Search

Abstract Background Access to primary healthcare services is a core lever for reducing health inequalities. Population groups living with certain individual social characteristics are disproportionately more likely to experience barriers accessing care. This study identified profiles of access and continuity experiences of patients registered with a family physician working in team-based primary healthcare clinics and explored the associations of these profiles with individual and organizational characteristics. Methods A cross-sectional e-survey was conducted between September 2022 and April 2023. All registered adult patients with an email address at 104 team-based primary healthcare clinics in Quebec were invited to participate. Latent class analysis was used to identify patient profiles based on nine components of access to care and continuity experiences. Multinomial logistic regression models were fit to analyze each profile’s association with ten characteristics related to individual sociodemographics, perceived heath status, chronic conditions and two related to clinic area and size. Results Based on 87,155 patients who reported on their experience, four profiles were identified. “Easy access and continuity” (42% of respondents) was characterized by ease in almost all access and continuity components. Three profiles were characterized by diverging access and/or continuity difficulties. “Challenging booking” (32%) was characterized by patients having to try several times to obtain an appointment at their clinic. “Challenging continuity” (9%) was characterized by patients having to repeat information that should have been in their file. “Access and continuity barriers” (16%) was characterized by difficulties with all access and continuity components. Female gender and poor perceived health significantly increased the risk of belonging to the three profiles associated with difficulties by 1.5. Being a recently arrived immigrant (p = 0.036), having less than a high school education (p = 0.002) and being registered at a large clinic (p

Abstract Background Being attached to a primary care (PC) provider is at the core of a strong primary health care system. Centralized waiting lists (CWL) for unattached patients have been implemented in eight provinces of Canada to support the attachment process. In Quebec, the Ministry of Health mandated the implementation of Primary Care Access Points (GAP) across the province to help unattached patients navigate the health system while awaiting attachment through the CWL. Several local health territories developed complementary innovations to the GAP to respond to local population needs. This paper aims to describe five organizational innovations implemented locally. Methods This multi-case qualitative study was conducted in four local health territories in the province of Quebec. Fifty-two semi-structured interviews with healthcare managers, nurses, physicians, other health professionals and administrative staff were conducted between April 2023 and April 2024. An interview guide was developed based on existing frameworks on the implementation of innovations and the evaluation of the GAP. Thematic analysis was conducted using NVivo software. Inductive and deductive approaches were used to develop relevant codes and themes. Logic models were built to describe the organizational innovations. Results Five organizational innovations are described. First, a multidisciplinary clinic aimed at responding to patients with mental health issues was implemented. Second, a nurse clinic was implemented to provide temporary care for patients with unstable chronic illnesses. The third innovation is a mobile proximity clinic where unattached GAP patients are first evaluated by a paramedic before receiving care from a nurse. Fourth, a pharmacist trajectory was implemented to increase engagement of community pharmacists to respond to GAP patients. The last innovation is a decentralized GAP offering in-person nursing care to unattached GAP patients. Conclusions Descriptions of these five innovations are key to inform other territories and provinces on ways to improve access for unattached patients while they are waiting to be attached. The introduction of the GAP and the organizational innovations, suggests a transition where access to PC services does not rely solely on attachment status.

Abstract Background Overcrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators. Methods We performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding. Results Of 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p

Abstract Background Cardiovascular disease is the leading cause of death worldwide. Cardiac rehabilitation (CR) programs are recognized as effective in reducing the burden of cardiovascular disease. However, CR programs are offered inequitably across regions and are available in less than 15% of remote areas worldwide. The main goal of this study was to design a CR program adapted to the contexts of remote areas to improve the service offered to patients. Methods We used an iterative user-centered design approach to understand the user context and services offered in cardiac rehabilitation in remote areas. We conducted two co-design processes with knowledge users in two remote regions. Two advisory committees were created in each of these regions, comprising managers (n = 6), healthcare professionals (n = 12) and patients (n = 2). We utilized the BACPR guidelines and the Hautes Autorités de santé operational model to support data collection in coding sessions to develop the CR program. We conducted four cycles of co-design with each of the committees to develop the cardiac rehabilitation program. Qualitative data were analyzed iteratively after each cycle. Results The co-design process resulted in developing a prototype cardiac rehabilitation program similar in both regions. It is based on a contextualized six-phase pathway of care designed for remote regions. For each phase 0 to 6 of the care pathway, knowledge users were asked to describe how to offer these phases in remote areas. Participants made structural changes to phases 0, 2, 3 and 4 in order to overcome staffing shortages in remote areas. These changes make it possible to decentralize cardiac rehabilitation expertise away from specialized centers, to ensure equity of service across the territory. Therapeutic patient education was integrated into phase 4 to meet patients' needs. Participants suggested that three follow-up offerings could come from nursing services to increase access to the cardiac rehabilitation program (primary care, home care, special chronic disease programs) in patients' home communities. Conclusion The co-design process enables us to meet the needs of remote regions in program development. This final program can be the subject of future implementation research.

Abstract Background The advanced access (AA) model is among the most recommended innovations for improving timely access in primary care (PC). AA is based on core pillars such as comprehensive planning for care needs and supply, regularly adjusting supply to demand, optimizing appointment systems, and interprofessional collaborative practices. Exposure of family medicine residents to AA within university-affiliated family medicine groups (U-FMGs) is a promising strategy to widen its dissemination and improve access. Using four AA pillars as a conceptual model, this study aimed to determine the theoretical compatibility of Quebec’s university-affiliated clinics’ residency programs with the key principles of AA. Methods A cross-sectional online survey was sent to the chief resident and academic director at each participating clinic. An overall response rate of 96% (44/46 U-FMGs) was obtained. Results No local residency program was deemed compatible with all four considered pillars. On planning for needs and supply, only one quarter of the programs were compatible with the principles of AA, owing to residents in out-of-clinic rotations often being unavailable for extended periods. On regularly adjusting supply to demand, 54% of the programs were compatible. Most (82%) programs’ appointment systems were not very compatible with the AA principles, mostly because the proportion of the schedule reserved for urgent appointments was insufficient. Interprofessional collaboration opportunities in the first year of residency allowed 60% of the programs to be compatible with this pillar. Conclusions Our study highlights the heterogeneity among local residency programs with respect to their theoretical compatibility with the key principles of AA. Future research to empirically test the hypotheses raised by this study is warranted.

Background Effective healthcare innovations are often not scaled up beyond their initial local context. Lack of practical knowledge on how to move from local innovations to large-system improvement hinders innovation and learning capacity in health systems. Studying scale-up processes can lead to a better understanding of how to facilitate the scale-up of interventions. eConsult is a digital health innovation that aims to connect primary care professionals with specialists through an asynchronous electronic consultation. The recent implementation of eConsult in the public health systems of four Canadian jurisdictions provides a unique opportunity to identify different enabling strategies and related factors that promote the scaling up of eConsult across jurisdictions.Methods We conducted a narrative case study in four Canadian provinces, Quebec, Ontario, Manitoba, and Newfoundland & Labrador, over a 3-year period (2018–2021). We observed provincial eConsult committee meetings (n = 65) and national eConsult forums (n = 3), and we reviewed internal documents (n = 93). We conducted semistructured interviews with key actors in each jurisdiction (eg, researchers, primary care professionals, specialists, policy-makers, and patient partners) (n = 40). We conducted thematic analysis guided by the literature on factors and strategies used to scale up innovations.Results We identified a total of 31 strategies related to six key enabling factors to scaling up eConsult, including: (1) multi-actor engagement; (2) relative advantage; (3) knowledge transfer; (4) strong evidence base; (5) physician leadership; and (6) resource acquisition (eg, human, material, and financial resources). More commonly used strategies, such as leveraging research infrastructure and bringing together various actors, were used to address multiple enabling factors.Conclusion Actors used various strategies to scale up eConsult within their respective contexts, and these helped address six key factors that seemed to be essential to the scale-up of eConsult.

