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Background Interprofessional collaborative teams (teams) have been introduced across Canada to improve access to and quality of primary care. However, the quality and speed of team implementation has been challenging and has not kept pace with increasing access issues. The aim of this research was to use an implementation framework to categorize and describe barriers and enablers to team implementation in primary care. Methods A narrative review that prioritized systematic reviews and evidence syntheseswas conducted. A search using pre-defined terms was conducted using Ovid MEDLINE, and potentially relevant grey literature was identified through ad hoc Google searches and hand searching of health organization websites. The Consolidated Framework for Implementation Research (CFIR) was used to categorize barriers and enablers into five domains: (1) Features of Team Implementation; (2) Government, Health Authorities and Health Organizations; (3) Characteristics of the Team; (4) Characteristics of Team Members; and (5) Process ofImplementation. Results Data were extracted from 19 of 435 articles that met inclusion/exclusion criteria. Most barriers and enablers were categorized into two domains of the CFIR: Characteristics of the Team and Government, Health Authorities, and Health Organizations. Key themes identified within the Characteristics of the Team domain were team-leadership, including designating a manager responsible for day-to-day activities and facilitating collaboration; clear governance structures, technology supports and tools that facilitate information sharing and communication; and a combination of formal and informal methods of communication. Key themes within the Government, Health Authorities, and Health Organizations domain were professional remuneration plans, regulatory policy, and interprofessional education that encourage and incorporate interprofessional competencies and values. Conclusions Barriers and enablers to implementing teams using the CFIR were identified, which enables stakeholders and teams to tailor implementation of teams at the local level to impact the accessibility and quality of primary care.

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR's) Strategic Plan 2021-2026 for accelerating health system transformation is well positioned to meet the strategic priorities being outlined by many health systems in Canada and internationally (CIHR IHSPR 2021). The IHSPR Health System Impact Fellow program has been a strong influence on the embedded research and scientist program in Nova Scotia, namely, the Network of Scholars Program, which was implemented just before the pandemic. The network includes scientists and scholars from diverse academic backgrounds and skill levels including alumni of the Health System Impact Fellow program. The Network of Scholars has over 30 scholars and approximately 100 academic partners and scientists supporting embedded activities such as rapid reviews, implementation science and rapid evaluation initiatives. These embedded activities are front facing to the needs and priorities of the health system. This commentary highlights the importance of IHSPR's outlined strategic plan and direction, which are consistent with the experience and the needs for embedded supports within the Nova Scotia health system.

Repeated calls to adopt more robust workforce planning, particularly for the nursing workforce, stretch back decades. These calls have generally not been met with action by health system decision makers, and the negative consequences - widespread shortages, even in wealthy countries, and decreased quality of care despite increased costs - have come to pass much as predicted. In contrast to this historical pattern, this paper presents Nova Scotia Health's experience in planning for its critical care nursing workforce during COVID-19 as a case study in integrating evidence-based workforce planning into the operations of a healthcare organization.

Background An upstream approach to palliative care in the last 12 months of life delivered by primary care practices is often referred to as Primary Palliative Care (PPC). Implementing case management functions can support delivery of PPC and help patients and their families navigate health, social and fiscal environments that become more complex at end-of-life. A realist synthesis was conducted to understand how multi-level contexts affect case management functions related to initiating end-of-life conversations, assessing patient and caregiver needs, and patient/family centred planning in primary care practices to improve outcomes. The synthesis also explored how these functions aligned with critical community resources identified by patients/families dealing with end-of-life. Methods A realist synthesis is theory driven and iterative, involving the investigation of proposed program theories of how particular contexts catalyze mechanisms (program resources and individual reactions to resources) to generate improved outcomes. To assess whether program theories were supported and plausible, two librarian-assisted and several researcher-initiated purposive searches of the literature were conducted, then extracted data were analyzed and synthesized. To assess relevancy, health system partners and family advisors informed the review process. Results Twenty-eight articles were identified as being relevant and evidence was consolidated into two final program theories: 1) Making end-of-life discussions comfortable, and 2) Creating plans that reflect needs and values. Theories were explored in depth to assess the effect of multi-level contexts on primary care practices implementing tools or frameworks, strategies for improving end-of-life communications, or facilitators that could improve advance care planning by primary care practitioners. Conclusions Primary care practitioners’ use of tools to assess patients/families’ needs facilitated discussions and planning for end-of-life issues without specifically discussing death. Also, receiving training on how to better communicate increased practitioner confidence for initiating end-of-life discussions. Practitioner attitudes toward death and prior education or training in end-of-life care affected their ability to initiate end-of-life conversations and plan with patients/families. Recognizing and seizing opportunities when patients are aware of the need to plan for their end-of-life care, such as in contexts when patients experience transitions can increase readiness for end-of-life discussions and planning. Ultimately conversations and planning can improve patients/families’ outcomes.

