Juanitas Final April 29 2007

ANALYSIS AND SYNTHESIS REPORT

Primary Health Care

Inter-professional Collaboration
Chronic Disease Management
Health Promotion and Disease Prevention
Activities, Processes and Tools

Submitted To: Ontario Ministry of Health and Long Term Care
Chair, Family Health Team Quality Management Collaborative
Submitted By: Juanita Barrett
Submission Date: April 29, 2007

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EXECUTIVE SUMMARY

In the fall of 2006, the Ontario Ministry of Health and Long Term Care (OMHLTC) identified the
need to provide ongoing leadership and direction to assist with the development and
implementation of a quality management strategy that would support Family Health Teams
(FHT’s) in delivering effective Primary Health Care (PHC) programs. A small Quality Management
Collaborative Steering Committee was initiated, and a Consultant contracted to complete an
analysis and synthesis of PHC activities in all jurisdictions of Canada, with the exception of
Ontario. The focus of the analysis and synthesis was on activities that supported Interdisciplinary
Collaboration (IDC), Chronic Disease Management (CDM) and/or Chronic Disease Prevention
and Management (CDPM), and Health Promotion and Disease Prevention (HPDP) changes.

The approach to the analysis and synthesis included review and analysis of current available
reports/ documents regarding processes/ tools from such sources as Health Canada, Canadian
College Family Physicians (CFPC)Toolkit, and Enhancing Collaborative Inter-professional
Practice (EICP) web-sites. A major part of the approach was a cross country Environmental Scan
(with a number of follow ups with the jurisdictional representatives for clarity and/or add
information) to identify processes and tools used to facilitate implementation of PHC changes for
CDPM, HPDP, and IPC in PHC teams within jurisdictions. Although time did not permit the
completion of the scan internationally, some information was obtained from the EICP and CFPC
toolkits regarding some of the processes and tools utilized to support changes in England and
New Zealand. Key findings, trends, lessons (including facilitators and barriers) of the processes
and tools were collated, and recommendations were developed to support the work of the Quality
Management Collaborative Steering Committee.

SUMMARY AND CONCLUSIONS

Jurisdictions across Canada have moved PHC changes forward with a focus on Inter-
Professional Collaboration, Chronic Disease Management and/ or Health Promotion/ Disease
Prevention, or some combination of 2 or 3 of them. Whatever the provincial direction, inter-
professional teams (with a minimum of at least 2 different professional groups one of which was a
family physician) were utilized and supported to provide services to defined populations, whether
it was a geographic population, a specific physician population or a special needs population.
Partnerships were developed, and included linkages with provincial Associations (especially
Medical Associations), Departments or Ministries of Health, Non-Governmental organizations,
and private sectors (e.g. Fee-for-Service physicians, pharmacists).

There was leadership for the changes, including frameworks in some jurisdictions, and some form
of provincial plans (supported through the Departments/ Ministries of Health with provincial offices
to support policy direction and implementation) in place in all jurisdictions. Health Councils or
some form of Provincial Advisory Committees, were evident in most jurisdictions. Family
Physician leaders were generally seen at the provincial and regional/ PHC team area levels, and
both regional and PHC team level administrative leaders (e.g. Directors at the regional level and
Coordinators and/or Facilitators at the PHC team level) were evident in a number of jurisdictions.
In all jurisdictions there were identified leaders who facilitated the various changes that occurred.

Numerous processes and tools were developed and utilized to support changes, with formalized
team development a focus for most areas. The Wagner Model was predominately used if there
was provincial direction for CDM, with a focus on one disease at least initially, and most of the
provinces that did not move in this direction are now looking to that model as the potential way to
move forward with their provincial initiatives for CDM. Additional processes and tools utilized in a
few jurisdictions to support access and management of chronic diseases were Advanced or
Improved Access, and Stanford Self-Management workshops. Most jurisdictions used Train-the-
Trainer methods to enhance uptake of changes and to support both implementation and
sustainability of their strategies.

