Roundtable on Policy Options for Team-Based Primary Health Care Finding the Right Policy Levers for Interprofessional Team Work in Primary Health Care Summary Report June 18, 2014

Workforce Research and Evaluation Alberta Health Services

Workforce Research and Evaluation

Table of Contents Meeting Overview - May 22, 2014, Calgary, Alberta ...................................................................................... 3 Key Findings and Outcomes from Policy Analysis ........................................................................................... 4 Discussion of Policy Imperatives ..................................................................................................................... 5 Impact and Implications of Implementing Policy Imperatives ........................................................................ 7 Next Steps........................................................................................................................................................ 9 Appendices .................................................................................................................................................... 10 Appendix 1: Participant Agenda ................................................................................................................ 10 Appendix 2: Participant List....................................................................................................................... 11 Appendix 3: Comparative Review of the Policy Landscape on Team-Based Primary Care Service Delivery in Western Canada - Research Overview .................................................................................................. 12 Appendix 4: Research Overview PowerPoint Presentation ...................................................................... 19 Appendix 5: Policy Options for Discussion ................................................................................................ 22 Appendix 6: Small Group Discussion of Policy Options ............................................................................. 23 Appendix 7: Small Group Discussion of Outcomes and Implementation Factors..................................... 27 Appendix 8: Evaluation Findings ............................................................................................................... 29

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Meeting Overview - May 22, 2014, Calgary, Alberta Host Workforce Research and Evaluation, Alberta Health Services

The Research Project The Canadian Institutes of Health Research (CIHR) funded a 12 month research project under the Healthcare Renewal Policy Analysis program to explore policies on team-based primary health care in three provinces: British Columbia, Alberta and Saskatchewan. The main research questions are: 1. How do policies, including regulations and legislations inform the design and implementation of team-based primary health care service delivery? 2. What can we learn from the experiences of the three provinces to inform key policy options for a pan-Canadian approach for team-based primary health care service delivery? The research team reviewed diverse evidence on the primary health care context in the three provinces, synthesized formal policies that impact team-based primary health care, and interviewed key provincial stakeholders to identify a set of potential policy options to move team-based care forward.

Roundtable Objectives (see Appendix 1 for participant agenda) • • •

Share key findings from the research Discuss the clarity, relevance and feasibility of identified policy options Consider the impact and implications of implementing identified policy options in advancing interprofessional team work in primary health care

Funding The event was funded by a Canadian Institutes of Health Research Healthcare Renewal Grant.

In Attendance Fifteen individuals from Saskatchewan, Alberta and British Columbia representing provincial health ministries, health authorities, universities and care providers (see Appendix 2 for the participant list).

Facilitator Anne Marie Downey, Downey Norris & Associates Inc., Edmonton, Alberta.

Acknowledgements We would like to thank the roundtable participant’s for the high level of energy and enthusiasm they brought to the discussions. The policy synthesis will clearly be strengthened by their rich insights and expertise. We would further like to acknowledge our facilitator Anne Marie Downey who never lost sight of the roundtable goals and gently guided us through the day.

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Key Findings and Outcomes from Policy Analysis Sara Mallinson, Research and Evaluation Consultant, Workforce Research and Evaluation, Alberta Health Services, provided an overview of the findings and outcomes flowing from: •

Review and synthesis of relevant policies in each of the three provinces involved, British Columbia, Alberta and Saskatchewan, and

•

Interviews with representatives of health ministries, health authorities, universities and care providers in the three provinces to validate the policy synthesis, explore key policy drivers and solicit recommendations for policy options to advance team-based primary health care.

The four policy options emerging from this work, and the focus for discussions during the roundtable were: 1. Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize team-based primary health care. 2. Develop appropriate and sustainable compensation models to support team-based primary health care. 3. Invest adequate resources to support system change and a team-based primary health care model. 4. Integrate collaborative practice metrics in primary health care monitoring and evaluation. See Appendices 3, 4 and 5 for details: Appendix 3 Comparative Review of the Policy Landscape on Team-Based Primary Care Service Delivery in Western Canada - Research Overview Appendix 4 Research Overview PowerPoint Presentation Appendix 5 Policy Options for Discussion

Following the presentation, participants asked questions for clarity and raised a number of points for consideration: • • • • • • • •

options require further delineation and sharpening to better assess potential implications and priority to make choices, conflicts and trade-offs need to be understood challenge is governments’ tendencies to cherry pick policy directions in support of shifting political agendas and timelines that differ from province to province options identified require long-term commitment and tenacity - 8-10 years governments need a roadmap a review of written policy would not necessarily align with a review of how those policies are executed policy is more than a set of stated objectives and inclusive of the regulations and programs that frame its execution and there are often multiple ways to achieve a stated objective these same directions/policy options have been identified repeatedly

The original intent for the day was to discuss each of the four policy option and prioritize the three options with the most promise to advance team-based primary health care. There was, however, a strong

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Workforce Research and Evaluation view among roundtable participants that all four options are essential. Specifically, participants preferred to not rank the policy options, but to further explore the key elements of each. They recommended that all of the policy options identified should be pursued and presented, and not as either/or but as a package of interdependent directions that lever and support each other. They further suggested changing the terminology to “policy imperatives” to avoid the temptation to “pick and choose” between options. As a result of these conversations, the roundtable discussions were refocused; all four policy imperatives were discussed in-depth with special consideration of interdependencies between policy imperatives and potential trade-offs.

Discussion of Policy Imperatives In small groups, participants discussed the key elements of each of the four policy imperatives, and the inherent conflicts and potential trade-offs. Detailed notes from the small group discussions can be found in Appendix 6. Highlights regarding key elements and inherent conflicts/potential trade-offs of each policy from group discussions are presented in Table 1. Table 1. Key elements and inherent conflicts/potential trade-offs of policy imperatives from small group discussions

Policy

Policy 1: Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize teambased primary health care

•

Policy 2: Develop appropriate and sustainable compensation models to support team-based primary health care

•

• • •

• • • •

Policy 3: Invest adequate resources to

• •

Key Elements

Need a systems perspective, ‘committed to thinking and acting as one’ (i.e. integration with community supports, education) Need to conduct a current state assessment (i.e. current workforce, how public dollars are allocated) Realignment of key players (ministry, health authorities) and focus (primary healthcare vs. primary care) Need to include accountabilities in regards to budget and health outcomes Payment model impacts system and care delivery Innovative strategies should be incorporated (incentive payments, blended compensation models) Add “achievement of health system goals” to policy statement Broaden policy discussion to include all providers Cultures of practice must be considered Need evidence based decisions and tangible measures of progress Need to ensure sustainability

