, and early perceptions of collaborative care. This study shows the importance of issues such as roles and scopes of practice, leadership, and space to effective team-based primary care, and provides a framework for understanding different types of interprofessional interventions used to support interprofessional collaboration.
This past decade has been important for primary health care reform in Canada, beginning with government reports documenting the challenges of fragmented health care 1 to the creation of policies and the allocation of funding to implement interprofessional team-based care. Research findings illustrate the process of the transition to health care teams and the benefits of this interprofessional approach. While evidence for interprofessional collaboration in primary care is emerging in Canada and internationally, further knowledge about progress and benefits is needed given the considerable changes involved and the importance of examining the effect on professional practice, quality of care, and health outcomes.
This study, part of a larger project on interprofessional clinical protocol development and implementation in FHTs, examines perspectives of primary health care providers engaged in the early stages of team-based care.
An exploratory case-study approach was employed for this study. The sample consisted of representatives from 12 FHTs and 2 team-based primary care practices. The 2 team-based primary care practices are not FHTs but have a similar focus on team care; given their similar objective of team care, the term FHT is used in the paper to include all of the participating primary care practices. A purposeful sample 20 was taken to ensure representation from the professional groups and the different FHTs, which were located in urban and rural Ontario.
Of the family physician interviews, however, half were conducted with female physicians and half were with male physicians. About half of the interviews involved FHT members who were relatively new to their FHTs, having been hired approximately within the previous year.
The interviews were conducted using a semistructured interview guide and occurred by telephone or in person.
Interviews lasted for approximately 30 to 45 minutes and were recorded and transcribed verbatim before analysis. The investigators involved in data collection and analysis J. Data were analyzed by employing an inductive thematic approach from which major and minor themes were generated. Twelve people provided feedback and indicated that this summary provided an accurate account of the findings; 3 of these people provided minor revisions. The findings reflect the key issues from the analysis and are reported in 5 main sections: rethinking traditional roles and scopes of practice, management and leadership, time and space, interprofessional initiatives, and early perceptions of collaborative care.
As noted above, the FHT approach involves considerable changes in the provision of care. Family physicians sometimes together with nurses were previously the main providers of care within primary care practices; however, now, in the new FHT model, a broader group of professionals are working with them. This transition involved uncertainty and substantial changes in terms of roles and responsibilities for each team member. As many participants noted, to work in a FHT one needed to adopt a new way of working.
A range of family physician attitudes toward team-based care were offered. Some participants, such as pharmacists and nurse practitioners, described the challenges of defining their roles within the FHT and educating their colleagues about their expertise and what they could contribute to the team and patient care.
While many had experience working in their professions before joining FHTs, there was much uncertainty about how this professional expertise would be applied within the FHT context:.
A few participants discussed the role of nurse practitioners and the need for further clarification about their expertise and responsibilities.
These roles were being filled by people from various professions; the challenge, however, was in defining and shaping these innovative roles. While some participants noted their practices were multiprofessional before forming FHTs, in that different health care professionals worked within the practice, they reported limitations in the extent of their communication and collaboration. The formal designation of an FHT and the hiring of additional health professionals meant that FHT members had a responsibility to explicitly reflect upon and address how to work as a team.
A range of perspectives regarding team-based care were also held. Some discussed the concepts of shared responsibility and accountability. For example, in one FHT, the importance of changing notions of who is the primary contact person was stressed:.
Others described how family physicians were learning to integrate various health professionals into what had previously been their practices. A few participants discussed the implications of their newly formed FHTs on medical residents and students.
The importance of faculty development for all health professionals whose roles included teaching medical residents and students was also noted.
Numerous participants discussed the essential role of a manager or executive director responsible for the overall management and team development of FHTs. It was reported that this individual should be innovative and creative, as well as possess project development and management skills:. So I think her communication skills are great.
And really, having discussions with all of us versus just the doctors, just the allied health, or just the front staff, that really, really helps get everyone on the same page. In cases where FHTs did not have an individual in such a role or the individual in that role was perceived as not performing optimally, participants lamented a lack of team development.
Family physician leadership was identified as another critical factor that could affect FHT development. Positive physician role modeling was also regarded as key to encouraging change. Many FHTs included large numbers of team members, who were frequently located at more than 1 site or on different floors within a building. This geographic separation resulted in a lack of shared time and space, which was believed to impede FHT development:.
Participants thought team spaces needed to be structured to optimize opportunities for communication and informal meetings and to discourage working in silos. In addition, it was generally agreed that FHT development required time for ongoing discussion and negotiation of roles and scopes of practice:. You have to have meetings to find a way to handle the uncertainty and ambiguity [when developing a FHT] ….
Participants reported on a range of activities and initiatives that FHTs were implementing to foster a team approach to care. Given that FHTs were at the early stages of development during this study, it was noted that a number of organizational activities were occurring, such as creation of team policies and the hiring of FHT members.