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Other facilitators of change and barriers to change were similar across the country, whether there
was a focus on Inter-Professional Collaboration, CDM or HPDP. Some consistent facilitators
identified included electronic health records of some sort (or some form of communicating
electronically), incentives, physician participation, inter-professional development, voluntary
participation, development of trust, and time to actually make the changes. Consistent barriers
included lack of electronic health records, lack of alternate payment models for physicians, lack of
integration across governmental areas within the Departments/ Ministries of Health, fear of loss of
focus on primary prevention, turf protection, silos within health care delivery, the acute care focus
of health, and lack of time for changes to occur.

There was a variety of methods, processes and tools developed to evaluate the initiatives that
have been tested through the period of the PHCTF funds, and they may provide the opportunity
for some further PHC evaluation and/ or research in the future. Early results of initiative
evaluations, regardless of team size/composition, population served or model utilized, are
showing some positive shifts in providers working together, some changes in adherence to
appropriate Clinical Practice Guideline’s for certain diseases, and also some enhanced self
management by clients.

Generally funds for the changes made were supported by the Health Canada PHCTF. However,
a number of jurisdictions did provide for changes in funding and payment models for physicians,
and incentives to support their participation as team members. As well some jurisdictions have
provided funds for ongoing changes into the future, including operational support for community
development and CDM.

RECOMMENDATIONS

The synthesized information about inter-professional collaboration, CDM and HPDP can provide
the MOHLTC and the Quality Management Collaborative Steering Committee with the processes
and tools, based on the evaluation completed across the country, to provide ongoing leadership
and direction to support FHT’s in Ontario.

It is therefore recommended that:

1. Inter-professional partnerships, based on the professionals in the FHT’s, and including
linkages and partnering with relevant Associations, be identified to develop a provincial
plan to support FHT’s in delivering effective programs.

2. A provincial plan, building on the frameworks and/ or plans of other jurisdictions, be
developed to support FHT’s in delivering effective programs.

3. This provincial plan should include at a minimum:
Specifics of provincial, regional and FHT leadership, and facilitation;
Focus of changes (i.e. inter-professional collaboration, CDM, HDPM);
Some criteria to identify population served;
If there is decision to move to a CDM model, consideration should be given to which
model, and if the Wagner model is used, which elements will be implemented and
how they will be supported;
Consideration should be given to the pursuit of Advanced Access approaches, and
incorporating them into the plan;
Consideration should be given to the Stanford Self-Management workshops as a
stand-alone or incorporated into the CDM model chosen;
Identification of the various processes and tools that will be required to support the
planned changes (team development, scope of practice shifts, community
development, support for any changes in use of electronics);

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Identification of the various electronic technologies that will be used and supported,
with associated change management plans;
Clarification and/or confirmation of any physician funding/ payment models and
incentives, with associated processes for accessing and monitoring;
Development of an associated overall implementation plan, with timelines;
Development and implementation of an evaluation process, with baseline data if
possible and processes for regular feedback to the FHT teams; and
Financial plan and budget for implementation and evaluation of the plan, with
identified reporting mechanisms.

4. The time frames associated with the plan should be appropriate and allow time, at a
minimum, for such things as:
The completion of the plan as outlined;
Relationship building with the various partners;
Participation of FHT representatives in the specific plans for their FHT;
Team development and work on scope of practice at the FHT levels;
Adjusting to am electronic environment if that is the route taken;
Monitoring of evaluation and client data provided; and
Case conferencing and team meetings as required.

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Table of Contents

EXECUTIVE SUMMARY

1.0. INTRODUCTION
1.1. Report Background Information
1.2. Approach to Analysis and Synthesis

2.0. PHC CHANGE: General Information
2.1. Frameworks
2.2. Planning Supports

3.0. PHC CHANGE: Inter-Professional Collaboration

3.1. Nunavut

No information was provided or accessible.