5

• • • • • • • • •



• •

Inherent Conflicts/Trade-offs

Need to examine the entire system (acute and primary care) to determine optimum redesign Cannot continue to reinvent the wheel Implementation of this policy may drive the other three policies Needs to reflect the provincial contexts (i.e. geographic dispersion) Leadership must have the courage to stay the course Need to reframe primary health care – not a ‘department’ May see negative repercussions (i.e. exodus of physicians) Need to also align dollars with health system goals Could potentially change the funding model, and providers will only have access if they are committed to the new care model Reimbursement model has the most potential for ‘disruptive impact motivation’ Cannot assume that ‘if we build it they will come’ Need to prepare for physician

Policy

support system change and a team-based primary health care model

Policy 4: Integrate collaborative practice metrics in primary health care monitoring and evaluation

Key Elements

• •

• • • •

(ongoing funding, technology, change management) Education and training for all levels of staff will be necessary Understanding return on investment and desired patient outcomes Need metrics to evaluate more than just collaborative practice (i.e. financials, patient outcomes) Need metrics to be user friendly and transparent Need to be able to demonstrate return on investment Metrics alone will not drive collaboration, stewardship is missing

Workforce Research and Evaluation Inherent Conflicts/Trade-offs • •

• • • •

backlash Staff should have some input, but team-based care should not be optional Team-based care will ‘free up’ physician time, who are doing tasks other are qualified to complete Must be embedded in all policy imperatives Requires clear accountability structures Don’t want to create duplication, metrics are needed to identify this Could encourage ‘competitive nature’ around performance

Policy 1: Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize team-based primary health care Participants expressed the necessity of a systems perspective and approach. Taking a systems perspective would ensure that we are “committed to thinking and acting as one”, a tagline developed by participants. There was consensus that a current state inventory would be necessary to understand the current workforce and how funding is currently being allocated. Participants felt that accountabilities must be included, both in regards to budget and health outcomes. Participants expressed that not only will key players need to be realigned (i.e. ministry and health authorities) but the focus as well (i.e. primary healthcare vs. primary care, patient centered care). Participants stated that the whole system (i.e. both acute and primary care) must be considered to ensure optimum redesign, however, at the same time we cannot continue to reinvent the wheel. Policy 2: Develop appropriate and sustainable compensation models to support team-based primary health care Participants acknowledged the impact payment models have on the system; for instance, fee-for-service encourages a large volume of patients and may challenge team-based models. Participants stated that innovative and flexible strategies should be incorporated into compensation redesign to reflect the environment in which providers operate today; for example, incentive payments, blended compensation models, or integration of authority funded nurses into fee-for-service. There was consensus that we need to broaden the compensation discussion to all providers (i.e. community based pharmacists). Participants were concerned about the potential impact of alternate funding models; e.g. if fee-for-service is replaced by contracts we may see an exodus of physicians from some areas, or if primary healthcare is improved we may see a change in emergency use which will require a change in emergency staffing models. Policy 3: Invest adequate resources to support system change and a team-based primary health care model

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Workforce Research and Evaluation Participants expressed the need for evidence based decisions and tangible measures of progress when allocating resources; existing models should be used to create a knowledge base. Several sustainability issues were discussed, such as the need for ongoing funding, proper infrastructure, adequate technology to facilitate collaboration, and change management plans. There was consensus that education and training will be needed at all levels (i.e. leaders, front line staff) to teach providers how to work effectively in collaborative teams. Participants acknowledged the importance of making a business case by understanding the potential return on investment in addition to desired patient outcomes; this knowledge could come from literature, case studies, and a current state assessment. Participants cautioned that we cannot assume ‘if we build it, they will come’, creating a culture of collaboration and team-based care will require additional supports. Policy 4: Integrate collaborative practice metrics in primary health care monitoring and evaluation There was consensus among participants that we will need more than collaborative practice metrics; metrics should also assess financials, patient outcomes, system improvements, etc. Participants felt that we need to ensure that the metrics are user friendly and transparent; this will ensure metrics can be used for routine evaluation and monitoring, as well as negotiations between government and providers. The metrics must also be able to demonstrate return on investment. Participants voiced concern that the metrics alone will not drive collaborative practice and that the stewardship component is missing. Participants argued that policy 4 needs to be embedded in all other policy imperatives and will require clear accountability structures. Participants cautioned that we need to be careful to not create duplication; metrics will be required to identify this. Overall, participants identified strong interdependencies among the 4 policy imperatives; implementing one policy will have an impact elsewhere in the system. Participants felt the issue was identifying how to best sequence the 4 policies; there was some indication from participants that policies 1 and 2 should be sequenced first. Given the interdependencies, participants felt that ‘cherry picking’ by policy makers will result in conflicts; as such, the policies need to be presented as one package, not options.

Impact and Implications of Implementing Policy Imperatives Each of the four groups explored one of the four policy imperatives identified, discussing the most important potential outcomes to pursue in the implementation of the policy imperative being discussed, and the most important factors/considerations to be anticipated and planned for in its implementation. Detailed notes from the small group discussions regarding each policy can be found in Appendix 7. Each group then reviewed and offered input on each of the remaining policy imperatives. The following table displays the three most important outcomes to be achieved through implementation of each of the policy imperatives and the five most important factors/considerations to be planned for as part of implementation, as identified by meeting participants. Table 3. Most important outcomes and implementation factors/considerations for each policy.

Policy

Most Important Outcomes

Policy 1: Align health system goals, policies, workforce

1. Better patient outcomes individual and population/community, access

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Most Important Factors/Considerations 1. Workforce resistance 2. Community engagement; converse early and often in partnership with health

Workforce Research and Evaluation Most Important Factors/Considerations

Policy

Most Important Outcomes

and structures (Ministry of Health, regional health authorities and independent practices) to optimize team-based primary health care Policy 2: Develop appropriate and sustainable compensation models to support teambased primary health care

continuity, accountability, equity, experience, responsiveness 2. Fiscal and system sustainability; better value for money 3. Engaged and informed civil society - citizens, taxpayers, patients, etc.

providers, governors, administrators, etc. 3. Political patience and perseverance; all want quick fixes 4. Sheer complexity - Timing; parallel versus sequential; competing priorities; creating blueprint easy for all to navigate 5. Prototyping and replication

1. System outcomes and goals aligned with payment and remuneration 2. ‘Bending cost curve’ with better payment system and use of resources in support of high performing PHC system and remove barriers to innovation 3. Improved provider satisfaction, and quality of life with an appropriate payment model

Policy 3: Invest adequate resources to support system change and a teambased primary health care model

1. Patient gets the right care by the right provider at the right time 2. Improve patient health outcomes 3. Reduce/avoid cost of more expensive institutions e.g. hospitals

Policy 4: Integrate collaborative practice metrics in primary health care monitoring and evaluation

1. Better coordination and, where needed, better continuity of care, particularly for chronic conditions, severe problems and multiple morbidities 2. Increased positive experiences and satisfaction by providers with working in teams 3. Reduced hospital stays - #, length, emergency visits, readmissions