Background: The aim of this study was to develop a patient-reported experience measure (PREM) for comparing the experience of care received by ambulatory patients with acute unexpected needs presenting in emergency departments (EDs), walk-in clinics, and primary care practices. Methods: The Ambulatory Patient EXperience (APEX) questionnaire was developed using a 5-phase mixed-methods approach. The questionnaire was pretested by asking potential users to rate its clarity, usefulness, redundancy, content and face validities, and discrimination on a 9-point scale (1 = strongly disagree to 9 = strongly agree). The pre-final version was then tested in a pilot study. Results: The final questionnaire is composed of 61 questions divided into 7 sections. In the pretest (n = 25), median responses were 8 and above for all dimensions assessed. In the pilot study, 63 participants were enrolled. Adjusted results show that access, cleanliness, and feeling treated with respect and dignity by nurses and physicians were significantly better in the clinics than in the ED. Conclusion: We developed a questionnaire to assess and compare experience of ambulatory care in different clinical settings.

Objectives Evidence suggests that healthcare quality improvement (QI) projects are more successful when decision-makers are involved in the process. However, guidance regarding the engagement of decision-makers in QI projects is lacking. We conducted a scoping review to identify QI projects involving decision-makers published in the literature and to describe the roles decision-makers played.Methods Following the Joanna Briggs Institute framework for scoping reviews, we systematically searched for all types of studies in English or French between 2002 and 2023 in: EMBASE, MEDLINE via PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature. Criteria for inclusion consisted of literature describing health sector QI projects that involved local, regional or system-level decision-makers. Descriptive analysis was performed. Drawing on QI and participatory research literature, the research team developed an inductive data extraction grid to provide a portrait of QI project characteristics, decision-makers’ contributions, and advantages and challenges associated with their involvement.Results After screening and review, we retained 29 references. 18 references described multi-site projects and 11 were conducted in single sites. Local decision-makers’ contributions were documented in 27 of the 29 references and regional decision-makers’ contributions were documented in 12. Local decision-makers were more often active participants in QI processes, contributing toward planning, implementation, change management and capacity building. Regional decision-makers more often served as initiators and supporters of QI projects, contributing toward strategic planning, recruitment, delegation, coordination of local teams, as well as assessment and capacity building. Advantages of decision-maker involvement described in the retained references include mutual learning, frontline staff buy-in, accountability, resource allocation, effective leadership and improved implementation feasibility. Considerations regarding their involvement included time constraints, variable supervisory expertise, issues concerning centralised leadership, relationship strengthening among stakeholders, and strategic alignment of frontline staff and managerial prioritiesConclusions This scoping review provides important insights into the various roles played by decision-makers, the benefits and challenges associated with their involvement, and identifies opportunities for strengthening their engagement. The results of this review highlight the need for practical collaboration and communication strategies that foster partnership between frontline staff and decision-makers at all levels.

Abstract Background A pilot intervention in a participatory research programme in Québec, Canada, used telephone outreach by volunteer patient navigators to help unattached persons from deprived neighbourhoods attach successfully to a family doctor newly-assigned to them from a centralized waiting list. According to our theory-based program logic model we evaluated the extent to which the volunteer navigator outreach helped patients reach and engage with their newly-assigned primary care team, have a positive healthcare experience, develop an enduring doctor-patient relationship, and reduce forgone care and emergency room use. Method For the mixed-method evaluation, indicators were developed for all domains in the logic model and measured in a telephone-administered patient survey at baseline and three months later to determine if there was a significant difference. Interviews with a subsample of 13 survey respondents explored the mechanisms and nuances of intended effects. Results Five active volunteers provided the service to 108 persons, of whom 60 agreed to participate in the evaluation. All surveyed participants attended the first visit, where 90% attached successfully to the new doctor. Indicators of abilities to access healthcare increased statistically significantly as did ability to explain health needs to professionals. The telephone outreach predisposed patients to have a positive first visit and have trust in their new care team, establishing a basis for an enduring relationship. Patient-reported access difficulties, forgone care and use of hospital emergency rooms decreased dramatically after patients attached to their new doctors. Conclusions As per the logic model, telephone outreach by volunteer navigators significantly increased patients’ abilities to seek, reach and engage with care and helped them attach successfully to newly-assigned family doctors. This light-touch intervention may have promise to achieve of the intended policy goals for the centralized waiting list to increase population access to appropriate primary care and reduce forgone care.

Abstract Background Primary care and other health services have been disrupted during the COVID-19 pandemic, yet the consequences of these service disruptions on patients’ care experiences remain largely unstudied. People with mental-physical multimorbidity are vulnerable to the effects of the pandemic, and to sudden service disruptions. It is thus essential to better understand how their care experiences have been impacted by the current pandemic. This study aims to improve understanding of the care experiences of people with mental-physical multimorbidity during the pandemic and identify strategies to enhance these experiences. Methods We will conduct a mixed-methods study with multi-phase approach involving four distinct phases. Phase 1 will be a qualitative descriptive study in which we interview individuals with mental-physical multimorbidity and health professionals in order to explore the impacts of the pandemic on care experiences, as well as their perspectives on how care can be improved. The results of this phase will inform the design of study phases 2 and 3. Phase 2 will involve journey mapping exercises with a sub-group of participants with mental-physical multimorbidity to visually map out their care interactions and experiences over time and the critical moments that shaped their experiences. Phase 3 will involve an online, cross-sectional survey of care experiences administered to a larger group of people with mental disorders and/or chronic physical conditions. In phase 4, deliberative dialogues will be held with key partners to discuss and plan strategies for improving the delivery of care to people with mental-physical multimorbidity. Pre-dialogue workshops will enable us to synthesize an prepare the results from the previous three study phases. Discussion Our study results will generate much needed evidence of the positive and negative impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity and shed light on strategies that could improve care quality and experiences.

Objectives The advanced access model is highly recommended to improve timely access to primary healthcare (PHC). However, its adoption varies among PHC providers. We aim to identify the advanced access profiles of PHC providers.Design A cross-sectional study was conducted between October 2019 and March 2020. Latent class analysis (LCA) measures were used to identify PHC provider profiles based on 14 variables, 2 organisational context characteristics (clinical size and geographical area) and 12 advanced access strategies.Setting and participants All family physicians, nurse practitioners and nurses working in the 49 university-affiliated team-based PHC clinics in Quebec, Canada, were invited, of which 35 participated.Primary outcome measure The LCA was based on 335 respondents. We determined the optimal number of profiles using statistical criteria (Akaike information criterion, Bayesian information criterion) and qualitatively named each of the six advanced access profiles.Results (1) Low supply and demand planification (25%) was characterised by the smallest proportion of strategies used to balance supply and demand. (2) Reactive interprofessional collaboration (25%) was characterised by high collaboration and long opening periods for appointment scheduling. (3) Structured interprofessional collaboration (19%) was characterised by high use of interprofessional team meetings. (4) Small urban delegating practices (13%) was exclusively composed of family physicians and characterised by task delegation to other PHC providers on the team. (5) Comprehensive practices in urban settings (13%) was characterised by including as many services as possible on each visit. (6) Rural agility (4%) was characterised by the highest uptake of advanced access strategies based on flexibility, including adjusting the schedule to demand and having a large number of open-slot appointments available in the next 48 hours.Conclusion The different patterns of advanced access strategy adoption confirm the need for training to be tailored to individuals, categories of PHC providers and contexts.