3.2. North West Territories

3.2.1. Service Changes and Partnerships
3.2.2. Teams
3.2.3. Physician/ Other Leadership/ Facilitation Support
3.2.4. Processes and Tools
3.2.4.1. Processes and Tools
3.2.5. Other Facilitators of Innovations
3.2.6. Outstanding Barriers to Innovations
3.2.7. Evaluation
3.2.8. Funding

3.3. Yukon

See Chapter 4.

3.4. British Columbia

See Chapters 4 and 5.

3.5. Alberta

3.5.2. Teams
3.5.7. Evaluation
3.5.8. Funding

3.6. Saskatchewan


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3.6.2. Teams
3.6.7. Evaluation
3.6.8. Funding

3.7. Manitoba

3.7.2. Teams
3.7.7. Evaluation
3.7.8. Funding

3.8. Quebec

3.8.2. Teams
3.8.7. Evaluation
3.8.8. Funding

3.9. New Brunswick

3.9.2. Teams
3.9.7. Evaluation
3.9.8. Funding

3.10. Nova Scotia

3.10.2. Teams
3.10.7. Evaluation
3.10.8. Funding

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3.11. Prince Edward Island

3.11.2. Teams
3.11.7. Evaluation
3.11.8. Funding

3.12. Newfoundland and Labrador

3.12.2. Teams
3.12.7. Evaluation
3.12.8. Funding

4.0. PHC CHANGE: Chronic Disease Management/ Chronic Disease Prevention and
Management

4.1. Nunavut



4.2.2. Teams
4.2.7. Evaluation
4.2.8. Funding

4.3. Yukon

4.3.2. Teams
4.3.7. Evaluation
4.3.8. Funding

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4.4.2. Teams
4.4.7. Evaluation
4.4.8. Funding

4.5. Alberta

4.5.2. Teams
4.5.7. Evaluation
4.5.8. Funding

4.6. Saskatchewan

4.6.2. Teams
4.6.7. Evaluation
4.6.8. Funding

4.7. Manitoba


4.8. Quebec

See Chapter 3.

4.9. New Brunswick

4.9.2. Teams
4.9.7. Evaluation
4.9.8. Funding

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4.10. Nova Scotia

4.10.2. Teams
4.10.7. Evaluation
4.10.8. Funding


4.11.2. Teams
4.11.7. Evaluation
4.11.8. Funding


4.12.2. Teams
4.12.7. Evaluation
4.12.8. Funding

5.0. PHC Change: Health Promotion/ Disease Prevention

5.1. Nunavut

No information provided.


5.2.2. Teams
5.2.7. Evaluation
5.2.8. Funding

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5.3. Yukon

See Chapter 4.


5.4.2. Teams
5.4.7. Evaluation
5.4.8. Funding

5.5. Alberta

5.5.2. Teams
5.5.7. Evaluation
5.5.8. Funding

5.6. Saskatchewan

5.6.2. Teams
5.6.7. Evaluation
5.6.8. Funding

5.7. Manitoba

5.7.2. Teams
5.7.7. Evaluation
5.7.8. Funding

5.8. Quebec


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5.9. New Brunswick

5.9.2. Teams
5.9.7. Evaluation
5.9.8. Funding

5.10. Nova Scotia

5.10.2. Teams
5.10.7. Evaluation
5.10.8. Funding


5.11.2. Teams
5.11.7. Evaluation
5.11.8. Funding


5.12.2. Teams
5.12.7. Evaluation
5.12.8. Funding

6.0. DISCUSSION: Activities, Processes and Tools Overview

6.1. General Information

6.2. Inter-professional Collaboration

6.2.1. Service Changes, Models and Partners
6.2.2. Teams

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6.2.3. Physicians/ Other Leadership/ Facilitation Support
6.2.4. Processes and Tools for Facilitation/ Implementation
6.2.5. Other Facilitators of Innovation
6.2.7. Evaluation
6.2.8. Funding Sources