1. Include all stakeholders (including patients) at table in developing goals and metrics 2. Perseverance – allow a longer time frame for implementation 3. Consider context when talking with physicians. How can we better compensate and support the work you do, with assurance that income won’t decline? 4. Public education to enhance transparency and trust as any new PHC model evolves 5. Consider incentivizing/compensating physicians, NPs and others to work in a team-based care model 1. Understanding current state and using that information to plan for the future 2. Return on PHC investment is very long stay the course 3. Difficult to measure PHC success 4. Public rallying behind PHC 5. Buy-in from governments, providers and patients to improve alignment of the system 1. Timely liberation of available data, while protecting privacy 2. Interoperability of multi sources of data 3. Public perception of, trust in and confidence that they are getting quality care that is well coordinated 4. Patient access to information to monitor their care and how it is coordinated patient portal developed from patient perspective 5. Build capacity of team to learn from each other locally, provincially and nationally, and to learn from patients; include capacity to measure

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Next Steps The research team will integrate the reflections and recommendations from the roundtable participants into the policy synthesis. The four policy imperatives will be highlighted including potential implementation challenges and anticipated impact. Once the policy synthesis is finalized, the research team will start to consult and engage with stakeholders that are considered key partners in implementing these policy imperatives. Esther Suter sought input from participants on who should be engaged in the coming months/year to help advance the policy imperatives discussed, and how that should be done. Initial input provided is outlined below. Alberta       

Primary Care Alliance Alberta Health Services Covenant Health Primary Care Physician Council Federation of regional leaders Collaborative Practice and Education Executive Committee Health Advisory/Patient Advisory Councils

Saskatchewan     

Medical Association Regional Health Authorities two forums Ministry Provincial Leadership Team Meetings between Health Professional / regulatory organisations and Ministry of Health

British Columbia      

Provincial Health Authorities AIPCC General Practice Services Committee (GPSC) Ministry Doctors BC Shared Care Committee and GP Committee Integrated Primary Care Leads

It was suggested that presentations to key stakeholder groups followed by discussion would be most appropriate. There might be opportunities to present at standing committees or meetings (e.g. PCN Forum) or to a broader audience at national conferences (e.g. Interprofessional Healthcare Conference September 2014). Targeted knowledge translation materials will need to be developed with key messages to facilitate clear and consistent communication on the purpose, intentions and outcomes of the policy imperatives. Timelines for completion of the work: Roundtable report forwarded to participants

Mid June

Draft knowledge translation and engagement plan to research team and roundtable participants

July 31, 2014

Final research report submitted to research team

August 31, 2014

Stakeholder engagement including dissemination of report

Start Fall 2014

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Appendices Appendix 1: Participant Agenda

Roundtable on Policy Options for Team Based Primary Health Care Finding the Right Policy Levers for Interprofessional Team Work in Primary Health Care Thursday May 22, 2014 8:30 a.m. to 3:30 p.m. Delta Calgary Airport Hotel, 2001 Airport Road NE Calgary, AB T2E 6Z8

Room: Katherine Stinson

Meeting Objectives   

Share key findings from policy synthesis Discuss the clarity, relevance and feasibility of identified policy options Discuss implementation considerations and impact of policies on health and health systems outcomes

Agenda

8:30 a.m.

Registration and Continental Breakfast

9:00 a.m.

Welcome and Meeting Objectives

Esther Suter

Introductions and Meeting Overview

Facilitator

Overview of Key Findings and Outcomes of Policy Analysis

Sara Mallinson

10:30 a.m.

BREAK

11:00 a.m.

Discussion of Policy Options - Clarity, Relevance, Feasibility

12:15 p.m.

LUNCH

1:00 p.m.

Impact and Implications of Implementing Policy Options

All

Input on Next Steps

Renee Misfeldt/All

Evaluation and Closing

Esther Suter

3:30 p.m.

Adjourn

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All

Workforce Research and Evaluation

Appendix 2: Participant List Participants Amanda Wilhelm Andrea Desjardins Andrea Wagner Anne Marie Downey Arden Birney Brian Geller Caroline McAuley Dennis Kendel Donna Harpell Hogg Esther Suter Farah Jamil Georgia Bekiou Greg Marchildon Heather Toporowski Jasvinder Chana Linda Sawchenko Louise Nasmith Omenaa Boakye Renee Misfeldt Sabrina Wong Sara Mallinson Sheila Achilles

Role Research and Evaluation Consultant, Workforce Research & Evaluation, Alberta Health Services Executive Director, Chinook Primary Care Network Director, Primary Health Services Branch, Saskatchewan Ministry of Health Facilitator, Downey Norris & Associates Inc. Research and Evaluation Consultant, Workforce Research & Evaluation, Alberta Health Services Director, Professional Affairs, Saskatchewan Medical Association Director, Primary Care Integration, Alberta Health Services Consultant Policy and Practice Consultant, College and Association of Registered Nurses of Alberta Director, Workforce Research & Evaluation, Alberta Health Services Acting Director, Education and Collaborative Practice, Alberta Health Executive Lead, General Practice Services Committee Canada Research Chair and Professor, Johnson-Shoyama Graduate School of Public Policy, University of Regina Lead, Provincial Primary Care, Alberta Health Services Executive Director , Primary Health Care, Alberta Health Adjunct Professor, School of Nursing, University of British Columbia Medical Doctor, College of Health Disciplines, University of British Columbia Research and Evaluation Consultant, Workforce Research & Evaluation, Alberta Health Services Senior Research and Evaluation Consultant, Workforce Research & Evaluation, Alberta Health Services Associate Professor, School of Nursing and Centre for Health Services and Policy Research, University of British Columbia Research and Evaluation Consultant, Workforce Research & Evaluation, Alberta Health Services Director, Primary Health Care, Saskatoon Health Region

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Appendix 3: Comparative Review of the Policy Landscape on Team-Based Primary Care Service Delivery in Western Canada - Research Overview

Comparative Review of the Policy Landscape on Team-Based Primary Health Care Service Delivery in Western Canada

RESEARCH OVERVIEW

May 22, 2014

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Research Team Workforce Research and Evaluation, Alberta Health Services Dr. Esther Suter Dr Renee Misfeldt Dr Sara Mallinson Amanda Wilhelm Omenaa Boakye Saskatchewan Dr Greg Marchildon Adam Smith Andrea Wagner Dr Dennis Kendel Alberta Caroline McAuley Bernard Anderson Dr Crista Carmichael Dr Daniel Lai British Columbia Dr. Louise Nasmith Dr Sabrina Wong Dr Brian Evoy