Abstract Background Improving access to primary health care is among top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results. The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes. Methods Cluster-controlled trial allowing for a comprehensive and rigorous evaluation of the proposed intervention 48 multidisciplinary primary care clinics will be recruited to participate. 24 Clinics from the intervention regions will receive the CQI intervention for 18 months including three activities carried out iteratively until the clinic’s improvement objectives are achieved: 1) reflective sessions and problem priorisation; 2) plan-do-study-act cycles; and 3) group mentoring. Clinics located in the control regions will receive an audit-feedback report on access. Complementary qualitative and quantitative data reflecting the quintuple aim will be collected over a period of 36 months. Results This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients’ experiences of care. Conclusion This mixed-method approach offers a unique opportunity to contribute to the scientific literature on large-scale CQI cohorts to improve AA in primary care teams and to better understand the processes of CQI. Trial registration Clinical Trials: NCT05715151.

Introduction The WHO has stated that vaccine hesitancy is a serious threat to overcoming COVID-19. Vaccine hesitancy among underserved and at-risk communities is an ongoing challenge in Canada. Public confidence in vaccine safety and effectiveness and the principles of equity need to be considered in vaccine distribution. In Canada, governments of each province or territory manage their own healthcare system, providing an opportunity to compare and contrast distribution strategies. The overarching objective of this study is to identify effective vaccine distribution approaches and advance knowledge on how to design and implement various strategies to meet the different needs of underserved communities.Methods and analysis Multiple case studies in seven Canadian provinces will be conducted using a mixed-methods design. The study will be informed by Experience-Based CoDesign techniques and theoretically guided by the Socio-Ecological Model and the Vaccine Hesitancy Matrix frameworks. Phase 1 will involve a policy document review to systematically explore the vaccine distribution strategy over time in each jurisdiction. This will inform the second phase, which will involve (2a) semistructured, in-depth interviews with policymakers, public health officials, researchers, providers, groups representing patients, researchers and stakeholders and (2b) an analysis of population-based administrative health data of vaccine administration. Integration of qualitative and quantitative data will inform the identification of effective vaccine distribution approaches for various populations. Informed by this evidence, phase 3 of the study will involve conducting focus groups with multiple stakeholders to codesign recommendations for the design and implementation of effective vaccine delivery strategies for equity-deserving and at-risk populations.Ethics and dissemination This study is approved by the University of Toronto’s Health Sciences Research Ethics Board (#42643), University of British Columbia Behavioural Research Ethics Board (#H22-01750-A002), Research Ethics Board of the Nova Scotia Health Authority (#48272), Newfoundland and Labrador Health Research Ethics Board (#2022.126), Conjoint Health Research Ethics Board, University of Calgary (REB22-0207), and University of Manitoba Health Research Board (H2022-239). The outcome of this study will be to produce a series of recommendations for implementing future vaccine distribution approaches from the perspective of various stakeholders, including equity-deserving and at-risk populations.

Abstract Background In Canada, the demand for mental health care exceeds the provision of services. This exploratory study aimed to assess the feasibility and impact of a new service delivery model for psychological consultations in primary care settings: the Single-Session Intervention (SSI), inspired by Advanced Access (AA) principles for appointment scheduling. The specific objectives were to examine whether the SSI increases accessibility to psychological consultations, to measure the effects of the intervention on different self-reported measures, and to assess users’ consultation experiences. Methods Participants were recruited in a University Family Medicine Group in Quebec (Canada), and the SSI was delivered by the on-site psychologist. No referral or formal diagnosis was needed to attend, and participants could promptly obtain an appointment. Participants rated the intensity of their problem, their level of psychological distress and their well-being, before and after the SSI. They also rated their satisfaction with their consultation experience. There was a follow-up 4 to 6 weeks later. Results Of the N = 69 participants who received SSI, 91% were able to obtain an appointment in less than 7 working days. The number of patients who were able to benefit from a psychological consultation was about 7 times higher after the implementation of SSI compared to previous years, when a traditional model of service delivery was in place. After SSI, participants felt that the intensity of their problem and psychological distress were lower, and that their well-being was increased, as indicated by significant pre-post test clinical measures (p

Abstract Background Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients. Methods We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations. Results The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p

BackgroundHealth measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation. ObjectiveWe will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs’ implementation strategies. MethodsWe will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis. ResultsThis study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022. ConclusionsResults from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies. Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513 International Registered Report Identifier (IRRID)DERR1-10.2196/48155

Abstract Background COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. Methods We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. Results We identified and analyzed six organizational innovations. Four of these – centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. Conclusion COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Introduction Measuring the performance of interprofessional primary care is needed to examine whether this model of care is achieving its desired outcomes on patient care and health system effectiveness as well as to guide quality improvement initiatives. The aim of this scoping review is to map the literature on primary care performance measurement indicators to determine the extent to which current indicators capture or could be adapted to capture processes, outputs and outcomes that reflect interprofessional primary care.Methods and analysis The review will be guided by the six-stage framework by Arksey and O’Malley (2005). MEDLINE, Embase, CINAHL, grey literature and the reference list of key studies will be searched to identify any study, published in English or French between 2000 and 2022, related to the concepts of performance indicators, frameworks, interprofessional teams and primary care. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Eligible indicators will be classified according to process, output and outcome domains proposed by two validated frameworks. This study started in November 2022 and is expected to be completed by July 2023.Ethics and dissemination This review does not require ethical approval. The results will be disseminated through a peer-reviewed publication, conference presentations and presentations to stakeholders.

Introduction Attachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients’ barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec’s 18 administrative regions to implement single points of access for unattached patients (Guichets d’accès première ligne (GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients’ experiences of navigation, access and service utilisation.Methods and analysis A longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients’ experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases.Ethics and dissemination This study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l’innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

Abstract Background In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models’ similarities and differences. Methods We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS’s components included in the initially designed program, Mitchell and Lewis (2003)’s logic model framework, and Chaudoir and colleagues (2013)’s framework on contextual factors’ influence on an innovation’s implementation. Results Findings show the APSS-CRDS program’s regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists’ availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors’ influence, like ministerial and medical associations’ involvement, collaborations, the context’s implementation readiness, physician practice characteristics, and the program’s adaptability. Interpretation Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

Abstract Background Primary healthcare is the main entry to the health care system for most of the population. In 2008, it was estimated that about 26% of the population in Quebec (Canada) did not have a regular family physician. In early 2017, about 10 years after the introduction of a centralized waiting list for patients without a family physician, Québec had 25% of its population without a family physician and nearly 33% of these or 540,000, many of whom were socially vulnerable (SV), remained registered on the list. SV patients often have more health problems. They also face access inequities or may lack the skills needed to navigate a constantly evolving and complex healthcare system. Navigation interventions show promise for improving access to primary health care for SV patients. This study aimed to describe and understand the expectations and needs of SV patients. Methods A descriptive qualitative study rooted in a participatory study on navigation interventions implemented in Montérégie (Quebec) addressed to SV patients. Semi-structured individual face-to-face and telephone interviews were conducted with patients recruited in three primary health care clinics, some of whom received the navigation intervention. A thematic analysis was performed using NVivo 11 software. Results Sixteen patients living in socially deprived contexts agreed to participate in this qualitative study. Three main expectations and needs of patients for navigation interventions were identified: communication expectations (support to understand providers and to be understood by them, discuss about medical visit, and bridge the communication cap between patients and PHC providers); relational expectations regarding emotional or psychosocial support; and pragmatic expectations (information on available resources, information about the clinic, and physical support to navigate the health care system). Conclusions Our study contributes to the literature by identifying expectations and needs specified to SV patients accessing primary health care services, that relate to navigation interventions. This information can be used by decision makers for navigation interventions design and inform health care organizational policies.