BackgroundPatient-centred interventions to help patients with multimorbidity have had mixed results.AimTo assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.Design and settingMixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.MethodPatients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention.ResultsA total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.ConclusionOverall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.

OBJECTIVE The purpose of this review is to describe how health service and delivery systems support health equity and to identify strategies and indicators being used to measure health equity. INTRODUCTION It is widely acknowledged that a population health and equity approach is needed to improve the overall health of the population. The health service and delivery system plays an important role in this approach. Despite this, system transformation to address health inequities has been slow. This is due, in part, to the lack of evidence-based guidance on how health service and delivery systems can address and measure health equity integration. Most studies focus on health equity integration in the public health sector at a provincial or national level, but less is known about integration within the health service and delivery system. More information is needed to understand how that transformation is occurring, or could occur, to make a meaningful contribution toward improving population health outcomes. INCLUSION CRITERIA This scoping review will identify studies that describe the strategies and indicators that health service and delivery systems are using to integrate health equity and how progress is measured. Evidence from qualitative, quantitative, mixed method studies, and gray literature will be included. METHODS This review will be conducted in accordance with JBI methodology for scoping reviews. A comprehensive search strategy, developed with a librarian scientist, will be used to identify relevant sources. Titles, abstracts, and full texts will be evaluated against inclusion criteria. Information will be extracted by two independent reviewers. Data will be synthesized and presented narratively, with tables and figures where appropriate.

Canadian and other healthcare systems are adopting primary care models founded on multidisciplinary, team-based care. This paper describes the development and use of a new tool, the Team Assessment of Self-Management Support (TASMS), designed to understand and improve the self-management support teams provide to patients with chronic conditions. Team Assessment of Self-Management Support captures the time providers spend supporting seven different types of self-management support (process strategies, resources strategies, disease controlling strategies, activities strategies, internal strategies, social interactions strategies, and healthy behaviours strategies), their referral patterns and perceived gaps in care. Four unique features make TASMS user-friendly: it is patient-centred, it uses provider-level data to create a team profile, it has the ability to be tailored to needs (diagnosis and visit type), and visual presentation of results are quickly and intuitively understood by both providers and planners. Currently being used by providers and planners in Nova Scotia, scaling up will allow more widespread use.

IntroductionAssessing and measuring patients’ chronic condition self-management needs are critical to quality health care and to related research. One in three adults around the world live with multiple chronic conditions. While many patient-reported measures of self-management have been developed, none has emerged as the gold standard, and all have one or more of the following limitations: (1) they fail to measure the different domains of self-management important to patients, (2) they lack sufficient specificity to support patient-centred care or identify the specific components of self-management interventions that work and/or (3) they lack suitability for patients with multiple chronic conditions.Methods and analysisThe Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC) is being developed to overcome these shortcomings. It will measure respondents’ perceived success (or difficulty) in self-managing seven domains important to patients. The protocol has three phases. Phase 1 is conceptual model development and item generation. Phase 2 is assessment of the relevance and understanding of items by people with chronic conditions. Phase 3 is item analysis, dimensionality assessment, scaling and preliminary validation of the PRISM-CC using an online survey of people with chronic conditions (n~750). The expected completion date is early 2021.Ethics and disseminationThis study will adhere to the Canadian Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans. Ethics approval for all phases has been obtained from the Nova Scotia Health Authority Research Ethics Board. Once completed, the PRISM-CC will be made available for research and healthcare at minimal to no cost.