Director Senior Research and Evaluation Consultant Research and Evaluation Consultant Research and Evaluation Consultant Research and Evaluation Consultant Professor and Canada Research Chair in Public Policy and Economic History, Johnson-Shoyama Graduate School of Public Policy Doctoral student, Johnson Shoyama Graduate School of Public Policy, University of Regina Director, Primary Care Services Branch, Saskatchewan Ministry of Health Health Care Consultant Director, Primary Care Innovation and Integration, Alberta Health Services Executive Director, Workforce Policy and Planning, Alberta Ministry of Health Director, Workforce Strategies Branch, Alberta Ministry of Health Professor, Faculty of Social Work, University of Calgary Professor, College of Health Disciplines, University of British Columbia Associate Professor, School of Nursing, University of British Columbia Former Executive Lead: Divisions of Family Practice, British Columbia Medical Association

Acknowledgements The research team would like to thank the key informants from the three provinces who generously gave us their time to validate the policy analysis and offered thoughts about policy options for team-based primary health care. The project is funded through the Canadian Institutes of Health Research Healthcare Renewal Grant (grant number 168121)

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BACKGROUND

Much has been reported on the challenges, successes and current state of team-based approaches in primary health care. Recent reports conclude that widespread progress has been made and that primary health care has entered a period of transformational change. Key initiatives have focused on primary health care teams and networks that include physicians. However, since overall policy development and implementation is provincial jurisdiction, each province has chosen different ways to conceptualize and operationalize primary health care team-based service delivery. Strategies and frameworks are driven by unique provincial political, social and economic contexts and different policy levers have been employed differently across jurisdictions to support primary health care reform. There are few, if any, detailed examinations of the policy and regulatory landscape that would provide an improved understanding of the key dimensions that support the implementation of team-based service delivery models in primary health care.

1. THE PROJECT

The Canadian Institutes of Health Research (CIHR) funded a 12 month research project under the Healthcare Renewal Policy Analysis program to explore policies on team-based primary health care. The main research questions are: 3. How do policies, including regulations and legislations inform the design and implementation of team-based primary health care service delivery? 4. What can we learn from the experiences of the three provinces to inform key policy options for a pan-Canadian approach for team-based primary health care service delivery? Three provinces were chosen for the comparative policy analysis: British Columbia, Alberta and Saskatchewan.

2. METHODOLOGY

The project has 5 stages: 1. Context Review: A review and comparative analysis of diverse evidence (including newspapers, blogs, bulletins, reports, papers) to understand the recent history and current policy context of primary health care in each of the three provinces.

2. Policy Review and Synthesis: A content review and extraction of publicly available, formal

policy documents. A policy synthesis was created for each of the provinces to identify cross cutting key themes around policy development and the implementation of team-based primary health care. 3. Stakeholder Interviews: Open-ended interviews with 8-10 key informants from each province, with 3 goals in mind: • To validate the provincial policy syntheses

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•

To explore in greater detail the key policy drivers identified in earlier stages of the review in each province; and • To gather stakeholder recommended policy options to advance team-based primary health care for refinement and ranking by key knowledge users on the research team. 4. Policy Roundtable: Senior health system stakeholders from the three provinces are invited to discuss the top policy options with the potential to move team-based primary health care forward. 5. Knowledge Translation and Dissemination: Final report drawing together the phases of the study, including versions of the policy options agreed at the roundtable, plus supporting information on the feasibility, acceptability and potential impact, and an action plan for provincial and national dissemination.

3. INTERIM FINDINGS

Evidence from the context review, the policy review and synthesis, and the stakeholder interviews is being integrated into a comparative analysis of Alberta, Saskatchewan and British Columbia. Our interim findings are outlined below. i) Conceptualization of Team-Based Care There are different definitions of team-based care and some variations in the language being used. Our focus was on the extent to which a conceptualization or definition of teams is included in the policy frameworks and the amount of supporting information explicating the provincial definition. In all three provinces, the strategic level policy documents and legislative frameworks do not provide detailed descriptions of primary health care teams. The composition, structure, and rationale for teams are left undefined. This may be intentional, thereby allowing teams to be configured in a way that meets community needs, or it may simply reflect a tendency for high level documents to focus on direction setting and to not include operational details. ii) Policies on Team-Based Care Provincial mandates set out the overall structure and direction for regional health authorities regarding primary health care services. All provinces demonstrate flexibility in policy implementation. Saskatchewan: In 2012, the Province released its Primary Health Care Framework, which provides a comprehensive vision on team-based primary health care. The Framework is geared

towards developing a model that is flexible and able to configure services to meet community needs, with communities defined very broadly: “… by geography, by need, or by culture”. An offshoot of the Framework is the establishment of eight innovation sites to serve as ongoing learning sites for

team-based care. Alberta: Alberta released a Primary Health Care Strategy in May 2014. The two main structures for delivering primary health care are: Primary Care Networks, which are physician led and have 15

Workforce Research and Evaluation generally given participating physicians considerable flexibility to configure health care services and teams; and Family Care Clinics, which can be physician or nurse practitioner led, and have a more explicit requirement for team composition and services to be specified in business plans. British Columbia: British Columbia released its Primary Health Care Charter in 2007, which notes that family physicians are the cornerstone of primary health care. The Charter mentions team based care at a very high level, but does not clearly conceptualize the approach. iii) Actors in Policy Development The provincial Health Ministries drive much of the policy development in the three provinces, though they are moving towards involving other actors or partners in this process. The three main groups of actors are: Family Physicians: Historically, implementing team-based primary health care has depended on the buy-in of family physicians; for example, British Columbia’s Primary Health Care Charter is premised on a partnership between the provincial government and the then British Columbia Medical Association (now Doctors of BC). The Primary Care Networks in Alberta were originally established as tri-partite agreement between the health ministry, Alberta Health Services and The Alberta Medical Association. In Saskatchewan, each primary health care team is expected to include or be connected to a family physician. Other health care providers: Often, the type and scale of involvement of other health care providers in developing and implementing policy around team-based primary health care cannot be discerned form the publicly available policy documents. Physicians, pharmacists and nurses on various working groups participated in developing the Saskatchewan Primary Health Care Framework and the British Columbia Primary Health Care Charter. Alberta involved diverse actors in the development of the Primary Health Care Strategy via a ministerial working group. Communities: Saskatchewan’s overall policy shows a move towards community engagement in policy development and implementation. The engagement and role of communities in drafting the British Columbia provincial and health authority policy is less clear. Some health authorities, such as Northern Health, have community integration committees to solicit input from community members on primary health care. Alberta is incorporating community engagement within Family Care Clinic development and governance, but community involvement in the development of the Primary Care Strategy is unclear. iv) Factors Influencing Team-Based Primary Health Care We identified the following key issues that influence primary health care policy implementation: Team leadership: In British Columbia and Alberta, team leadership is implicitly viewed as the purview of family physicians. Saskatchewan’s Framework does not explicitly identify any profession as de facto team leaders. In Alberta’s Primary Care Networks, physicians lead service delivery and governance structures while the new Family Care Clinics model creates the possibility for other health care providers to have a leadership role. Resource Allocation: All three provinces invest in primary health care. Saskatchewan invested $5.5 million in 2012 to strengthen primary health care services. Sustainable funding is in place for