Abstract Background The COVID-19 pandemic has driven primary healthcare (PHC) providers to use telehealth as an alternative to traditional face-to-face consultations. Providing telehealth that meets the needs of patients in a pandemic has presented many challenges for PHC providers. The aim of this study was to describe the positive and negative implications of using telehealth in one Canadian (Quebec) and one American (Massachusetts) PHC setting during the COVID-19 pandemic as reported by physicians. Methods We conducted 42 individual semi-structured video interviews with physicians in Quebec (N = 20) and Massachusetts (N = 22) in 2020. Topics covered included their practice history, changes brought by the COVID-19 pandemic, and the advantages and challenges of telehealth. An inductive and deductive thematic analysis was carried out to identify implications of delivering care via telehealth. Results Four key themes were identified, each with positive and negative implications: 1) access for patients; 2) efficiency of care delivery; 3) professional impacts; and 4) relational dimensions of care. For patients’ access, positive implications referred to increased availability of services; negative implications involved barriers due to difficulties with access to and use of technologies. Positive implications for efficiency were related to improved follow-up care; negative implications involved difficulties in diagnosing in the absence of direct physical examination and non-verbal cues. For professional impacts, positive implications were related to flexibility (teleworking, more availability for patients) and reimbursement, while negative implications were related to technological limitations experienced by both patients and practitioners. For relational dimensions, positive implications included improved communication, as patients were more at ease at home, and the possibility of gathering information from what could be seen of the patient’s environment; negative implications were related to concerns around maintaining the therapeutic relationship and changes in patients’ engagement and expectations. Conclusion Ensuring that health services provision meets patients’ needs at all times calls for flexibility in care delivery modalities, role shifting to adapt to virtual care, sustained relationships with patients, and interprofessional collaboration. To succeed, these efforts require guidelines and training, as well as careful attention to technological barriers and interpersonal relationship needs.

Abstract Background The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. Methods Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. Discussion Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec’s ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.

BackgroundAdherence to care plans is a major issue in health care systems. Improved adherence has several potential benefits such as ensuring treatment effectiveness and control of chronic diseases. There is currently a lack of tools to maximize treatment adherence in an integrated manner, that is, covering multiple aspects of patients’ health continuously throughout their medical care. To ensure better adherence, such tools must meet the needs of patients with chronic conditions as well as those of health care professionals. Acknowledging the health issues associated with nonadherence to treatment, an industry-research-clinical partnership aims to adapt a digital platform—facilitating patient-health care professional interactions—to improve therapeutic adherence in patients with chronic illnesses. The platform allows for exchanges between patients and health care professionals to facilitate the timing of medication use or chronic disease management and maximize patient adherence. ObjectiveThis study aims to (1) identify the needs of patients living with a chronic condition and their health professionals concerning their interactions regarding treatment; (2) codevelop an adaptation of an interactive patient-professional platform that meets the needs identified; and (3) then test the platform and document its effects and acceptability in a clinical setting. MethodsThe study will use a creative design thinking process based on the needs expressed by users (patients and health professionals) concerning treatment adherence for chronic diseases (eg, diabetes, asthma, high blood pressure, depression and anxiety, chronic obstructive pulmonary disease). A mixed method evaluation research design will be used to develop and evaluate the platform. Qualitative data will be used to assess user needs and acceptability of the platform, and quantitative data will provide the necessary insights to document its effects. ResultsTechnological development of the platform has been completed. Recruitment for the first part of Phase 1 started in May 2022. The results of this project to codevelop an interprofessional digital platform to increase therapeutic adherence will be relevant to clinicians and managers seeking contemporary solutions that support patient adherence to treatment for chronic diseases. These results will enable optimal use of the platform and identify areas for improvement in interactive patient-health care professional apps. ConclusionsThe adoption of an interactive digital platform to facilitate effective exchanges between patients and health care professionals in primary care settings could improve adherence to treatment. The platform tested in this project takes a first step in this direction by ensuring that the technological product is developed according to the needs of patients as well as the health professionals who are likely to use it. International Registered Report Identifier (IRRID)DERR1-10.2196/34463

Improving health services integration for patients with complex needs is a national priority in Canada. Health systems in all provinces grapple with the rising complexity of patients and the services they need. Team-based primary health care (PHC) models have been implemented in diverse ways to improve patients' experiences, increase the coordination of care, improve population health and reduce costs. While some provinces have more than two decades of experience with PHC teams, others such as British Colombia (BC) have made changes more recently. We conducted an in-depth analysis of 12 provincial policy documents produced since 2011 to study the evolution of interprofessional models in PHC. BC has integrated team-based care through overarching policy support and funding from the provincial government. Structural practice changes to support team-based care, such as Primary Care Networks (PCNs), were designed to address the quadruple aim, a framework designed to improve health system performance through integrated primary care. Policies have addressed the vision and goals of team-based care, but discussion of processes that support teams, such as a strategy for capitation-based funding and team composition, were non-specific. Finally, there is a significant need for a provincial strategy for continuous quality improvement and evaluation of reforms. Améliorer l'intégration des services de santé pour les patients ayant des besoins complexes est une priorité au Canada. Les systèmes de santé de toutes les provinces sont aux prises avec une augmentation du nombre des patients qui nécessitant des services complexes. Différents modèles variés de services de première ligne ont été mis en œuvre afin d'améliorer l'expérience des patients améliorer la coordination des services, améliorer la santé de la population ainsi que de réduire les coûts. Si certaines provinces ont plus de vingt ans d'expérience dans la mise en place d'équipes de première ligne interdisciplinaires, d'autres provinces comme la Colombie-Britannique (CB) n'innovent que depuis peu. Nous avons mené une analyse approfondie de 12 politiques provinciales mise en place depuis 2011 pour étudier l'évolution des modèles interprofessionnels de première ligne. La CB a intégré des équipes de première ligne interdisciplinaires grâce à des politiques et des financements du gouvernement provincial. Les changements structurels pour soutenir le travail en équipe, comme les Réseaux de soins primaires (PCN), ont été conçus pour répondre au « quadruple objectif », qui est un cadre conceptuel pour améliorer la performance des systèmes de santé, par le biais de services de première ligne intégrés. Les politiques ont détaillé les visions et objectifs des équipes de première ligne, mais les discussions sur les processus qui soutiennent ces équipes comme les stratégies de financement par capitation et la composition des équipes n’ont pas été explicitées. Enfin, il existe un besoin important d'une stratégie provinciale pour l'amélioration continue de la qualité et l'évaluation des réformes.

Abstract Background The rapid shift in hospital governance in the past few years suggests greater orthopedist involvement in management roles, would have wide-reaching benefits for the efficiency and effectiveness of healthcare delivery. This paper analyzes the dynamics of orthopedist involvement in the management of clinical activities for three orthopedic care pathways, by examining orthopedists’ level of involvement, describing the implications of such involvement, and indicating the main responses of other healthcare workers to such orthopedist involvement. Methods We selected four contrasting cases according to their level of governance in a Canadian university hospital center. We documented the institutional dynamics of orthopedist involvement in the management of clinical activities using semi-structured interviews until data saturation was reached at the 37th interview. Results Our findings show four levels (Inactive, Reactive, Contributory and Active) of orthopedist involvement in clinical activities. With the underlying nature of orthopedic surgeries, there are: (i) some activities for which decisions cannot be programmed in advance, and (ii) others for which decisions can be programmed. The management of unforeseen events requires a higher level of orthopedist involvement than the management of events that can be programmed. Conclusions Beyond simply identifying the underlying dynamics of orthopedists’ involvement in clinical activities, this study analyzed how such involvement impacts management activities and the quality-of-care results for patients.