Refugees tend to have greater vulnerability compared to the general population reporting greater need for physical, emotional, or dental problems compared to the general population. Despite the importance of creating strong primary care supports for these patients, it has been demonstrated that there is a significant gap in accessing primary care providers who are willing to accept the refugee population. These have resulted in bottlenecks in the transition or bridge clinics and have left patients orphaned without a primary care provider. This in turn results in higher use of emergency service and other unnecessary costs to the healthcare system. Currently there are few studies that have explored these challenges from primary care provider perspectives and very few to none from patient perspectives. A novel collaborative implementation initiative in primary healthcare (PHC) is seeking to improve primary medical care for the refugee population by creating a globally recommended transition or beacon clinic to support care needs of new arrivals and transitions to primary care providers. We discuss the innovative elements of the clinic model in this paper.

Objectives There is an urgent need for healthcare providers and healthcare systems to support productive interactions with patients that promote sustained health behaviour change in order to improve patient and population health outcomes. Behaviour change theories and interventions have been developed and evaluated in experimental contexts; however, most healthcare providers have little training, and therefore low confidence in, behaviour change counselling. Particularly important is how to integrate theory and method to support healthcare providers to engage in behaviour change counselling competently. In this article, we describe a general training model developed from theory, evidence, experience and stakeholder engagement. This model will set the stage for future evaluation research on training needed to achieve competency, sustainability of competency, as well as effectiveness/cost-effectiveness of training in supporting behaviour change. Design and Methods A framework to support competency based training in behaviour change counselling is described in this article. This framework is designed to be integrative, sustainable, scalable and capable of being evaluated in follow-up studies. Results and Discussion Effective training in behaviour change counselling is critical to meet the current and future healthcare needs of patients living with, or at risk of, chronic diseases. Increasing competency in establishing change-based relationships, assessing and promoting readiness to change, implementing behaviour modification and addressing psychosocial issues will be value added to the healthcare system.

Introduction: Timely, precise, and relevant communication between hospital-based clinicians and primary care physicians post-discharge (DC) ensures quality transitions, thereby reducing patient safety incidents and preventing readmission. At the present time there is limited knowledge of elements of quality or methods to score the quality criteria in the context of DC summaries. The Nova Scotia Health Authority, a provincial health system responsible for the delivery of services in a small Canadian province, embarked on a system-level approach to the standardization of DC summaries in an effort to improve quality and safety at care transitions from hospital to primary care. Materials and Methods: A comprehensive literature review to retrieve items relevant to quality in DC summaries, retrospective audit of charts, a consensus development process, and, finally, validation of a scoring tool were conducted in order to develop a quality scoring tool for DC summaries. Results: Relevant items were identified through the literature review and consensus development process. Corresponding definitions that were established assisted the development of the quality criteria, which were subsequently used to score the quality of DC summaries in our organization. Conclusion: The scoring tool developed through this work will be applied to help us gain a more in-depth understanding of quality in DC summaries and support the development of suitable education and quality processes in the health authority that can best support safe care transitions for patients.