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Workforce Research and Evaluation the eight innovation sites. Alberta also continues to invest in the Primacy Care Networks and Family Care Clinics with $208 million allocated in the 2014/15 budget to ongoing operations of the province’s 42 Primary Care Networks and up to $45 million for the establishment of nine new Family Care Clinics. British Columbia’s investments in team-based care are less clear. Funding for primary health care in the province flows through physician organizations (e.g. the General Practice Services Committee) as well as regional health authorities. British Columbia provides incentives to family physicians to provide a wide range of primary health care services (e.g. preventative services, mental health and maternity care). Funding and Compensation Models: Existing funding models can limit the ability of some providers to fill identified service gaps or join teams. Fee for service payment is often described as a constraint to service innovation and new ways of working such as team-based care. The “whites of eyes” rule is a particular problem, since it means physicians need to see a patient to be compensated. On the other hand, flexible physician engagement and payment models, such as blended contracts, may encourage physicians to be part of teams. Integrating other health care providers into primary health care teams requires additional resources (for example to improve infrastructure or to provide change management support) and this is often not routinely available. Accountability and performance management: Clear goals, indicators and accountabilities for team-based care and collaborative practice may help to drive change. For example, Saskatchewan’s Framework for Primary Health Care proposes benchmarks such as the engagement of physicians in primary health care teams and the logic model outlined in Alberta’s Primary Care Strategy and it’s Evaluation Framework include interdisciplinary collaborative care as a key enabler for system and practice change. In British Columbia the Ministry monitors the delivery of health services, which informs strategic planning and policy direction. An external evaluator and committee review initiatives by the General Practice Services Committees (GPSC). The British Columbia Primary Health Care Charter mentions the need to evaluate integrated health network teams and physician incentive payments. Tools and Processes: Saskatchewan has integrated quality improvement through LEAN technologies as part of its overall health care transformation program. The Framework aims to ‘enable’ teams to implement clinical practice redesign and continuous quality improvement through facilitation and change management supports. In Alberta, the Primary Care Strategy, and Family Care Clinic reference documents, reference standards and frameworks that, at least in part, consider team-based care and collaboration as part of culture change. These include, for example, the Alberta Access Improvement Measures (AIM), the Alberta Collaborative Practice and Education Framework for Change and the Canadian Interprofessional Health Collaborative documents as reference tools. British Columbia’s Charter emphasizes implementing evidence based quality improvement practices which have been refined based on international primary health care experiences as well as experiences of providers and health authorities. Outcome measures are outlined in the Charter which aligns the direction of the Ministry with regional health authorities. The collaborative approach in British Columbia entails both top-down (system redesign) and bottom-up (practice redesign) approaches. The Triple Aim Initiative is used by the

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Workforce Research and Evaluation General Practice Services Committee to assess existing and new initiatives. Progress in achieving goals is also tracked through performance scorecards. Other factors: Some of the policy documents alluded to other areas for consideration such as recruiting and retaining health care providers, especially family physicians in rural and remote area or the need to expand roles of some health care providers (such as pharmacists) to enable team-based care. It was also recognized that appropriate infrastructure and information systems need to be in place to support collaboration. Team-based care is highlighted as a foundational value

within the policies. This requires a culture shift among team members to optimize the role and contribution of each provider.

v) Policy Options to move team-based primary health care forward. We used the key issues highlighted through the documentary review and policy synthesis in combination with reflections from the interviews with key stakeholders to create a list of policy options with the potential to move team-based care forward. The policy options were diverse in scope and focus. They were grouped into the following themes: • • • • • •

Payment, billing and funding issues Conceptualization of team-based care System alignment to support team-based care Information management and privacy Engagement and communication Scope of practice, regulation, liability

The first list of policy options, initially drafted by the WRE team, was revised and then ranked by knowledge-user members of the research team based on perceived relevance, feasibility and impact. The policy options with the highest combined rank score are the focus of the discussion at the roundtable. Participants at the roundtable will discuss and validate the draft policy options outlined in the document Comparative Policy Options (attached in the email dated May 15th 2014) and further refine them to the top three. The roundtable will also give stakeholders an opportunity to suggest key elements to be incorporated in an action plan.

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Appendix 4: Research Overview PowerPoint Presentation

Welcome

Comparative Review of the Policy Landscape on Team Based Primary Health Care Service Delivery in Western Canada

• Focus on team based primary health care in Canada • Large investments in primary care driven by First Ministers Agreement (2000) - includes $800m Primary Care Transition fund (2001)

Workforce Research and Evaluation Roundtable, May 22nd, 2014

• Development of primary health care structures varies across Canada (FHT, Divisions of Family Physicians, PCN, FCCs, Health Innovation Sites)

Funded by the Canadian Institutes of Health Research

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Acknowledgements

Research project funded under CIHR Healthcare Renewal Policy Analysis program:

Core Team Members: Dr. Esther Suter, Dr. Renee Misfeldt, Dr. Sara Mallinson, Omenaa Boakye, Amanda Wilhelm Saskatchewan: Dr. Greg Marchildon, Dr. Dennis Kendel, Andrea Wagner, Adam Mills Alberta: Caroline McAuley, Crista Carmichael, Dr. Daniel Lai, Bernard Anderson British Columbia: Dr. Louise Nasmith, Dr. Sabrina Wong, Dr. Brian Evoy Funded by: Canadian Institutes of Health Research (CHIR)

• How do polices inform the design and implementation of team based primary health care? • What can we learn from the experiences of three provinces to inform policy options? 3

Meeting Objectives

4

Meeting Rules

• Share key findings from policy synthesis

• Everybody’s wisdom is appreciated and important to achieving the best results

• Discuss clarity, relevance and feasibility of policy options

• You will hear and be heard

• Discuss implementation considerations and impact of policies on health and health systems outcomes

• There are no wrong answers - only perspectives • You can change your mind

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Workforce Research and Evaluation

Research Objectives

Methodology

Compare policies relevant to interprofessional teams in

• Context Review

primary care in three provinces (British Columbia, Alberta,

• Policy Review and Synthesis

Saskatchewan) and identify policy options to move team

• Stakeholder Interviews

based primary health care forward.