Abstract Background The advanced access (AA) model has attracted much interest across Canada and worldwide as a means of ensuring timely access to health care. While nurses contribute significantly to improving access in primary healthcare, little is known about the practice changes involved in this innovative model. This study explores the experience of nurse practitioners and registered nurses with implementation of the AA model, and identifies factors that facilitate or impede change. Methods We used a longitudinal qualitative approach, nested within a multiple case study conducted in four university family medicine groups in Quebec that were early adopters of AA. We conducted semi-structured interviews with two types of purposively selected nurses: nurse practitioners (NPs) (n = 6) and registered nurses (RNs) (n = 5). Each nurse was interviewed twice over a 14-month period. One NP was replaced by another during the second interviews. Data were analyzed using thematic analysis based on two principles of AA and the Niezen & Mathijssen Network Model (2014). Results Over time, RNs were not able to review the appointment system according to the AA philosophy. Half of NPs managed to operate according to AA. Regarding collaborative practice, RNs were still struggling to participate in team-based care. NPs were providing independent and collaborative patient care in both consultative and joint practice, and were assuming leadership in managing patients with acute and chronic diseases. Thematic analysis revealed influential factors at the institutional, organizational, professional, individual and patient level, which acted mainly as facilitators for NPs and barriers for RNs. These factors were: 1) policy and legislation; 2) organizational policy support (leadership and strategies to support nurses’ practice change); facility and employment arrangements (supply and availability of human resources); Inter-professional collegiality; 3) professional boundaries; 4) knowledge and capabilities; and 5) patient perceptions. Conclusions Our findings suggest that healthcare decision-makers and organizations need to redefine the boundaries of each category of nursing practice within AA, and create an optimal professional and organizational context that supports practice transformation. They highlight the need to structure teamwork efficiently, and integrate and maximize nurses’ capacities within the team throughout AA implementation in order to reduce waiting times.

Introduction Over the last 20 years, the Canadian province of Ontario implemented several new models of primary care focusing on changes to physician remuneration, clinics led by nurse practitioners and the introduction of interprofessional primary care teams. Health outcome and cost evaluations of these models thus far have been mostly cross-sectional and in some cases results from these studies were conflicting. The aim of this population-based study is to investigate short, medium and long-term effectiveness of these reforms over the past 15–20 years.Methods and analysis This is the protocol for a retrospective cohort study including fee-for-service (FFS) and community health centre cohorts (control cohorts) or patients who switched from either being unattached or from FFS to a new practice model (eg, capitation, enhanced FFS, team, nurse practitioner-led) from 1997 to 2020. The primary outcome is total healthcare costs and secondary outcomes are primary care costs, other (non-primary care) health costs, hospitalisations, length of stay, emergency department visits, accessibility and mortality. A combination of hard and propensity matching will be used where relevant. Outcomes will be adjusted for demographic and health factors and measured annually. Interrupted time series models will be used where data permits and difference-in-differences methods will be used otherwise.Ethics and dissemination Ethics approval has been received from Queens University and Memorial University. The dissemination plan includes conference presentations, papers, brief evidence summaries targeted at select audiences and knowledge brokering sessions with key stakeholders.

Introduction In Canada, as in most Organisation for Economic Co-operation and Development countries, healthcare systems face significant challenges in ensuring better access to primary care. A regional healthcare organisation in Quebec (Canada) serving a population of approximately 755 459 citizens has implemented a standardised access approach to primary care services for this population. The objective of this new clinical and organisational practice is to ensure that users benefit from the same referral process, regardless of the entry point, in order to be directed to the right services. This new practice integrates a shared decision-making process between the user and the professional, and a collaborative process between different health professionals within and between services. The objective of our research is to identify and characterise the conditions of implementation of this practice.Methods This effectiveness-implementation hybrid investigation will use an embedded single-case study, defined in this case as the process of implementing a clinical and organisational practice within a healthcare organisation. Further to an evaluation conducted during a preliminary phase of the project, this study consists of evaluating the implementation of this new practice in four medical clinics (family medicine groups). A qualitative analysis of the data and a quantitative preimplementation and postimplementation analysis based on performance indicators will be conducted. This study is ultimately situated within a participatory organisational approach that involves various stakeholders and users at each step of the implementation and evaluation process.Ethics and dissemination This study was approved by the Ethics Committee of the Sectoral Research in Population Health and Primary Care of the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (#2020-1800). The results of the investigation will be presented to the stakeholders involved in the advisory committees and at several scientific conferences. Manuscripts will be submitted to peer-reviewed journals.

Introduction Access to a primary care provider is a key component of high-functioning healthcare systems. In Canada, 15% of patients do not have a regular primary care provider and are classified as ‘unattached’. In an effort to link unattached patients with a provider, seven Canadian provinces implemented centralised waitlists (CWLs). The effectiveness of CWLs in attaching patients to regular primary care providers is unknown. Factors influencing CWLs effectiveness, particularly across jurisdictional contexts, have yet to be confirmed.Methods and analysis A mixed methods case study will be conducted across three Canadian provinces: Ontario, Québec and Nova Scotia. Quantitatively, CWL data will be linked to administrative and provider billing data to assess the rates of patient attachment over time and delay of attachment, stratified by demographics and compared with select indicators of health service utilisation. Qualitative interviews will be conducted with policymakers, patients, and primary care providers to elicit narratives regarding the administration, use, and access of CWLs. An analysis of policy documents will be used to identify contextual factors affecting CWL effectiveness. Stakeholder dialogues will be facilitated to uncover causal pathways and identify strategies for improving patient attachment to primary care.Ethics and dissemination Approval to conduct this study has been granted in Ontario (Queens University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board, file number 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol number 40335), Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project number 2020–3446) and Nova Scotia (Nova Scotia Health Research Ethics Board, file number 1024979).

Abstract Background Achieving equity of access to primary healthcare requires organizations to implement innovations tailored to the specific needs and abilities of vulnerable populations. However, designing pro-vulnerable innovations is challenging without knowledge of the range of possible innovations tailored to vulnerable populations’ needs. To better support decision-makers, we aimed to develop a typology of pro-vulnerable organizational innovation components – akin to “building blocks” that could be combined in different ways into new complex innovations or added to existing organizational processes to improve access to primary healthcare. Methods To develop the typology, we used data from a previously conducted a) scoping review (2000–2014, searched Medline, Embase, CINAHL, citation tracking, n = 90 articles selected), and b) environmental scan (2014, online survey via social networks, n = 240 innovations). We conducted a typological analysis of the data. Our initial typology yielded 48 components, classified according to accessibility dimensions from the Patient-Centred Accessibility Framework. The initial typology was then field-tested for relevance and usability by health system stakeholders and refined from 2014 to 2018 (e.g., combined similar components, excluded non-organizational components). Results The selected articles (n = 90 studies) and survey responses (n = 240 innovations) were mostly from the USA, Canada, Australia and the UK. Innovations targeted populations with various vulnerabilities (e.g., low income, chronic illness, Indigenous, homeless, migrants, refugees, ethnic minorities, uninsured, marginalized groups, mental illness, etc.). Our final typology had 18 components of organizational innovations, which principally addressed Availability & Accommodation (7/18), Approachability (6/18), and Acceptability (3/18). Components included navigation & information, community health worker, one-stop-shop, case management, group visits, defraying costs, primary healthcare brokerage, etc. Conclusions This typology offers a comprehensive menu of potential components that can help inform the design of pro-vulnerable organizational innovations. Component classification according to the accessibility dimensions of the Patient-Centred Accessibility Framework is useful to help target access needs. Components can be combined into complex innovations or added to existing organizational processes to meet the access needs of vulnerable populations in specific contexts.

