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Policy PointsConsiderable investments have been made to build high‐performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions.There is significant variation in the degree of implementation of structural features of high‐performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. Context: Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high‐performing primary care systems. Methods: A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high‐performing primary care systems to describe each case and assess changes over time. Findings: The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. Conclusions: Progress toward building high‐performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research. [ABSTRACT FROM AUTHOR]

Context: During the last decade, Canada's provinces and territories have embarked on primary care reform toward high-performing systems. A paper entitled "Towards Primary Care Strategy" identified 12 features of high-performing primary healthcare systems. Objective: This study examines the evolution of primary care systems across Canada between 2013 and 2021. Study design and Analysis: A multiple comparative case-study approach was used to explore changes in the 13 Canadian jurisdictions. Each case consisted of: (1) qualitative interviews with academics, provincial leaders, and healthcare professionals) and 2) a document and literature review of policies and innovations. Data for each case were thematically analyzed using the 12 features of high-performing primary care to describe each case and assess changes over time. This was followed by cross-case analyses. Setting: Canada. Population studied: Primary care systems. Intervention/Instrument: Evolution of primary care systems. Outcome measures: Progress in the 12 features of high-performing primary care systems. Results: We found that British Columbia, Alberta, Ontario, and Quebec have made the most significant progress toward primary care transformation in Canada, although no jurisdiction has achieved all attributes. There has been considerable progress in adopting health information technology across the country. Four jurisdictions have established a policy direction for primary care. Some jurisdictions have or are implementing collaborative primary care governance models. More jurisdictions are involved in patient enrollment and supporting quality improvement training. Experimentation with new interprofessional team models and funding arrangements continues. However, more investments are needed for wide-scale implementation of primary care governance mechanisms, interprofessional teams and funding arrangements, patient engagement, comprehensive performance measurement systems, leadership development, systematic evaluation, and building research capacity. Conclusion: The pace of primary care transformation has been slow in Canada. While there has been some progress toward high-performing systems, each jurisdiction has distinct opportunities to advance primary care to the level of best-performing countries. Further funding investments are needed by federal and provincial/territorial governments and by regional health authorities for primary care transformation. [ABSTRACT FROM AUTHOR]

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select 'appropriate' cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying "successful" models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research. [ABSTRACT FROM AUTHOR]

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated communitybased and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them. [ABSTRACT FROM AUTHOR]

Introduction: Community based primary health care (CBPHC) organizations are critical providers of integrated care for complex patients. Exemplar cases exist, but efforts to scale up and spread successful models continue to face major challenges. While scale and spread has become a popular topic, there are still significant gaps in our understanding of what components or activities of integrated care models should and can be spread from one locale or jurisdiction to the next, and to what degree we allow for local adaptation of those activities. Theory/Methods: To address this identified gap we developed a survey for managers and providers in CBPHC organizations that allows respondents to specify which activities require local adaptation for their scale up and spread and which need to be more standardized. The survey builds on learning from the iCOACH project, a study analyzing 9 integrated models of community-based primary health care (CBPHC) in Ontario, Quebec and New Zealand. To develop the survey we carried out 1) a targeted literature review identifying existing reviews of key activities of integrated CBPHC; 2) a workshop session with CBPHC managers and providers to validate the approach and aim of the survey; 3) mapping the findings of the literature review to coded qualitative data from the iCOACH study to validate identified activities; and 4) validation and initial testing of a pilot survey. Results: The literature review yielded 32activities of integrated CBPHC, each of which were found to be present in iCOACH case studies. The workshop session was run in January 2018 with 17 participants. from 3 case study sites. Participants identified all activities as important to models of integrated care; but reported varying needs for standardization or adaptation for specific elements. Discussion from the workshop was used to refine survey wording and structure. The draft survey was tested with managers and providers in CBPHC organizations using cognitive interviewing techniques to refine the instrument. Small scale testing of the survey will be undertaken with staff in 2 CBPHC sites. Discussion: Multiple methods were used to validate the key activities of integrated care; however, the ways in which these activities are implemented in scale and spread efforts are nuanced and context dependent. Conclusions: The survey tool developed will help us to unpack these nuances and contextual influences, with the aim of clarifying core versus peripheral activities of integrated care at different stages of the scale and spread process (e.g., whether early or later stages of adoption). Lessons learned: One critical finding from the symposium was that conceptualizations of fidelity and adaptation are widely varied and needs to be clearly stated in any assessment. Ensuring clarity of these terms was central to the development of this survey. Limitations: While the survey has strong content validity due to our development methodology, additional work will be required to test reliability and other components of validity prior to wider adoption of the survey. Suggestions for future research: Following testing in Canadian settings, we plan to deploy the survey to CBPHC organizations internationally. [ABSTRACT FROM AUTHOR]

