Background
Healthcare integration
Ontario Health Teams
Methods
Phase I: plan and design
Study design
Theoretical framework
Phase II: recruitment, Data Collection and within-case analysis
Setting
Recruitment of participants
Data collection
Data analysis
Phase III: cross-case analysis and conclusions
Quality of research
Ethics approval
Findings
Case 1 • Cohort 2, approved Nov 2020 • Geography: Rural region • Participants: 4 FPs, 6 non-FPs | Case 2 • Cohort 1, approved Dec 2019 • Geography: Rural/northern region • Participants: 4 FPs, 6 non-FPs |
Case 3 • Cohort 2, approved Nov 2020 • Geography: Rural/urban mix region • Participants: 5 FPs, 6 non-FPs | Case 4 • Cohort 2, approved Nov 2020 • Geography: Rural/remote/northern region • Participants: 4 FPs, 4 non-FPs |
How are FPs engaging with and/or being engaged by the OHT, and were there any structures or processes that were beneficial to participation? |
Case 1 • Generational differences in FP engagement (Younger FPs more likely to participate) • Physician champions influential • Process: Need for process; immature at moment • Structure: Previous primary care structure; standalone and separate from OHT |
Case 2 • Generational differences in FP engagement (Younger FPs more likely to participate) • Representation from all sites • Process: ∘ FPs involved in development of governance model ∘ COVID-19 pandemic forced FP engagement with OHT • Structure: OHT model built on previous project successes |
Case 3 • Physician champions influential • Process: FPs invited to table early during OHT application process; High level of FP participation • Structure: Established through early buy-in and engagement through a physician council |
Case 4 • Minimal to no processes and structures in place • Some existing structures prior to OHTs influencing collaboration, but on a grassroots level |
Why is it challenging to include FPs in OHT decision making and system change? |
Case 1 • Skepticism of change • Administrative heavy/not relevant to FPs • Meetings not good investment of time • Inconvenient meeting times • Lack of compensation • Tangible outcomes needed • Lack of FPs in region • COVID-19 pandemic interrupting progress • Burnout and heavy workload • Challenged communication |
Case 2 • Meaningful and consistent communication methods needed • Skepticism; promises unfulfilled previously • Government and hospital control; power imbalance • Time commitment and high workload • COVID-19 pausing most OHT activities |
Case 3 • Skepticism, cynicism towards change • Silos and power imbalances between different actors • Workload and burnout • FPs volunteering • Unequal resources in region • COVID-19 pausing most OHT activities |
Case 4 • Compensation model • Limited resources • No consultation • No tangible impact • Power imbalance • Skepticism and cynicism towards change • Burnout and workload |
Themes | Case 1 | Case 2 | Case 3 | Case 4 | |
---|---|---|---|---|---|
1. | Structure for FP participation was viewed as valuable | Structure pending development | Well-defined structure in place and active participation | Well-defined structure in place and active participation | Discussions started related to a FP structure |
2. | Communication with FPs a challenge Relationship-building/collaboration pivotal to OHT development | Not well, not “super-strong”, “horribly piecemeal” Collaboration between FPs evident within small communities but minimal across the region | Too much info, too little that’s relevant to FPs; consistent mechanism needed High degree of previous collaboration through similar integration work very beneficial to OHT development and FP participation | Strong start to FP communication but challenged by different practice models Power imbalances between providers and OHT partners had detrimental impact on OHT development | Communication minimal, efforts underway to create website Minimal region-wide collaboration between FPs due to remote nature of services but some situational collaborating evident |
3. | Challenges; Skepticism FP Workloads Pandemic impact | Some skepticism from FPs re: OHT success Burnout and heavy workload of FPs seen as poorly understood by non-FP OHT partners Pandemic shifted focus away from OHT work | High degree of skepticism from FPs noted Overworked FPs had limited their ability to participate Pandemic response viewed as a success due to collaboration history | Some skepticism from FPs re: government FPs noted that an integrated care model may increase the burden on them Pandemic stalled OHT development | Minimal skepticism from FPs noted; enthusiasm instead for OHT work Workload for FPs exacerbated by need for multiple roles in rural regions Pandemic pushed back all OHT activities; late start in securing admin lead, digital presence |
1. | Structures for decision making A strong emphasis on establishing a governance structure for FPs was clear in 2 cases. In both, FPs were participating at governance and community levels with one making a significant effort to ensure representation on all working groups In one case FP participation was primarily at the governance level In still another case, there were no FPs participating in any role. |
2. | Communication successes Face-to-face communication was highly favoured in 1 case, viewed as respectful by FPs which resulted in more participation by FPs FPs in rural communities that practiced in hospitals frequently received OHT updates from the Medical Advisory Committee which kept them informed Relationship-building/collaboration In 1 case, relationships that pre-existed before the OHT allowed this community to ramp up quickly as an OHT In another case, history played a detrimental role as power imbalances and challenges in partnering made engaging with FPs difficult. In one case engagement with a large First Nations community highlighted the need for cultural safety training for all partners |
Within-case analysis results
1) Structure for decision making
“On the primary care side, they have to be able to organize, to speak with one voice so you’re not getting six different answers from six different practices”(non-FP/Hospital Director).
2) Processes
Communication
Relationship building/collaboration
3) Challenges to FP participation
Skepticism
Burnout and workload
COVID-19 pandemic
“It’s really enabled us to have a strong and robust COVID response. So a really integrated approach initially with the assessment centres between the Family Health Team staff and the primary care physicians doing the bulk of the testing. That kind of evolved into just being ready and able to work collaboratively by the time that the vaccine started coming” (non-FP/Executive Director).
Cross-case analysis results
1) Structures for decision-making
2) Processes
Communication
“I think in a perfect world someone would sit down with us in a face-to-face meeting and explain to us what this OHT is going to look like and how the vision is of how primary care is going to be involved. I don’t feel like that’s happened” (FP).
“That’s been the feel, on the ground, is the opportunity for consultation has largely been survey-based, passive, do this survey for 20 minutes and give us your opinion. As a primary care practitioner, the starting point needed to be consultation on the ground …before any bigger conversation happened about who we hire as admin support and which communities we include” (FP).