Background Understanding and addressing the needs of frail persons is an emerging health priority for Nova Scotia and internationally. Primary healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not standard practice and, in general, there is a lack of awareness about how to identify and respond to frailty. A web-based tool called the Frailty Portal was developed to aid in identifying, screening, and providing care for frail patients in PHC settings. In this study, we will assess the implementation feasibility and impact of the Frailty Portal to: (1) support increased awareness of frailty among providers and patients, (2) identify the degree of frailty within individual patients, and (3) develop and deliver actions to respond to frailtyl in community PHC practice. Methods This study will be approached using a convergent mixed method design where quantitative and qualitative data are collected concurrently, in this case, over a 9-month period, analyzed separately, and then merged to summarize, interpret and produce a more comprehensive understanding of the initiative’s feasibility and scalability. Methods will be informed by the ‘Implementing the Frailty Portal in Community Primary Care Practice’ logic model and questions will be guided by domains and constructs from an implementation science framework, the Consolidated Framework for Implementation Research (CFIR). Discussion The ‘Frailty Portal’ aims to improve access to, and coordination of, primary care services for persons experiencing frailty. It also aims to increase primary care providers’ ability to care for patients in the context of their frailty. Our goal is to help optimize care in the community by helping community providers gain the knowledge they may lack about frailty both in general and in their practice, support improved identification of frailty with the use of screening tools, offer evidence based severity-specific care goals and connect providers with local available community supports.

PURPOSE To measure the effectiveness of a 4-month interdisciplinary multifaceted intervention based on a change in care delivery for patients with multimorbidity in primary care practices. METHODS A pragmatic randomized controlled trial with a mixed-methods design in patients aged 18 to 80 years with 3 or more chronic conditions from 7 family medicine groups (FMGs) in Quebec, Canada. Health care professionals (nurses, nutritionists, kinesiologists) from the FMGs were trained to deliver the patient-centered intervention based on a motivational approach and self-management support. Primary outcomes: self-management (Health Education Impact Questionnaire); and self-efficacy. Secondary outcomes: health status, quality of life, and health behaviors. Quantitative analyses used multi-level mixed effects and generalized linear mixed models controlling for clustering within FMGs. We also conducted in-depth interviews with patients, family members, and health care professionals. RESULTS The trial randomized 284 patients (144 in intervention group, 140 in control group). The groups were comparable. After 4 months, the intervention showed a neutral effect for the primary outcomes. There was significant improvement in 2 health behaviors (healthy eating with odds ratios [OR] 4.36; P = .006, and physical activity with OR 3.43; P = .023). The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results. CONCLUSIONS Quantitatively, this intervention showed a neutral effect on the primary outcomes and substantial improvement in 2 health behaviors as secondary outcomes. Qualitatively, the intervention was evaluated as positive. The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.

IntroductionCanadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but little evidence to support or refute this. The goal of this study is to inform primary care planning by: (1) identifying values and preferences shaping the practice intentions and choices of family medicine residents and early career PCPs, (2) comparing practice patterns of early-career and established PCPs to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of PCPs) or period effects (changes over time across all PCPs) and (3) integrating findings to understand the dynamics among practice intentions, practice choices and practice patterns and to identify policy implications.Methods and analysisWe plan a mixed-methods study in the Canadian provinces of British Columbia, Ontario and Nova Scotia. We will conduct semi-structured in-depth interviews with family medicine residents and early-career PCPs and analyse survey data collected by the College of Family Physicians of Canada. We will also analyse linked administrative health data within each province. Mixed methods integration both within the study and as an end-of-study step will inform how practice intentions, choices and patterns are interrelated and inform policy recommendations.Ethics and disseminationThis study was approved by the Simon Fraser University Research Ethics Board with harmonised approval from partner institutions. This study will produce a framework to understand practice choices, new measures for comparing practice patterns across jurisdictions and information necessary for planners to ensure adequate provider supply and patient access to primary care.

