Background
the integration of primary care and public health could enhance the capacity of both sectors to carry out their respective missions and link with other stakeholders to catalyze a collaborative, intersectoral movement toward improved population health. [5] p.1.
Primary Care: “…the crucial foundation of a health care system, and defines the key features of primary care as being the first point of entry to a health care system, the provider of person-focused care (not disease oriented] over time for all but the most uncommon conditions and the part of the system that integrates or co-ordinates care provided elsewhere or by others.” (Starfield, 1998) | |
Public Health: “…an organized activity of society to promote, protect and improve, and when necessary, restore the health of individuals, specified groups, or the entire population. It is a combination of sciences, skills, and values that function through collective societal activities and involve programs, services, and institutions aimed at protecting and improving the health of all people. The term “public health” can describe a concept, a social institution, a set of scientific and professional disciplines and technologies, and a form of practice. It is a way of thinking, a set of disciplines, an institution of society, and a manner of practice. It has increasing number and variety of specializes domains and demands of its practitioners [and] increasing array of skills and expertise” (Public Health Agency of Canada, 2008) p.13. | |
Collaboration: is defined as: “a recognized relationship among different sectors or groups, which have been formed to take action on an issue in a way that is more effective or sustainable than might be achieved by [any one group or sector] acting alone.” (Public Health Agency of Canada, 2008). p.9 |
Methods
Sector | BC n (%) | ON n (%) | NS n (%) | National n (%) | Total n (%) |
---|---|---|---|---|---|
PC | 10 (50.0) | 9 (47.4) | 10 (47.6) | 3 (21.4) | 32 (43.2) |
PH | 10 (50.0) | 10 (52.6) | 10 (47.6) | 3 (21.4) | 33 (44.6) |
PC and PH | 0 (0) | 0 (0) | 1 (4.8) | 6 (42.9) | 7 (9.5) |
Neither | 0 (0) | 0 (0) | 0 (0) | 2 (14.3) | 2 (2.7) |
TOTAL | 20 (100) | 19 (100) | 21 (100) | 14 (100) | 74 (100) |
Role | Number | Percent |
---|---|---|
Direct service providers | 17 | 22.9 |
Senior program managers | 14 | 18.9 |
Executive officers | 11 | 14.9 |
Middle Managers | 10 | 13.5 |
Policy Makers | 8 | 10.9 |
Other (e.g., health educator, coordinator, consultant, researcher) | 14 | 18.9 |
Total | 74 | 100 |
Discipline | Number | Percent |
Physicians | 14 | 18.9 |
Registered nurses (not including public health nurses) | 14 | 18.9 |
Public health nurses | 11 | 14.9 |
Business administrators | 8 | 10.8 |
Nurse practitioners | 7 | 9.5 |
Other professional disciplines (health promoter, dietitian, social worker, epidemiologist, psychologist, public health dentist, etc.) | 20 | 27.0 |
Total | 74 | 100 |
Results
Influencing factors on collaboration at the organizational level
Organizational Level Influencing Factors | Elements of Each Factor from this Study | Comparable Scoping Review Results (Factors and related descriptors) |
---|---|---|
1. Clear Mandates Vision and Goals | • Clear mandate for collaboration • Congruent focus • Formal agreements • Organizational structures that enable collaboration • Role delineation |
Lack of a common agenda
• Lack of a common agenda or vision • Different focus • Lack of joint planning
Leadership, management and accountability issues
• Contractual agreements • Designated staff supporting collaboration • Supportive job descriptions |
2. Strategic Coordination and Communication Mechanisms between Partners | • Formalized communication processes • Strategic plan development by partners • Coordinated clinical and administrative services • Exchange of client/health information |
Shared protocols, tools and information sharing
• Shared standardized information systems • Shared protocols re: practice, quality assurance, data collection and dissemination |
3. Formal Organizational Leaders as Collaborative Champions | • Ability to move towards a common goal • Leadership buy-in to collaboration • Transformative leadership qualities and skills |
Leadership, management and accountability issues
• Change management • Optimal functioning of healthcare providers • Stable, diverse teams • Management training for supporting collaborative teams |
4. Collaborative Organizational Culture | • Valuing the work of the other sector • Organizational readiness for collaboration • Avoiding turf protection |
Lack of a common agenda
• Lack of organizational support • Differences in organizational culture • Devaluing PH activities |
5. Optimal Use of Resources | • Investment of resources to initiate and maintain collaboration • Funding mechanisms • Geographic proximity of partners • Time for working on collaboration |
Knowledge and resource limitations
• Financial Resources • Space limitations • Lack of time for collaboration
Geographic proximity of partners
• Co-location to facilitate communication, information exchange, trust |
6. Optimal Use of Human resources | • Matched professional skills to needs • Professionals work to optimal scope of practice • Organizational mandates enable working to optimal scope of practice • Flexible, accommodating application of skill sets |
Knowledge and resource limitations
• Human Resources • Needs assessment skills in PH
Leadership, management and accountability
• Optimal functioning of healthcare providers • Stable, diverse teams • Administrative support |
7. Collaborative Approaches to Programs and Services Delivery | • Engaged community • Client-centred approach • Inter-professional teams, • Integrated or coordinated programs and services between public health and primary care |
Leadership, management and accountability issues
• Community based committees with diverse membership • Community engagement • Involvement of multiple professionals |
Influencing factor 1: clear mandates, vision, and goals
So organizationally, collaboration became a mandate and became a way of doing things. That hasn’t happened yet in most Health Authorities. And it certainly hasn’t happened at the community level to the extent that there is potential. I think that there’s opportunity for the organization and governance of things to facilitate that at some point. [NS/PC].