Abstract Background Expanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada. Methods We conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research. Results This study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes. Conclusions Efforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.

Abstract Background Timely access in primary health care is one of the key issues facing health systems. Among many interventions developed around the world, advanced access is the most highly recommended intervention designed specifically to improve timely access in primary care settings. Based on greater accessibility linked with patients’ relational continuity and informational continuity with a primary care professional or team, this organizational model aims to ensure that patients obtain access to healthcare services at a time and date convenient for them when needed regardless of urgency of demand. Its implementation requires a major organizational change based on reorganizing the practices of all the administrative staff and health professionals. In recent years, advanced access has largely been implemented in primary care organizations. However, despite its wide dissemination, we observe considerable variation in the implementation of the five guiding principles of this model across organizations, as well as among professionals working within the same organization. The main objective of this study is to assess the variation in the implementation of the five guiding principles of advanced access in teaching primary healthcare clinics across Quebec and to better understand the influence of the contextual factors on this variation and on outcomes. Methods This study will be based on an explanatory sequential design that includes 1) a quantitative survey conducted in 47 teaching primary healthcare clinics, and 2) a multiple case study using mixed data, contrasted cases (n = 4), representing various implementation profiles and geographical contexts. For each case, semi-structured interviews and focus group will be conducted with professionals and patients. Impact analyses will also be conducted in the four selected clinics using data retrieved from the electronic medical records. Discussion This study is important in social and political context marked by accessibility issues to primary care services. This research is highly relevant in a context of massive media coverage on timely access to primary healthcare and a large-scale implementation of advanced access across Quebec. This study will likely generate useful lessons and support evidence-based practices to refine and adapt the advanced access model to ensure successful implementation in various clinical contexts facing different challenges.

Abstract Background Chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD) are common and burdensome diseases primarily managed in primary care. Yet, evidence points to suboptimal quality of care for these conditions in primary care settings. Quality improvement collaboratives (QICs) are organized, multifaceted interventions that can be effective in improving chronic disease care processes and outcomes. In Quebec, Canada, the Institut national d’excellence en santé et en services sociaux (INESSS) has developed a large-scale QIC province-wide program called COMPAS+ that aims to improve the prevention and management of chronic diseases in primary care. This paper describes the protocol for our study, which aims to evaluate implementation and impact of COMPAS+ QICs on the prevention and management of targeted chronic diseases like diabetes and COPD. Methods This is a mixed-methods, integrated knowledge translation study. The quantitative component involves a controlled interrupted time series involving nine large integrated health centres in the province. Study sites will receive one of two interventions: the multifaceted COMPAS+ intervention (experimental condition) or a feedback only intervention (control condition). For the qualitative component, a multiple case study approach will be used to achieve an in-depth understanding of individual, team, organizational and contextual factors influencing implementation and effectiveness of the COMPAS+ QICs. Discussion COMPAS+ is a QI program that is unique in Canada due to its integration within the governance of the Quebec healthcare system and its capacity to reach many primary care providers and people living with chronic diseases across the province. We anticipate that this study will address several important gaps in knowledge related to large-scale QIC projects and generate strong and useful evidence (e.g., on leadership, organizational capacity, patient involvement, and implementation) having the potential to influence the design and optimisation of future QICs in Canada and internationally.

Primary Health Care (PHC) teams are an important component of the health system – particularly in terms of integrating care for vulnerable patients living with complex health and social needs. Over the last two decades, PHC teams have been implemented in different forms across Canadian provinces and territories. This article explores the health care policies that shaped the form and functions of PHC team-based care in Québec over the past 20 years (2002-2022). In Québec, the main model of multidisciplinary PHC teams – Family Medicine Groups or Groupe de médecine de famille (GMFs) – were created in 2002. In 2004, structural reforms led to the creation of local health networks (LHNs). LHNs promoted coordinated and collaborative activities between health and social services providers such as GMFs located in the same geographic regions. This was followed by another structural reform of the health system in 2015, leading to the creation of broader territorial health networks with the aim to heighten coordination and collaboration among provider organizations. Various policies have strengthened the PHC team-based model. For instance, the introduction of nurse practitioners, pharmacists, and social workers with extended scopes of practice shaped the configuration of GMFs while enhancing inter-professional collaborative practices. This article highlights important insights that could advance the understanding and creation of future PHC policy initiatives. Les équipes de premières lignes sont une composante importante du système de santé – en particulier en ce qui concerne l’intégration des services pour les patients les plus vulnérables qui ont des besoins sanitaires complexes. Au cours des deux dernières décennies, des équipes de premières lignes ont été mises en œuvre sous différentes formes dans les provinces et les territoires du Canada. Cet article explore les politiques de santé qui ont façonné la forme et le fonctionnement des équipes de premières lignes au Québec au cours des 20 dernières années (2002-2022). Au Québec, le principal modèle de première ligne – les Groupes de médecine de famille (GMF) – a été créé en 2002. Les réformes structurelles de 2004 ont conduit à la création des réseaux locaux de services (RLS). Les RLS ont favorisé des activités coordonnées de collaborations entre les établissements publics, les organisations privées, dont les GMF, et les organisations communautaires localisées sur les mêmes territoires géographiques. Cette initiative a été suivie d'une autre réforme structurelle du système de santé en 2015, qui a conduit à la création de réseaux territoriaux de santé et de services sociaux dans le but d'accroître la coordination et la collaboration entre les établissements. Diverses politiques ont renforcé le modèle d'équipe de première ligne. Par exemple, l'introduction d'infirmières praticiennes spécialisées en première ligne, de pharmaciens et de travailleurs sociaux ayant des champs de pratique élargis a façonné l'évolution du modèle des GMF tout en améliorant les pratiques de collaboration interprofessionnelles. Cet article met en évidence des idées importantes qui pourraient améliorer la compréhension et la création de futures politiques de santé de première ligne.

Background: Integrated care pathways (ICPs) could improve the organisation and delivery of care for community dwelling older adults. An ICP was developed and implemented in Québec to support home care processes. This study explores the perspectives of home care staff on the use of an ICP to support the organisation and delivery of health and social care to community-dwelling older adults with complex needs. Theory and Methods: A case study based on eleven semi-structured interviews and analysis of documents was carried out in an urban home care unit. The Normalization Process Theory was used for mixed thematic analysis. Results: While its capacity to store data and enhance interprofessional information exchange was appreciated by home care staff, the broad scope, and automated features of the ICP tool were often problematic. Concerns about increased provider workloads, disruption to provider-client relationships during clinical encounters, and difficulties engaging clients in decision-making were main obstacles in the use of the ICP. Conclusion: Given the importance of ICPs in advancing clinical integration, it is critical to continuously adjust their design to align with providers’ realities in order to optimize their potential in real life contexts.