6.3. Chronic Disease Prevention and Management

6.3.2. Teams
6.3.7. Evaluation

6.4. Health Promotion and Disease Prevention
6.4.2. Teams
6.4.7. Evaluation

7.0 CONCLUSIONS and RECOMMENDATIONS: Application of Activities,
Processes and Tools in Ontario Family Health Teams

7.1. Conclusions

7.2. Recommendations

REFERENCES

APPENDICES:

Appendix A Environmental Scan Templates

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1.0. INTRODUCTION

1.1. Report Background Information

Family Health Teams (FHT’s) in Ontario vary in size from 2 or 3 to about 20 Family Practice
Physicians, and are located in urban, rural, remote or northern areas in the province. More than
half are led by physicians, some by community boards and some by a mixed governance
structure. The population served varies from 2,000 in rural and remote areas to 20,000 to 40,000
or so in large urban areas. All FHT’s are interdisciplinary, with at least one health provider
(nurse, nurse practitioner, social worker, dietitian, and/or pharmacist) and a physician.

In the fall of 2006, the Ontario Ministry of Health and Long Term Care (OMHLTC) identified the
need to provide ongoing leadership and direction to assist with the development and
implementation of a quality management strategy that would support FHT’s in delivering effective
programs. A small Quality Management Collaborative Steering Committee was initiated, and a
Consultant contracted to support some of the initial work to assist with this leadership.

The mandate of the consultant, based on direction from OMLTC representatives, was to:
Provide a written report with a synthesis and analysis of the information, including key
findings, trends and lessons (facilitators and barriers), of processes and tools utilized for
implementation of CDPM, HPDP, and Interdisciplinary Collaboration in PHC settings.

1.2. Approach to Analysis and Synthesis

The approach to the analysis and synthesis included:
Development (and approval by OMHLTC representatives) of a plan and template for data
collection to focus on Chronic Disease Prevention and Management (CDPM), Health
Promotion and Disease Prevention (HPDP), & Interdisciplinary Collaboration processes
and tools;
Review and analysis of current available reports/ documents re processes/ tools across
Canada (except Ontario) regarding CDPM, HPDP, & IDC approaches from such sources
as Health Canada, Canadian College Family Physicians (CFPC)Toolkit, and Enhancing
Collaborative Inter-professional Practice (EICP) web-site was completed;
Using the developed templates and jurisdictional linkages, an Environmental Scan (with a
number of follow ups with the jurisdictional representatives for clarity and/or added
information) was done to identify processes and tools used to facilitate implementation of
Primary Heath Care (PHC) changes for CDPM, HPDP, and Interdisciplinary Collaboration
in PHC teams across the country (except for Ontario);
Time did not permit the completion of the scan internationally; however efforts were made
to obtain information from England without success, and some information was obtained
from the EICP and CFPC toolkits regarding some of the processes and tools in England;
The key findings, trends, lessons (including facilitators and barriers) of processes and
tools used to facilitate implementation CDPM, HPDP, Interdisciplinary Collaboration in
PHC settings were drafted;
Various drafts of parts of the report was shared with the OMHLTC representatives to
ensure that the information being collected, analyzed and synthesized was meeting the
needs; and
A final draft of the report was submitted prior to final report submission.

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2.0. PHC CHANGE: General Information
This chapter provides information regarding identified frameworks and/or models that promoted
and/or supported PHC changes and the various planning supports for changes including: Health
Councils, scope of practice joint statements, job descriptions, various associations roles/
descriptions for disciplines, performance management, policies and procedures, population
health approach, information and communication, regulations, and inter-professional education.
It also integrates any information gathered regarding national and international initiatives.

2.1. Frameworks

Some of the jurisdictions developed frameworks or models to provide direction for PHC changes.