If you think population health is [about] acting only at a policy level then you are not going to collaborate with PC, are you? [NS/PH].
The work processes in PC tend to be individual, episodic and, in the case of PH they tend to be quite different in terms of the way that the business process works. There’s a lot more group work, there’s a lot more in the field work and a lot more regulatory [work]. [BC/PH].
So we have what is called an MOU – a memorandum of understanding – of how we work together. So the MOU says that each partner agrees to put 4 h of service in on a weekly basis. And from that memorandum, we have a planning day every year. And so it could be that PH is going to do some immunizations for us.
The bureaucracy drives me crazy and the inactivity and inability that happens when you get caught up in meetings and bureaucracy. And you’re unable to act because you are too busy talking about how to reach the sex trade worker and, what are the attributes of a sex trade worker and, rather than getting out there and actually talking, touching, and making connections. [NS/PC].
…if we think about any of the roles where PH and PC intersect. Whether it’s community health assessment, immunization, chronic disease, communicable disease, even emergency preparedness, there are certain pieces within each of those that require a PH philosophy and a PC philosophy. And it may be just a matter of sitting down with each program and having a discussion with somebody from PC and PH to say, ‘okay, what do you do under this heading? What can you offer?’ This is where you [PC] would come in. This is where I [PH] would come in. [NS/PH].
Influencing factor 2: strategic coordination and communication mechanisms between partners
Language has played an important role in the division of culture between these two groups and so finding common terminology and words that people can live with and the lens that people are bringing to the application of those words has been very important in doing translation and in finding joint projects. [BC/PH].
Everybody communicates, collaborates. Do your gap analysis. Say ‘this is what we bring to the table’. Share, and then whoever is best positioned to move an initiative forward does so. And then it is done in cooperation with all the other groups. Then you can pull back and develop your program, and then you come back forward again and say ‘okay, how are we doing’. Rather than the traditional, which is, develop your own program in isolation of everybody else. [NS/PC].
[PH] are right here when we’re making our most basic decisions of our governance and vision and what we’re looking for, for the following year [ON/PC].
If you’re going to leave it to family docs, you don’t just say, ‘good luck guys go and do immunization.’ You have to actually organize getting them the vaccine. You have to organize them reporting who they vaccinated... [PH/BC].
There would be more regularized referrals between PC and PH. […] particularly [if you had] more records and electronic medical record sharing between the two sectors [BC/PH].
We had an automatic relationship with [PC], but often we don’t get reports back from physicians as to what families they’ve immunized and it makes it difficult for our records, etc. [BC/PH].
There is data collection by PH that we could not piggy back onto. We couldn’t add our notes or assessments [PC/ON].
Influencing factor 3: formal organizational leaders as collaborative champions
So, if the leader doesn’t have a vision of what it’s going to look like then they’re not going to lead the way. [PH/ON].
And it’s up to the managers, I believe. That is a key role of directors, but especially the managers, to create the environments to allow that to happen. [NS/PC].
[the health authority did not] see [delivering immunizations to older adults] as their role. They don’t see that there’s any importance to that. And so it really… hampers community-based provision of appropriate care to people at risk. [BC/PC].