• Integration and Development of Policy Options • Roundtable

7

Interim Findings

8

Interim findings (continued) • Key actors and policy development

• Conceptualization of team based care

• Factors influencing team based care

• Policies on team based care

Team leadership

Resources

Accountability

9

Policy Options

Tools & processes

10

Policy Option One

Themes • • • • • •

Compensation

 Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize team based primary health care

Payment, Billing and Funding Conceptualization of Teams System Alignment Information and Privacy Engagement and Communication Clarity of Scope of Practice/Regulation/Liability

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12

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Workforce Research and Evaluation Policy Option Two

Policy Option Three  Invest adequate resources to support system change and a team based primary health care model

 Develop appropriate and sustainable compensation models to support team based primary health care

13

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Policy Option Four

Next Steps

 Integrate consistent collaborative practice metrics in primary health service monitoring and evaluation

• Evaluating the options • Clarity • Feasibility • Relevance • Priority of the options • Impact and implementation challenges 16

15

Thank you!

Questions?

Workforce Research and Evaluation, Alberta Health Services http://www.albertahealthservices.ca/wre.asp [email protected]

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Workforce Research and Evaluation

Appendix 5: Policy Options for Discussion

POLICY OPTIONS 1. Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize team-based primary health care The need to better align health system goals and resources was evident across all three provinces at the provincial, regional and service delivery levels. There are several examples of how a lack of system alignment undermines collaborative practice and created barriers to team-based care. For example clinics may refuse nonphysician referrals despite the promotion of team-based delivery in new primary care structures. Different governance structures also create separate lines of accountability between health regions and family physicians. Well-articulated goals that are relevant to, but extend beyond primary health care, may help to remove barriers and advance team-based care. 2. Develop appropriate and sustainable compensation models to support team-based primary health care Concerns about compensation models and their potential impact on service delivery, service improvement and team-based models of care emerged from the review in all three provinces. While fee-for-service (FFS) is currently the dominant funding model, it is recognized that FFS (and the ‘whites of eyes’ rule in particular) may limit some aspects of collaboration and tend to promote status quo in services over innovation. It is a priority to identify alternative payment models that are perceived to be equitable by primary health care team members, facilitate collaborative practice, and support innovation and improvement. 3. Invest adequate resources to support system change and a team-based primary health care model Each province has made significant investments in primary health care, some of which clearly support the development and implementation of team-based primary health care models. Ongoing funding is required to sustain new models of working and strengthen the team approach. This might include resourcing health service infrastructure conducive to team-based care (for example EHRs that can be shared by team members, or primary health care facilities that provide an opportunity for teams to do collaborative work), or providing change management support for people moving to new models of delivery. Sustainable changes to practice are likely to need long-term investments in training, professional development programs, and leadership support to ensure the workforce has the skills and competencies needed for team-based primary health care. 4. Integrate collaborative practice metrics in primary health care monitoring and evaluation Both Saskatchewan and Alberta have monitoring and evaluation frameworks to guide ongoing evaluations of primary health care. It is important to have comparable indicators across provinces as this will assist in the evaluation of comparative cost-benefits of various models. There is a need to develop consistent collaborative practice metrics and include them in primary health care evaluation frameworks. Collaborative practice metrics will help to drive improvement of new models of working by requiring providers to plan and report activity and by identifying things that work well, and can be shared, and areas that need additional support.

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Workforce Research and Evaluation

Appendix 6: Small Group Discussion of Policy Options

Key Elements of Policy Options Policy 1: Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize team-based primary health care Group A •

•

• •

• • •

• • •

Need a systems perspective and approach - “committed to thinking and acting as one” Need to realign the ministry and health authorities and consider who else needs to be aligned Need to define primary healthcare - OT, dentist, pharmacist, insured services; care vs. healthcare Most family physicians practice outside the “system” - those missed seen to be responsibility of health authorities Population health changes are the end point; the vision Need a workforce inventory Need to refocus resources; must first know how dollars are spent now “Better team” is a distinct goal in SK These are integrated policy imperatives vs. options Need to be clear about how information is shared

Group B •

• •

•

• • • •

A systems approach, integrated with community supports, education, police, mental health, etc. - policy makers in all sectors know primary health care (PHC) is foundational to improved health care system and addressing social determinants of health; may require interdepartmental integration (e.g. justice, health) Government and key organisations are making PHC a priority. Alignment comes from the establishment of shared priorities, the development of trust and a grassroots approach.. A system that enables local solutions to health issues important to achieving sustainable systemwide outcomes Clear accountabilities for health outcomes Policy supported by clearly defined stakeholders Need a common infrastructure Get the public on board with PHC

23

Group C • •

•

•

•

• • • •

Need an inventory of current state first - consistency needed. Ministry pays physicians and authorities pay rest – separation does not help alignment Need to address accountability RHAs driven by a balanced budget; control of funds; Physicians accountable to themselves and collectively to master agreement. Alignment around primary health care vs. primary care; need to move from physician-centric to patientcentered New governance structures should be considered to bring together PHC under one system Allocation of monies to a shared fund - ministry & RHA dollars System-level conversations needed Clarity around roles Forced redistribution of workforce

Workforce Research and Evaluation Policy 2: Develop appropriate and sustainable compensation models to support team-based primary health care Group A • • •

• • •

•

FFS can stifle physician initiatives and challenge team-based models FFS becoming less of an option; does it have a place? Be creative and look at: - blended comp. models - New Zealand - region holds $ - dentists where comp. played large role in big changes screening, electronic records Link more strongly to system alignment Policy needs to apply to all, not only physicians Look at integration of authority funded nurses into FFS as an example Add “achievement of health system goals” to statement

Group B •

•

•

•

Define population health needs understand resources available, align to meet population health needs, deploy to sustain new model Update/design compensation models to reflect environment in which today’s providers operate Broaden compensation discussion to consider how all providers are compensated (e.g. community based pharmacists) No one size fits all model, but approach could be similar as part of an overarching strategy that enables local solutions based on available resources

Group C •

•

•

•

• •

Payment model impacts behaviour, e.g. volume driven FFS, especially ‘whites of eyes’ rule, does not support continuity of care or team models. Central funding is important, but not sufficient to enhance teambased care; must change incompatible payment models across all provider groups Cultures of practice are entrenched and payment models are part of the culture. Must be addressed as part of overall realignment. Innovative/flexible strategies should be incorporated into compensation redesign e.g., incentive payments may support care delivery and increase interaction, i.e., BC - $200 million incentive payments Evaluation: need to tie payments to outcomes Appropriate provider for patient and communication between providers fundamental

Policy 3: Invest adequate resources to support system change and a team-based primary health care model Group A • •

• •

•

•

Challenge when policy imperative very broad Need ongoing funding, rather than one-time, to sustain new ways, e.g. shared care plan with EMR Some cost is inherent in change; need accountability Need to understand what is spent now on primary healthcare; what does the literature say is good ratio/value for dollars Need evidence based decisions when allocating resources and tangible measures of progress Public may not accept changes resulting from primary healthcare success, e.g., closing unneeded