Background: Integrated care systems coordinate services for individuals and populations, linking health and community care providers and engaging patients and families to improve outcomes. Many jurisdictions have identified better integration as a key strategy for improving healthcare system performance. But these policies supporting integration are often inconsistent and require local adaptation and alignment to support implementation. This paper reports the experience of 9 community-based primary care organizations in three jurisdictions (the provinces of Ontario and Quebec in Canada, and New Zealand). Detailed case studies of these organizations identify the challenges of integration, the leadership and organizational strategies to foster integrated care, and the unintended consequences of policy frameworks, regulation, funding and program design. Theory and Methods: Results are pulled from the 9 case studies and include document analysis and key informant interviews with providers and organizational managers/leaders from each of the case sites, as well as interviews with policy-makers from each of the three jurisdictions. Qualitative thematic analysis was used to code interview transcripts and documents using both a deductive approach, based on the Context for Integrating Care theoretical framework developed to guide this study, as well as an inductive, data-driven approach. After coding, single case analysis methods will be used to understand tensions at each of the 9 cases, and cross-case analysis methods will be used to compare across the 9 cases. As we are still completing data collection, results presented below are based on preliminary analysis of findings generated from coding a sub-sample of available data. Results: Preliminary data analysis identified common challenges faced by leaders trying to integrate care across programs and organizations. These challenges include inadequate information sharing, often due to limited IT infrastructure and connectivity, inadequate time and human resources to launch new programs, high rates of HR turnover (in some cases), and confusion over "who owns the patient" with regard to integrated practice across multiple organizations. Beyond these organizational level challenges, leaders face a host of funding and policy issues. While funders and regulators in each jurisdiction have provided resources and supports for integration, these supports often take the form of one-time project funding that may not be sustainable over the longer term. Regulatory requirements often vary between programs in different sectors, raising local conflicts about integrating programs. As a result policy frameworks may be inconsistent and not conducive to integrating care, leading organizations to integrate in spite of policy rather than because of it. Policy and regulation thus have unintended consequences, creating tensions for leaders, undermining efforts to integrate care that require managing separate funding streams, conflicting regulatory regimes, and other complexities. Early analysis suggests that lack of sustained funding results in organizations behaving opportunistically rather than strategically, leading to potentially inefficient program designs. Discussion: Preliminary analysis suggests that in the face of these tensions, leaders often rely on past and present inter-organizational partnerships and the opportunities offered by fragmented funding programs to develop more integrated models of care for their patients. Leaders seek to present a coherent image to both funders and patients despite substantial organizational complexity that may create inefficiencies and frustrations for clients and staff. Developing a shared vision and sharing scarce resources have been key strategies in some of these cases to enable partners to secure funding for more integrated programs and provide a more coordinated care experience for patients and their families. Further analysis will illustrate how leaders brought individuals with differing perspectives and goals together from across the spectrum of health and social care to develop more integrated approaches to service. Conclusions: Our findings suggest that strong leadership is needed to navigate the tensions of integrating care. At the organizational level, leaders need to be able to identify and manage these tensions early to avoid inefficient and ineffective program design. Policy makers, in turn, need to assess the unintended consequences of fragmented funding and overlapping program designs, acknowledging the challenges these present for organizational leaders in health care. Finally, investment is needed in strategies to more systematically support and develop leadership capabilities for building collaboration and integration throughout the health system. [ABSTRACT FROM AUTHOR]

This paper focuses on successful engagement strategies in recruiting and retaining primary care physicians (PCPs) in a quality improvement project, as perceived by family physicians in small practices. Sustained physician engagement is critical for quality improvement (QI) aiming to enhance health system integration. Although there is ample literature on engaging physicians in hospital or team-based practice, few reports describe factors influencing engagement of community-based providers practicing with limited administrative support. The PCPs we describe participated in SCOPE: Seamless Care Optimizing the Patient Experience, a QI project designed to support their care of complex patients and reduce both emergency department (ED) visits and inpatient admissions. SCOPE outcome measures will inform subsequent papers. All the 30 participating PCPs completed surveys assessing perceptions regarding the importance of specific engagement strategies. Project team acknowledgement that primary care is challenging and new access to patient resources were the most important factors in generating initial interest in SCOPE. The opportunity to improve patient care via integration with other providers was most important in their commitment to participate, and a positive experience with project personnel was most important in their continued engagement. Our experience suggests that such providers respond well to personalized, repeated, and targeted engagement strategies. [ABSTRACT FROM AUTHOR]