Objectives The objective of this study is to evaluate the uptake of competency-based behaviour change counselling training within a primary healthcare setting. Specific questions concerning provider readiness for training, perceived importance of training in the context of service demands and perceptions of competence after training were addressed. Study design A process-focused study which adopted a complex systems approach to implementation. Each step was evaluated before the next step was developed. The design was guided by the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. Methods Four specific primary care services were identified and behaviour change counselling training tailored to each service was provided, based on a model of training built around competencies in establishing change-based relationships, assessing and promoting readiness to change, using evidence-based behaviour modification skills when ready and addressing psychosocial determinants of behaviour within scope of practice. Before training, a manager's readiness to facilitate training and identification of peer leaders to support ongoing practice of skills were completed. Results Two programs negotiated 8 h of formal training, one program received 10 h and one program received 12 h. All programs engaged in peer support activities. Despite willingness to support training, 90% of managers were ambivalent about training activities, relative to one half of healthcare providers (HCPs). Few HCPs and no managers self-identified as ready without ambivalence. Furthermore, HCPs were reluctant to be evaluated by an expert and preferred self-evaluation methods. In contrast, HCPs uniformly endorsed the relevance, value and professional commitment to all component skills of the behaviour change counselling model. At the end of the training, over 75% of staff reported receiving formal training (reach). Almost 80% of staff reported using change-based relationship skills daily, with less frequent use of skills associated with addressing psychosocial issues. The degree of corrective feedback was generally low, however. An index of competency based on formal training, frequent use and receiving corrective feedback indicated that most HCPs did not meet these criteria. Conclusion Training in behaviour change counselling competencies was successfully implemented in this project. The vast majority of HCPs received training, despite ambivalence. Furthermore, HCPs strongly valued these skills and used them frequently. However, they were reluctant to accept corrective feedback. Future research is needed to evaluate innovative strategies to overcome obstacles to receiving corrective feedback in the use of behaviour change counselling skills.

Background Frailty is associated with multi-system deterioration, and typically increases susceptibility to adverse events such as falls. Frailty can be better managed with early screening and intervention, ideally conducted in primary health care (PHC) settings. This study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework during the second stage piloting of a novel web-based tool called the Frailty Portal, developed to aid in the screening, identification, and care planning of frail patients in community PHC. Methods This qualitative study conducted semi-structured key informant interviews with a purposive sample of PHC providers (family physicians, nurse practitioners) and key PHC stakeholders who were administrators, decision makers and staff. The CFIR was used to guide data collection and analysis. Framework Analysis was used to determine the relevance of the CFIR constructs to implementing the Frailty Portal. Results A total of 17 interviews were conducted. The CFIR-inspired interview questions helped clarify critical aspects of implementation that need to be addressed at multiple levels if the Frailty Portal is to be successfully implemented in PHC. Finding were organized into three themes 1) PHC Practice Context, 2) Intervention attributes affecting implementation, and 3) Targeting providers with frail patients. At the intervention level the Frailty Portal was viewed positively, despite the multi-level challenges to implementing it in PHC practice settings. Provider participants perceived high opportunity costs to using the Frailty Portal due to changes they needed to make to their practice routines. However, those who had older patients, took the time to learn how to use the Frailty Portal, and created processes for sharing tasks with other PHC personnel become proficient at using the Frailty Portal. Conclusions Structuring our evaluation around the CFIR was instrumental in identifying multi-level factors that will affect large-scale adoption of the Frailty Portal in PHC practices. Incorporating CFIR constructs into evaluation instruments can flag factors likely to impede future implementation and impact the effectiveness of innovative practices. Future research is encouraged to identify how best to facilitate changes in PHC practices to address frailty and to use implementation frameworks that honor the complexity of implementing innovations in PHC.