The challenge of defining job descriptions and recruiting qualified individuals who could work collaboratively was reported:. We need to be flexible, both the new team members and the more established team members …. A range of other organizational initiatives eg, creating interprofessional committees or working groups, organizing team retreats to enable interprofessional dialogue was also reported. The key aim of these organizational activities was to create systems to support the goal of the most effective provider providing the necessary care:.
They could see a nurse. That opens up a minute slot for the physician to use. Other activities that were identified aimed to facilitate the actual process of collaboration in practice. Many participants discussed challenges with inappropriate referrals and scheduling difficulties. As a result a number of FHTs had developed approaches to improve this process, such as a checklist to use during annual health examinations, which would indicate whether a referral to the pharmacist was required.
A few participants noted that their FHTs had begun regular activities such as interprofessional case conferences or case management rounds, in which members of the team met to discuss and develop interprofessional care plans for specific patients.
The electronic medical record EMR was a further tool being used within some practices to facilitate collaboration. A number of successes were reported; for example, in one FHT the EMR was used by the physicians, nurse, and dietitian to enter and share patient information, thus avoiding duplication of effort in the interprofessional diabetes program.
While challenges with EMRs were encountered, their potential to facilitate communication was recognized. Because FHTs were at an early stage of development, organizational and practice issues were a priority. As a result, there had not been as much opportunity to focus on interprofessional education activities, but their importance was recognized.
Other examples include an interprofessional journal club and education rounds. Some particularly valued the interprofessional interactions that were occurring, such as an increasing focus on collaborative patient-centred care:. Participants also thought the FHT transition was an adjustment for patients, who were accustomed to seeing their physicians, and in some cases nurses, for their primary care visits.
A few participants discussed the need for patient education to explain this new model of care:. Participants recognized the value of patients consulting with health professionals with the greatest expertise for particular problems.
This shared care approach enabled physicians to have more time to see other patients. In addition, participants thought that patients who were attending interprofessional clinics or were being referred appropriately to other professions were benefiting from, and appreciative of, the enhanced primary care that was provided. This study contributes to the developing literature on interprofessional collaboration in primary care by providing insight into the emerging collaborative experiences of FHT members.
Owing to FHTs being a new model of primary care, participants focused on the importance of defining and understanding changing roles and scopes of practice. This finding supports other studies in this area. The critical role of physician leadership in supporting change to collaborative care has similarly been documented elsewhere 23 and was confirmed by our findings.
This study also highlights the essential role of the FHT manager, whose expertise appears to be critical in supporting and sustaining an interprofessional FHT. This finding should not be surprising, as it is not feasible to expect physicians or other health professionals to perform this vital organizational role in addition to their clinical responsibilities. As a number of FHTs within this study were based in multiple practice sites, their ability to work effectively as interprofessional teams was challenged.
Therefore, it is important to consider how space can be used to support interprofessional collaboration. This study also documents the different strategies and initiatives being used by the FHTs to support interprofessional care.
These can be categorized into 3 main types of interprofessional interventions: organizational, practice-based, and educational. This classification is taken from an interprofessional framework that was developed based on a scoping review of the literature and consultations with health care and education decision makers.
As noted above, many of the interprofessional interventions undertaken in the FHTs at the time of the study were aimed at fostering change at the organizational level, some also aimed at making change at the practice level, and a few aimed at the education level. The emphasis on interventions will change over time as the FHTs develop their foundations and determine priorities for clinical program development and focus. While challenges were described, in general participants reported that FHTs were progressing toward an interprofessional approach to delivering care.
Indeed, most perceived that this approach was making positive changes in patient care. Such perceptions are important, as they can have implications for satisfaction of the team as well as its morale. Such perceptions, however, require further evaluation to understand their relationship to the realities of accessibility of care and improvement in patient health outcomes. While this study had representation from a range of FHT members and yielded a number of rich insights, it is small in nature.
As a result, care is needed when applying its findings in other primary care settings. Nevertheless, as noted above, other studies on interprofessional collaboration in primary care settings have identified similar themes, which reinforces the significance of these findings.
The impact of inequality on health in Canada: a multi-dimensional framework
In Canada, racialised, immigrant and refugee groups are most at risk for the negative health effects that result from persistent health disparities, arising from race, socio-economic status, poverty, citizenship status and other social determinants, which expose them to macro-structural and micro-situational inequalities. The term racialised is a sociological term that is often used to describe non-white and non-European heritage communities that lack social, economic and political power in white dominant societies. Several Canadian studies have shown that the main determinants of health are not rooted in medical or behavioural factors, but rather in a host of social, economic and environmental factors that expose individuals to various health risks and barriers and produce health disparities between more and less advantaged groups Raphael, , ; AccessAlliance MulticulturalCommunity Health Centre, This paper uses a social determinants of health approach to examine how inequality and discrimination expose individuals to various social, environmental, economic and political factors that compromise the health status and well-being of marginalised groups, communities and jurisdictions.
Interprofessional collaboration in family health teams: An Ontario-based study.