Group B • 





 

Support leaders, providers, etc. through good change management Resources for communication that enables care, i.e., help providers work in teams; systems that talk to each other; effective use of IT Reallocation/new dollars and people, e.g., nurse practitioners, allied health Integrate all providers into the PHC team; govt. should not advance any profession; integrating providers as appropriate should be the focus Invest in training providers to work in collaborative/team environments Provide opportunities for providers to work in collaborative teams; some providers/students can’t find

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Group C 









Provide space/infrastructure virtual team work possible, but close proximity still crucial Primary care vs. primary health care funded by govt., i.e., new BC projects funded by divisions of FP and physician teams – BC govt. policy; 2 extreme models. Need to create better knowledge base - articulate existing/new models and share Need to ensure adequate technology (e.g. EMR) to facilitate collaboration Need appropriate training/change management at all levels, including through basic education - teach providers how to work in a

• •

• • •

Workforce Research and Evaluation

hospitals/services Embed team-based care in education programs Need current state assessed to determine what to fund first, i.e. education, EMR, etc. Investments tied to ROI/patient outcomes; need business cases What outcomes do we want from team-based care?; solutions and funding depend on this ‘Value screen’ mapping, e.g., how can we rework primary healthcare to reduce need for access to ED

teams in which to work; trained to work in teams but clinical practice teams not available



team/collaborate and promote culture of collaboration Seek consistency

Policy 4: Integrate collaborative practice metrics in primary health care monitoring and evaluation Group A 

     





What is measured? Are they the right measures? What do they prompt us to do? How is access at the population level measured? Current efforts are disjointed Need to demonstrate ROI No collaboration measures in AHS Measure to improve vs. to account for actions - both needed Improvement measures most lacking; easier area to engage staff Simple outcome measures for patient populations necessary did patient outcomes improve, e.g., physician report cards with comparison to other clinics Collaborative practice metrics too narrow; need health outcomes and system improvements also Team processes/effectiveness need to be monitored, i.e., team survey re effectiveness and satisfaction

Group B 



 

Develop team metrics - patient outcomes, effectiveness, community health Move away from solely collecting financial metrics; financial metrics do not accurately capture if a provider is contributing to the team Metrics should measure multiple outcomes Metrics need to be used to encourage collective responsibility to improve practice

Group C 







  

25

Need to create good quality information and comparison – that means developing useable metrics for routine evaluation and monitoring, negotiations between govt. and physicians, and govt. and salaried providers Transparent metrics and broad dissemination to get comparable data Set expectations around monitoring indicators of team-based care but also look beyond to its impact on patients and practitioners Be aware that metrics alone will not drive collaboration; definitely not the means to the end Stewardship is missing Time consuming Address any misconceptions around privacy and access to data

Workforce Research and Evaluation

Inherent Conflicts and Potential Trade-offs Group A 





 

   







   



Policy imperatives all interdependant; doing one impacts others; systems approach; about sequencing vs conflicts/trade-offs E.g., if FFS replaced by contracts may see exodus of physicians from some areas E.g., if primary healthcare improved may see change in emergency use; does that mean change in emergency staffing? Policies 1 & 2 need to come 1st Workforce issues important consideration; staff input/ say important but team-based care should not be optional Team composition needs to be based on evidence and data Need to align dollars with health systems goals Need to reframe primary healthcare - not a ‘department’ Be careful to not create duplication; need metrics to identify this Could change the funding model – providers have access to new funding if committed to the new care model Reimbursement model has the most potential for ‘disruptive impact motivation’ Rostering – formal way to fund, tied to compensation; called ‘attachment’ in Chinook, but not tied to funding Encourage ‘competitive nature’ around performance Prepare for physician backlash If one province makes the move, others will be impacted Team-based care ‘frees up’ physician time doing tasks that other are qualified to do Need patient education

Group B  





Conflicts arise when alignment is missing Cherry picking by policy makers of parts of interdependent policy directions will result in conflicts Implementation of policy option #1 will drive the other three policy options. But these need to reflect provincial contexts (e.g. Sask is more geographically dispersed) Need leadership, to encourage dissention, and to have the courage to stay the course. Need strategy for the “roll-up” of successful models.

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Group C Not necessarily mutually exclusive options, but might be approached selectively. This would limit impact as there are important interdependencies. Policy 1:  Governance shift will have radical implications. Realignment of structures, policies and workforce  Need to examine the whole system (acute care, primary care, etc.) to explore optimum redesign. To run both systems in parallel would be great, but this requires $$.  Need to stop reinventing the wheel. Policy 2:  Of the 4 options, this one easier to isolate; it’s the only one governments have looked at and experimented with. That is dangerous because it is only one part of the wider system alignment needed Policy 3:  Take care not to assume that ‘if we build it, they will come.’ When looking at infrastructure etc. Creating a culture of collaboration and team-based primary health care requires additional supports. Policy 4:  Has to be embedded in all policy options; overarching/underpinning  Requires clear accountability structures  Need an information system to support it  A quality improvement ethos to drive monitoring could result in change 

Workforce Research and Evaluation

Appendix 7: Small Group Discussion of Outcomes and Implementation Factors Outcomes for this Policy to Achieve

Factors/Considerations for Implementation

Policy 1: Align health system goals, policies, workforce and structures (Ministry of Health, regional health authorities and independent practices) to optimize team-based primary health care            

Clear accountabilities to avoid and reduce multiple systems and cultures clashing Consistent practice guidelines; interprofessional approach Sense of team and commitment to team Reduction of duplications and gaps in care Better patient experience Easier recruitment and retention of staff Increased patient and provider satisfaction Better responsiveness - continuity of care, hrs. of access, range of interventions, patient information, etc. Reduced disparity in how resources/services are allocated Providers working to full scope of practice Fiscal sustainability More overarching professional body – alignment across professional bodies

     

   

    

Big effort put into current system; may get resistance, as success can’t be guaranteed Current structures need to be altered - unions, contractors, medical associations Community must be engaged & trust that process/decisions will be transparent Need perseverance and patience at the political level; will be some noise; consider the political cycle Can’t expect overwhelming acceptance; 60% hopeful Sheer complexity; will be risk and unintended consequences; need to adjust as we go; build in research and measurement from start Provider engagement is necessary Prototype certain implementation details if possible, e.g., governance model for shared space; collect good data Build good spread model to ensure it gets good traction Need marketing campaign to increase demand by public for changes to PC vs. acute; sell by communicating clear impact on patients and community; concrete examples Political sustainability important; Ministry must drive; demonstrate better patient outcomes and satisfaction Needs to be understood financial sustainability takes time Transition period needed for redistribution of resources; short period of duplication Have to work closely with stakeholders, i.e., unions, health authorities, etc. Should be a careful use of incentives and regulations

Policy 2: Develop appropriate and sustainable compensation models to support team based primary health care 