Introduction Timely access is one of the cornerstones of strong primary healthcare (PHC). New models to increase timely access have emerged across the world, including advanced access (AA). Recently in Quebec, Canada, the AA model has spread widely across the province. The model has largely been implemented by PHC professionals with important variations; however, a tool to assess their practice improvement within AA is lacking. The general objective of this study is to develop a self-reported online reflective tool that will guide PHC professionals’ reflection on their individual AA practice and formulation of recommendations for improvement. Specific objectives are: (1) operationalisation of the pillars and subpillars of AA; (2) development of a self-reported questionnaire; and (3) evaluation of the psychometrics.Methods and analysis The pillars composing Murray’s model of AA will first be reviewed in collaboration with PHC professional and stakeholders, patients and researchers in a face-to-face meeting, with the goal to establish consensus on the pillars and subpillars of AA. Leading from these definitions, items will be identified for evaluation through an e-Delphi consultation. Three rounds are planned in 2020–2021 with a group of 20–25 experts. A repository of recommendations on how to improve one’s AA practice will be populated based on the literature and enriched by our experts throughout the consultation. Median and measures of dispersions will be used to evaluate agreement. The resulting tool will then be evaluated by PHC professionals for psychometrics in 2021–2022.Ethics and dissemination The Centre Intégré de Santé et de Services Sociaux de la Montérégie-Centre Scientific Research Committee approved the protocol, and the Research Ethics Board provided ethics approval (2020-441, CP 980475). Dissemination plan is a mix of community diffusion through and for our partners and to the scientific community including peer-reviewed publications and conference presentations.

Introduction: Team-based care can improve integrated health services by increasing comprehensiveness and continuity of care in primary healthcare (PHC) settings. Collaborative models involving providers from different professions can help to achieve coordinated, high-quality person-centred care. In Canada, there has been variation in both the timing/pace of adoption and approach to interprofessional PHC (IPHC) policy. Provinces are at different stages in the development, implementation, and evaluation of team-based PHC models. This paper describes how different policies, contexts, and innovations across four Canadian provinces (British Columbia, Alberta, Ontario, Quebec) facilitate or limit integrated health services through IPHC teams. Methods: Systematic searches identified 100 policy documents across the four provinces. Analysis was informed by Walt and Gilson’s Policy Triangle (2008) and Suter et al.’s (2009) health system integration principles. Provincial policy case studies were constructed and used to complete a cross-case comparison. Results: Each province implemented variations of an IPHC based model. Five key components were found that influenced IPHC and integrated health services: patient-centred care; team structures; information systems; financial management; and performance measurement. Conclusion: Heterogeneity of the implementation of PHC teams across Canadian provinces provides an opportunity to learn and improve interprofessional care and integrated health services across jurisdictions.

BackgroundThe COVID-19 pandemic has significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible; pharmacies remaining open with restrictions on patient interactions; rapid uptake of virtual care; and reduced referrals for lab tests, diagnostics, and specialist care. ObjectiveThe PUPPY Study (Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year) seeks to understand the impact of the COVID-19 pandemic across the quadruple aims of primary care, with particular focus on the effects on patients without attachment to a regular provider and those with chronic health conditions. MethodsThe PUPPY study builds on an existing research program exploring patients’ access and attachment to a primary care practice, pivoted to adapt to the emerging COVID-19 context. We intend to undertake a longitudinal mixed methods study to understand critical gaps in primary care access and coordination, as well as compare prepandemic and postpandemic data across 3 Canadian provinces (Quebec, Ontario, and Nova Scotia). Multiple data sources will be used such as a policy review; qualitative interviews with primary care policymakers, providers (ie, family physicians, nurse practitioners, and pharmacists), and patients (N=120); and medication prescriptions and health care billing data. ResultsThis study has received funding by the Canadian Institutes of Health Research COVID-19 Rapid Funding Opportunity Grant. Ethical approval to conduct this study was granted in Ontario (Queens Health Sciences & Affiliated Teaching Hospitals Research Ethics Board, file 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol 40335) in November 2020, Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project 2020-3446) in December 2020, and Nova Scotia (Nova Scotia Health Research Ethics Board, file 1024979) in August 2020. ConclusionsTo our knowledge, this is the first study of its kind to explore the effects of the COVID-19 pandemic on primary care systems, with particular focus on the issues of patient’s attachment and access to primary care. Through a multistakeholder, cross-jurisdictional approach, the findings of the PUPPY study will inform the strengthening of primary care during and beyond the COVID-19 pandemic, as well as have implications for future policy and practice. International Registered Report Identifier (IRRID)DERR1-10.2196/29984

Abstract Background Canada has been referred to as the land of ‘perpetual pilot projects’. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times – one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients’ medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. Methods We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). Discussion This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Abstract Background Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists. Methods A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients’ socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs. Results Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas. Conclusion Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.

Abstract Background The concept of “mechanism” is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand). Methods In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC. Results We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions. Conclusions We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

Abstract Background First-contact accessibility remains an important problem in Canada, with this indicator staying the worst of all Organization for Economic Co-operation and Development countries. In the province of Quebec, a number of primary healthcare (PHC) organizations have adopted measures to improve access (e.g. advance access scheduling, expanded nursing role, electronic medical record, financial incentives). The impact of those changes is unknown. The goal of this study is to assess which PHC organizations’ characteristics are associated with improved first-contact accessibility. Methods We conducted a secondary data analysis of the Quebec survey, conducted as part of the QUALICO-PC study on primary care performance. QUALICO-PC is a cross-sectional study to assess quality, costs and equity in PHC across 35 countries and jurisdictions. Organizational characteristics were measured from the family practitioners’ questionnaire. First-contact accessibility was measured from the patient questionnaire filled by patients who received care in the participating PHC organizations. Multi-level logistic regression was used to assess the association of organizational characteristics as predictors of patient-reported accessibility. Results A total of 218 family practitioners participated in the study with 1798 of their patients. PHC organizations characteristics associated with increased first-contact accessibility included the possibility to have a same-day appointment or to walk in the clinic without an appointment, higher number of physicians per clinic and higher number of hours worked by the family physician. Electronic medical record and expanded nursing role were not associated with increased accessibility. Conclusions Same-day access and higher family physician working hours are associated with improved patient-reported accessibility. Other PHC organizations characteristics targeted by recent reforms were not associated with improved accessibility.

A growing body of literature suggests combining organizational ethnography and case study design as a new methodology for investigating complex organizational phenomena in health care contexts. However, the arguments supporting the potential of organizational ethnographic case studies to improve the process and increase the impact of qualitative research in health care is currently underdeveloped. In this article, we aim to explore the methodological potentialities and limitations of combining organizational ethnography and case study to conduct in-depth empirical health care research. We conducted a scoping review, systematically investigating seven bibliographic databases to search, screen, and select empirical articles that employed organizational ethnographic case study to explore organizational phenomena in health care contexts. We screened 573 papers, then completed full-text review of 74 papers identified as relevant based on title and abstract. A total of 18 papers were retained for analysis. Data were extracted and synthesized using a two-phase descriptive and inductive thematic analysis. We then developed a methodological matrix that positions how the impact, contextualization, credibility, and depth of this combined methodology interact to increase the generative power of in-depth qualitative empirical research in health care. Our review reveals that organizational ethnographic case studies have their own distinct methodological identity in the wider domain of qualitative health care research. We argue that by accelerating the research process, enabling various sources of reflexivity, and spreading the depth and contextualization possibilities of empirical investigation of complex organizational phenomena, this combined methodology may stimulate greater academic dynamism and increase the impact of research. Organizational ethnographic case studies appear as a new in-depth qualitative methodology that both challenges and improves the conventional ways we study the lives of organizations and the experiences of actors within the interconnected realms of health care.

Introduction: Providers, managers, health system leaders, and researchers could learn across countries implementing system-wide models of integrated care, but require accessible methods to do so. This study assesses if a common framework could describe and compare key components of international models of integrated care. Theory and methods: A framework developed for an international study of programs that address high needs high cost patients was used to describe and compare 11 case studies analyzed in two international research projects; the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study in Canada and New Zealand, and the Vilans research group exploring models in the Netherlands. Comparative summaries were generated, with findings discussed at a 2019 International Conference on Integrated Care workshop. Results: The template was found to be useful to compare integrated case analyses in different contexts, and stands apart from other case comparison approaches as it is easily applied and can provide practical guidance for frontline staff and managers. Areas of improvement for the template are identified and two updated versions are presented. Conclusions and discussion: There is value to using a common template to provide guidance in international comparison of models of integrated care. We discuss the applicability of the approach to support scale and spread of integrated care internationally.