…a more democratic, open, sort of leading from the heart, not just the head type of approach. So the ability to put yourself in each other’s worlds and understanding where people are coming from. […] And recognizing that everybody has a part to play, and that one role isn’t more important than the other. But all together, we can make such a difference, a positive impact on the outcomes for clients, for communities, for populations. [NS/PH].
Influencing factor 4: collaborative organizational culture
There is a lack of respect sometimes for primary healthcare providers. If people understood what [PC has] to deal with day-in and day-out and the volume of work, there would be more understanding. [NS/PC].
…the importance of PH and prevention within the context of chronic disease and its management. [ON/PH].
I think the whole world wants to see PH actually do something. PH [has] to show themselves to be credible. And they’re not credible by handing out pamphlets. I think that all PC people are looking to have a partnership where PH doesn’t see themselves as a consultant but sees themselves as a worker […] prepared to get their hands dirty. [ON/PH].
… the goals and the principles and values as well are important to have, so that people … are thinking of things in a similar way. [ON/PC].
We would like a PH nurse to come out 4 h a week to do a breast feeding clinic. And it actually got turned down because they thought if they did it for us, they might have to do it for other clinics too. [NS/PC].
When some of our ‘primary healthcare’ people get into prevention… PH is saying, ‘That is ours.’ [NS/PC].
…We [PC] want to work with you. And they say: ‘Just a minute now. I’m a little worried when you say that because typically what that means to me in the past is to come along and take away. Take away our business, take away our resources.’ [Nat/PC].
Influencing factor 5: optimal use of resources
Unfortunately, in an effort to perhaps reconcile and protect [PH’s] scarce resources, we are finding a pretty strong line about not only what they will do or not do but what they will even be involved in planning. [NS/PC].
So [PH is] not quite sure about how to connect up with the [PC] system where people don’t work that way. I mean, of course, [PC does not] pay somebody, they don’t get paid (to collaborate) and so [PH] feels awkward to try to get to [PC] to loosen up time when they’ve got bills to pay and staff to pay and so on. [BC/PC].
…if I wanted to bring a PH nurse out to have a home in our clinic 4 h a week, logistically there [are] overhead costs associated. We have computerized patient records. So they would need a computer. They would need supplies and equipment. The receptionist would be checking in patients so there is additional workload. They would need a phone. And that is because they (PC) are private businesses right now. It’s fee-for-service. So they have to pay for everything that happens in that clinic. [NS/PC].
I think an acknowledgment from management to senior management to funders of the amount of time and dedication that it takes to develop, sustain and maintain collaborations. That’s critical…. to develop and sustain. (ON/PH).
There’s many other small examples of collaboration. One of them is the fact that ‘primary healthcare’ and PH administratively are side by side in the same corridor which allows for greater collaboration. [NS/PC].
Unfortunately, the nurses that were there were kind of bopping back and forth between the two places carrying their records with them. And it just became very difficult for them. Ultimately, we would like to have a one site vision where we would all be in one site under the same roof. [Nat/PC].
There’s a cost and energy to that communication. […] thinking that you were, for example, in a community health center and you had a team of eight people. The number of times you have to communicate to be clear is totally different than if you only have two people [BC/PC].
their income depends on moving clients through their fee-for-service system. We’ve had more success breaking down that barrier, if we can provide them with auxiliary staff to support the project. [BC/PH].
Influencing factor 6: optimal use of human resources
They’re trying to get some synergies out of the program. If the PH dieticians end up with some people participating in their programs that actually need a little bit more counselling, they can refer them onto the dieticians in Family Health Teams. PH dieticians are a little bit more adept at understanding the Canadian community health data statistics that come out. And so they can interpret those and work together to try to address the needs in the community. [NAT/Neither].
We really want to see PC services delivered according to many different models; some based on general needs, others on population health needs. So, that requires inter-professional collaboration. And the roles of registered nurses in PC and PH really being well understood and nurses being able to work to their full scope of practice. [NAT/BC].
… one of the things that I think is so positive about ‘primary healthcare’ models is that it’s taking that pressure off one or two providers to do everything for everybody. But the benefit of that larger team to share the responsibility and the patients. I think that is a tremendous help to seeing it from again a healthier, more balanced perspective and then you can start thinking about the collaboration. [BC/PH].