    



Single pot of money to allow consideration of other models, ensure right providers for every patient, reduce duplication of services Know what we want and need providers to do and design system and funding around that Improved physician work life balance Patient satisfaction with care Same goals and outcomes to drive new payments equals cohesive team Alignment of remuneration with modern health system; demands to build strong and sustainable PHC system; best model based on population needs; cost avoidance planning to keep sustainable; needs keep shifting so can’t be static Look at whole system; strong PHC system reduces costs in acute care and ER, but cost savings are not



    



27

Recognize all compensation models have challenges how they are applied is critical; need flexibility to adjust for context, e.g., part-time/occasional, FFS for dieticians, consultants, physiotherapists, dentists, pharmacists, etc. Team-based quality metrics to underpin pay changes Accountability needed around alternative payment systems – what works, what exists already? Change outcome measures to align with changes in funding structures and team-based care Include all providers and patients, in setting metrics, goals and payment ‘package’ Currently lack defined problem and solution – what is it we want to achieve; what are we doing now, what approaches to pay would help achieve goals; work back from what you want to achieve Ministry level responsibility – implementation needs to be

Workforce Research and Evaluation Factors/Considerations for Implementation

Outcomes for this Policy to Achieve demonstrated immediately; can’t expect quick wins 

aligned and have single accountability structure Manage expectations from patients and public about who they see and how often

Policy 3: Invest adequate resources to support system change and a team based primary health care model 

      

 

Patient gets right care from right provider at right time; measure access; use community resources, e.g., spiritual elders for counselling; not all conditions medical Improved patient health outcomes Better use of existing resources - providers skills and knowledge, program resources Better patient safety Reduced readmissions to hospitals; better transitions between care providers Less duplication of efforts Culture change among providers and patients; more working teams and less hierarchy Reduce/avoid cost of more expensive institutions and reallocate resources - bending the cost curve; may not always happen Enhance citizen reliance Focus on these outcomes will address the triple AIM

           



Not all providers will be supportive of the change Invest to reap the benefits; new and old must run simultaneously as old is phased out Change culture for up and coming providers via education - colleges and universities Change culture at the workplace; continuous education, skill development and education Resources to support collaborative practice Availability of resources - $, human, collaborative practice facilitators Clear understating by public and govt. of how collaborative practice fits with other priorities., e.g., wait times Return on PHC investment takes time; stay the course Difficult to measure PHC success Engage public/patients to advocate for change; use real people and stories Engage stakeholders early and involve in decisions; need buy-in - govt., providers, patients to improve alignment Understand the current state and use information to plan the future; lack of understanding leads to duplication and lack of alignment Health system bombarded with change

Policy 4: Integrate collaborative practice metrics in primary health care monitoring and evaluation       

     

Measure for improvement - small scale changes; quick feedback; ongoing change; builds team Better patient outcomes and population health outcomes, but less impt. to advance team effectiveness Multi-layers of measurement; lag and lead Right provider/right time/right situation Integration of action and delivery Increased team effectiveness better coordination and continuity of care where needed, particularly for chronic, severe and multiple morbidities Engagement of team members Increased provider retention Increased positive experiences and satisfaction by providers with working in teams Reduced hospital stays - #, length, emergency visits, readmissions Critical that desired outcomes be measurable Efficiency/cost

        

  



28

Review existing/available data Build the data inputs Timely liberation of available data, while protecting privacy Exploit EMR data, administration data and cross ref. Interoperability of multi sources of data Security of data is important consideration Public perception of, trust in and confidence that they are getting quality care that is well coordinated Ability for providers across system to chart in one place Patient access to information to monitor their care and how it is coordinated - patient portal developed from patient perspective, e.g., Kaiser Permanente in US A small set of clear standards/metrics are needed Data comparing GP practices; team reviews to improve from each other Build capacity to learn from each other locally, provincially and nationally, and to learn from patients; include capacity to measure Common technical/IT systems in to be in place and integrated to

Workforce Research and Evaluation

Appendix 8: Evaluation Findings

Introduction This report provides an analysis of the participant evaluations for the May 22, 2014 Roundtable on Policy Options for Team-Based Primary Health Care. 15 participants were given the opportunity to complete the evaluation form; seven (47%) participated in the evaluation.

Quantitative Data The following tables provide a summary of the Likert survey questions. Introduction and Small Group Discussion of Policy Options (Morning)

Percentage of Respondents (n=7)

80% 70% 60% 50% 40% 30% 20% 10% 0% The objectives were clear

The presentations were informative

The small groups were an effective way to discuss each of the 4 policy options

Strongly Disagree

0.00%

0.00%

0.00%

0.00%

0.00%

Disagree

0.00%

0.00%

0.00%

0.00%

0.00%

The small groups were an effective way to prioritize the policy options

There was sufficient opportunity to share my insights

Neutral

0.00%

0.00%

0.00%

0.00%

0.00%

Agree

71.43%

71.43%

28.57%

42.86%

42.86%

Strongly Agree

28.57%

28.57%

71.43%

57.14%

57.14%

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Workforce Research and Evaluation

Small Group Discussion on Implementing Policy Options (Afternoon)

Percentage of Respondents (n=7)

80% 70% 60% 50% 40% 30% 20% 10% 0% There was sufficient opportunity to share my insights

The chosen policies are feasible and appropriate for implementation

Appropriate stakeholders were identified in the engagement plan for implementation of the policies

0.00%

0.00%

0.00%

0.00%

Disagree

0.00%

0.00%

0.00%

0.00%

Neutral

0.00%

0.00%

14.29%

0.00%

Agree

42.86%

42.86%

57.14%

71.43%

Strongly Agree

57.14%

57.14%

28.57%

28.57%

The small groups were effective in discussing implementation of policy options

Strongly Disagree

Overall Event Assessment

Percentage of Respondents (n=7)

80% 70% 60% 50% 40% 30% 20% 10% 0% The pace of the The event was event was well organized appropriate

I had an There was The facilitator opportunity to The venue was enough time was effective in share for questions engaging appropriate information and discussion participants and network

Strongly Disagree

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

Disagree

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

Neutral

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

Agree

71.43%

71.43%

71.43%

57.14%

42.86%

42.86%

Strongly Agree

28.57%

28.57%

28.57%

42.86%

57.14%

57.14%

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Workforce Research and Evaluation

Qualitative Data The survey had a number of open-ended questions. The following is a summary of participant responses. What participants liked most about the event • Small group discussions (2) • Having the opportunity to discuss each policy • Effective facilitation (2) • Learning from other participants Suggested Areas for Improvement • Provide more detailed background material on the state of team-based primary care in the three provinces • Bundling ideas makes action hard and ideas lose sharpness and focus Overall Comments: • Excellent use of time • Everyone had opportunity for input

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