Abstract Background Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients’ prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal. Methods This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment. Results Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients’ experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization. Conclusions This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.

Introduction: Integrated care models for older adults are increasingly utilised in healthcare systems to overcome fragmentations. Several groups of stakeholders are involved in the implementation of integrated care. The aim of this study is to identify the main concerns, convergences and divergences in perspectives of stakeholders involved in the implementation of a centralised system-wide integrated care model for older adults in Quebec. Theory and methods: Qualitative multiple-case study. Semi-structured interviews of key stakeholders: policymakers (n = 11), providers (n = 29), managers (n = 34), older adult patients (n = 14) and caregivers (n = 9), including document analysis. Thematic analysis of the views of stakeholders along the lines of the six dimensions of the Rainbow Model of Integrated Care. Results: While patients/caregivers were mostly concerned by their unmet individual needs, policymakers, managers and providers were concerned by structural barriers to integrating care. Stakeholders’ diverse perspectives indicated implementation gaps in a top-down implementation context. Conclusion: Mandated system-wide integration appears to have structural, organizational, functional, and normative transformations, but its clinical changes are more uncertain in view of the observed divergent perspectives of actors. It will be interesting to explore if the systemic changes are precursors of clinical changes or, on the contrary, explains the lack of clinical changes.

Background: Health systems globally are still struggling to roll out system-wide models of integrated health and social care. While pockets of innovation exist they often remain stuck within single jurisdictions, or, worse yet, never expand beyond the pilot phase. Researchers, providers, managers and health system leaders could learn from the experiences of other countries facing similar challenges, however lack a standardized comparative method to take findings from different contexts and relate them back to their own. Aims and Objectives: This workshop will walk participants through one approach to conducting comparative program summaries originally developed by the Commonwealth Fund in the United States and applied to cases of integrated care across three different countries. The template captures key components of integrate care including client access and eligibility, care coordination and transition processes, information management systems, self-management and caregiver supports, program maturity, measures of success, and evaluation. Audience members will learn about the strengths, weaknesses, opportunities and challenges of adopting this type of comparative work, drawing on the examples presented by a panel of international researchers who have applied the Commonwealth Fund template on integrated care to their original studies SUSTAIN (Netherlands) and iCOACH (Canada, New Zealand). Participants will have the opportunity to go through the exercise of adopting the approach. Participants will be broken up into small groups and given short-form templates that can be applied to their own models of integrated care. Groups will go through the exercise and engage in a facilitated discussion on: 1) whether it can be applied to their contexts; 2) what they can learn from this type of exercise to improve and build on existing or new models; and 3) what is missing and what are the challenges when we try to learn across borders. Target audience: This workshop will be of interest to providers, manager and decision-makers seeking to learn from other examples as they adopt, grow, or spread their own models of care. Researchers will also benefit from this workshop as we tackle the methodological and conceptual challenges of complex comparative case analysis, using a case summary templates as a starting point. Learnings/Take away: Participants of this workshop will learn: How to apply a standardized template to analyze their local contexts. Methods to share knowledge across international borders as a means to further their programs and models of care The values and challenges in engaging in cross-national comparative case analysis

Introduction: Integrated community-based primary healthcare models are multi-component organisational models which are embedded in complex multi-level healthcare systems. They are implemented within natural environments marked by complex interactions between actors operating at the macro (policymakers), meso (managers) and micro (providers/users) levels of health systems. Institutional entrepreneurs are actors whose activities shape the way innovations - such as integrated care - are implemented. Furthermore, institutional entrepreneurs operate within top-down (mandated) or bottom-up (enabling) environments, that may influence their activities. Understanding the nature of institutional entrepreneurship in the implementation of integrated care within top-down/bottom-up contexts may inform stakeholders on how to improve the implementation of integrated care. This study aimed at exploring the institutional entrepreneurship of macro-level actors in the implementation of integrated care for older adults in the top-down context of Québec and the bottom-up context of Ontario as perceived by multiple stakeholders. Theory/methods: Maguire’s (2004) activities of institutional entrepreneurs – subject position, theorisation, and institutionalisation - will influence the implementation of Valentijn’s (2015) six dimensions – clinical, professional, organisational, system, functional and normative - of integrated care. Qualitative multiple case study consisting of 78 semi-structured interviews of policymakers, managers and providers in Québec and Ontario, and document analysis. The Nvivo 11 software was used for a thematic analysis of the qualitative data. Results: Several actors such as policymakers, managers or providers contributed in shaping integrated care in both contexts. With a focus on macro level actors, patient- centered care aimed at improving ageing at home was a subject position both governments of Québec and Ontario articulated in their integration policies. In a top-down manner the government of Québec influenced the implementation of all six dimensions of integration by designing and mandating the implementation of nine major components of integrated care in each of the 94 Local Health Networks of their territory. Conversely, the government of Ontario mainly influenced the systemic and normative dimensions of integration by passing enabling legislation and funding support that enabled the bottom-up development of 82 Health Links with different forms of clinical, professional, organisational, and functional integration. Discussions: The implementation of integrated care necessitates new practices or the adaptation of existing practices. Both governments articulated patient-centered care and healthy ageing policies but differed in implementation approaches. Québec’s top-down approach resulted in the “same” integrated care model in all Local Health Networks of its territory, while Ontario’s bottom-up approach enabled local communities to develop and shape their integrated care models. Conclusions: Activities of institutional entrepreneurs in top-down/bottom-up environments highlight the complexity of healthcare systems. Successful implementation of integrated care needs strategies that address various organisational forms. Lessons learned: Institutional entrepreneurship in various organisational forms can results to different implementation outcomes. This can complicate the implementation of integrated care in real-life contexts. Limitations: Factors other than top-down/bottom-up organisational forms can influence the activities of institutional entrepreneurs (e.g. funding models) in the implementation of integrated care. Suggestions for future research: Explore the institutional entrepreneurship of meso and micro level actors in the implementation of integrated care.

Context: Provinces across Canada are seeking new and innovative ways to manage the efficiency, effectiveness and quality of their healthcare systems. The implementation of integrated care pathways is viewed as an answer to the problem of fragmentation of care. We conducted a developmental evaluation to study the implementation of integrated care pathways in one healthcare organization and it network in Quebec. Objective: In this study we describe the development of the integrated care pathways and analyze the process of governance innovation within a developmental framework. We seeks to understand how change in governance occurred and its impact of primary healthcare deliveries through intersectorial network. Design: Using a qualitative approach, we conduct a process analysis with three case study with multilevel of analysis. The analysis used a conceptual framework based on the Complex Adaptive Systems (CAS) approach of multi-level governance (Maillet, 2016) and Organizational Knowledge Creation theory (Nonaka, 2007). Empirical data were collected through documentation, observation (N=23), and semi-structured interviews with key informants (N=20). Results: Our preliminary results give a detail account of the practices put in place by the implementers and the impacts of the feedback on the adaptation processes. Our findings highlight the role of sense-making processes primarily to help promote change. The results also identify the struggle to disseminate the knowledge gained from the project within the rest of the organization. Finally, our results identify several individual, organizational, program design and contextual factors that facilitated and/or impeded the implementation of the integrated care pathways within and outside the healthcare organization. Conclusion: Our study provided interesting insights into how the development came about and what adaptation processes were successful to bring change in the governance. Our results will be of interest for health care decision makers aiming to better respond to the needs of users and to increase their participation at all levels of organization and networks.