So, sometimes you just got to pitch in and do the dirty work together. And they did it. Those nurses were incredible that did that. See, that’s not your [job]. No one would sign up for that. It was time limited and they thought [it was] a way of building the partnership. [ON/PH].
So organizational mandates do get in the way of collaborative work. We need to know what our subsequent roles are, absolutely, and what our boundaries and scope of practice is. But within that, there needs to be flexibility to work with the community. So that dietician wasn’t going to be doing something outside of her scope of practice [for example] to go to this wellness day. And the flexibility to be able to enable that. It was determined that it was a good idea to do an 18 month wellness [assessment]… for the PH nurse to be able to go work with that family practice and not say, ‘No, that is the family practice’s thing. They’ve got a nurse practitioner. She can do it.’ [NS/PH].
Influencing factor 7: collaborative approaches to programs and services delivery
A lot of PH staff have been trained in community development. They could be that [dedicated resource] person who makes the links between all the pieces of the system [NS/PHN].
...you have to be able to bring it up to a community area level […] So, you need to bring all your clients together and then look at what the community needs. [Nat/Both].
It is the whole client focus that is so central to the whole community health centre way of thinking. [PC/ON].
I would assume that in Family Health Teams, particularly where there are more disciplines that are represented, that the coordination and collaboration with PH is probably easier than in those family health teams that only have physicians or nurses [PH/ON].
If you were meeting with [PH] and saying: ‘We have this set of population, these people. Who could do what to serve those people best?’ But I think we are still very much in our own little silos [NS/PC].
…you have to incentivize getting group practices together. And I think one of the ways you can incentivize a group practice is by providing to a group practice PH services. But that will require an expansion of PH services to be able to meet a growing demand. [BC/PH].
Relationships among influencing factors
...if you start with the leadership and the vision then you need to have your processes in place. Having a team that’s knowledgeable enough to know what needs to be integrated. What would promote collaboration, like the agreement that we talked about, or having the same phones, the same computer system for their whole information technology that promotes collaboration. [Nat/Both].
[Having] a common vision, identified common goals. If there were a collective of primary caregivers around the local [PH] unit, [and] there was an agreement that low birth weight rate in the city that you live in would go from six to five or seven to five or whatever, with common planning, that would work. [ON/PH].
People who work in those two different settings are just oriented to those different approaches. So, to bring them together to solve a mutual concern…and I think that’s one of the other issues is that PH and PC, from my experience, have rarely been brought to the same table to address a common issue. [ON/Both].
PH has all-embracing vision statements. So I think as both groups started to think a little more about what really is our role and where can we make the greatest impact, [there was] some kind of refinement of those visions and concepts. I think as both realized that to work together that you can no longer be doing the same thing. So I think part of it has been driven by resources, not just money, but human resources. And having to look at just to practice differently, away from the family doctor, everything - to family practice nurses and practitioners. And people were more open to what could happen to work better together. [NS/PH].
They’ve never had these resources available to them and they’ve not had to think about changing the way they do business to incorporate other team members. [BC/PC].
We really want to see PC services delivered according to many different models; some based on general needs, others on population health needs. So, that requires inter-professional collaboration and the roles of registered nurses in PC and PH really being well understood and nurses being able to work to their full scope of practice (Nat/Both).
Younger physicians and practitioners in general coming out are getting more used to work in group practices. […] You have to incentivize getting group practices together. And I think one of the ways you can incentivize a group practice is by providing to a group practice PH services. But that will require an expansion of PH services to be able to meet a growing demand then, and it would require some level of funding. (BC/PH).
There’s a complete difference in socialization that leads to a major barrier in understanding between physicians and other staff. And that is probably the most huge barrier. And then, of course, just the fact that they’re not in the same location [BC/PH].
You find new stuff and you develop a program around it. Unknown to you, you do that [in PH]. But the same program is also being built or has been built in [PC]. If you are not discussing and communicating, you don’t know that each other has this going on. Once you’ve gotten into it and you start developing it, you develop a certain ownership of it in terms of protection, and the empire is built. [NS/PC].
Discussion
At a minimum, each partner should be committed to a shared goal of improved population health and be willing and able to contribute to achieving that goal. The contribution may range from ideas and planning assistance, to financial or human resources, to goods or a physical space, but ideally will include a shared vision for an ongoing and sustainable relationship and a continual dialogue that goes beyond a single project. (p. 29).