Background: Understanding and addressing the needs of frail patients has been identified as an important strategy by the Nova Scotia Health Authority (NSHA). Primary care (PC) providers are in a key position to aid in the identification of, and response to frailty as part of routine care. Unlike singular chronic conditions such as diabetes and hypertension which garner a disease-based approach and identification as part of standard practice, frailty is only just emerging as a concept for PC. The web-based Frailty Portal was developed to aid in the identification of, assessment and care planning for frail patients in PC practice. In this study we assess the implementation feasibility and impact of the Frailty Portal by: (1) identifying factors influencing the Frailty Portal’s use in community PC practice, and (2) examination of the immediate impact of the ‘Frailty Portal’ on frail patients, their caregivers and PC providers. Methods: A convergent mixed method approach was implemented among PC providers in community-based practice in the NSHA, Central Zone. Quantitative and qualitative data were collected concurrently over a 9-month period. A sample of patients who underwent assessment and/or their caregiver were approached for survey participation. Results: Fourteen community PC providers (10 family physicians, 4 nurse practitioners) completed 48 patient assessments and completed or begun 41 care plans; semi-structured interviews were conducted among 9 providers. Nine patients and 5 caregivers participated in the survey. PC providers viewed frailty as an important concept but implementation challenges were met, primarily with respect to the time required for use and lack of fit with traditional practice routines. Additional barriers included tool usability and accessibility, training and care planning steps, and privacy. Impacts of the tools use with respect to confidence and knowledge showed early promise. Conclusion: This feasibility study highlights the need for added health system supports, resources and financial incentives for successful implementation of the Frailty Portal in community PC practice. We suggest future implementation integrate the Frailty Portal to practice electronic medical records (EMRs) and target providers with largely geriatric practice populations and those practicing within interdisciplinary, collaborative primary healthcare (PHC) teams.

Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.

Background Recognizing the significant impact of wait times for care for individuals with complex chronic conditions, we applied a LEAN methodology, namely – an adaptation of Value Stream Mapping (VSM) to meet the needs of people with multiple chronic conditions and to improve wait times without additional resources or funding. Methods Over an 18-month time period, staff applied a patient-centric approach that included LEAN methodology of VSM to improve wait times to care. Our framework of evaluation was grounded in the needs and perspectives of patients and individuals waiting to receive care. Patient centric views were obtained through surveys such as Patient Assessment of Chronic Illness Care (PACIC) and process engineering based questions. In addition, LEAN methodology, VSM was added to identify non-value added processes contributing to wait times. Results The care team successfully reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction are also outcomes of this innovative initiative. In addition, successful transformations and implementation have resulted in resource efficiencies without increase in costs. Patients have shown significant improvements in functional health following Integrated Chronic Care Service (ICCS) intervention. The methodology will be applied to other chronic disease management areas in Capital Health and the province. Conclusion Wait times to care in the management of multimoribidities and other complex conditions can add a significant burden not only on the affected individuals but also on the healthcare system. In this study, a novel and modified LEAN methodology has been applied to embed the voice of the patient in care delivery processes and to reduce wait times to care in the management of complex chronic conditions.

Individuals with multimorbidity have complex care needs along with significant impacts to their functional health and quality of life. Recent evidence-based and experience-based explorations have revealed the importance of patient perspectives and functional health management in improving care delivery and health outcomes for individuals with multimorbidity. The impact of managing multimorbidity is evident at multiple levels of healthcare – the individual, the provider, and the system. Our local experience dealing with these challenges has led to the development of a functional health model that includes patient perspectives in care delivery within the Integrated Chronic Care Service (ICCS) of the health authority in Nova Scotia. In this paper, we present a discussion of the challenges, guiding models, and service-level transformations that have been integrated into care delivery at the ICCS to meet the healthcare needs of people with multiple health conditions. We describe our redesign strategies for care team planning, treatment approach, and patient inclusion. Journal of Comorbidity 2016;6(2):76–84

Improving care for chronic conditions requires system-level transformations to ensure multiple levels of adoption and sustainability of the implemented improvements. These comprehensive solutions require transformations and supports at various levels, leadership and process changes at service/program level. Recognizing the importance of an organization-wide strategy to mitigate the growing issue of chronic disease prevention and management, a novel system-level approach has been developed in a district health authority in Nova Scotia, Canada. In this paper, the contextual factors and efforts that led to the conceptual framework of the Chronic Disease Prevention and Management (CDPM) "Corridor©" to management of chronic conditions are discussed. The CDPM Corridor© essentially constitutes a system-level redesign process; common elements, tools and resources; and a hub of supports for chronic disease prevention and management. The CDPM Corridor

IntroductionSignificant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada.Methods and analysisWe will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method.Ethics and disseminationThis study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.