Source: EICP/ CFPC Toolkit

North West Territories Primary Community Care Framework:
This policy document is guiding the transition to interdisciplinary team approach through an
Integrated Service Delivery Model for the NWT health and Social Services System. Both a plain
language and detailed versions of this model are accessible on the public website.
http://www.hlthss.gov.nt.ca/Features/Programs_and_Services/isdm/pcc/primary_community_care
.asp.

North West Territories Integrated Service Delivery Model for the North West Territories
Health and Social Services System: This report provides information on the Integrated Services
Delivery Model, which fulfills Action Item 5.2.1 of the HSS System Action Plan. It describes the
vision and philosophy of the Integrated Services Delivery Model and the three elements of
integrated service: primary community care, agency integration and core services.
http://www.hlthss.gov.nt.ca/content/Publications/Reports/ISDM/isdmdetailedmarch2004.pdf.
Also a plain language summary at:
http://www.hlthss.gov.nt.ca/content/Publications/Reports/ISDM/isdmsummarymarch2004.pdf

Nova Scotia The Advisory Committee on PHC Renewal, with broad stakeholder consultation
across the jurisdiction, created a vision for primary health care in Nova Scotia that set the stage
for future renewal of Nova Scotia’s primary health care system. Reaching the preferred future
conveyed by Nova Scotia’s Vision for Primary Health Care required a strategic approach.
Consequently, the Advisory Committee on PHC Renewal proposed the following four strategic
approaches for use of Nova Scotia’s funding allocation from the Primary Health Care Transition
Fund:
• Shifting the focus of primary health care from family physicians in solo or group practice
to collaborative primary health care teams that involve many different primary health care
providers offering a defined range of comprehensive services to a defined population;
• Developing a cultural shift among primary health care providers that supports a
population health approach, collaboration and an enhanced role for health promotion;
• Changing the primary health care funding system so that primary health care
professionals are remunerated by means that are not volume-driven;
• Preparing the primary health care system for the future implementation of an electronic
patient record that easily facilitates sharing of information among primary care providers
and between the primary, secondary and tertiary health care systems.
For more information, contact: Nova Scotia Department of Health or see framework on
www.gov.ns.ca.

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Newfoundland and Labrador Moving Forward Together: Mobilizing Primary Health Care: A
Framework for Primary Health Care Renewal in Newfoundland and Labrador
This is a framework document that was developed in 2003 for the province to support
implementation of primary health care renewal. It discusses PHC renewal though a number of
measures including an interdisciplinary PHC model and promotes the following features to
support PHC change: inter-professional teams, enhanced scope of practice, wellness and health
promotion, chronic disease prevention and management, enhanced access to services,
enhanced communication and information management, and funding and payment models for
family physicians and other providers.
For more information, see
http://www.health.gov.nl.ca/health/publications/pdfiles/Moving%20Forward%20Together%20appl
e.p.

Source: EICP and CFPC

Barriers and Facilitators to Enhancing Interdisciplinary Collaboration in Primary
Healthcare: The Enhancing Interdisciplinary Collaboration in Primary Healthcare (EICP)
Initiatives. This document provides information regarding barriers and challenges to be
addressed when enhancing interdisciplinary collaboration in PHC. It is good for validation of
some of processes and use of tools to ensure success and manage challenges. For more
information, see http://www.eicp-cis.ca/en/resources/pdfs/Barriers-and-Facilitators-to-
Enhancing-Interdisciplinary-Collaboration-in-Primary-Health-Care.pdf.

Implementing Family Medicine Groups: The Challenge in the Reorganization of Practice
and Interprofessional Collaboration: M-D Beaulieu et al, Physician Sadok Besrour Chair in
Family Medicine, Montreal, April 2006. 5 case studies provided examples of challenges in
enhancing collaboration, advise to administrators, and ethical dimensions. For more
information, see www.medfam.umontreal.ca/chaire_sadok_besrour/chaire/chaire.htm.

Joint Statement on Resolving Ethical Conflicts Between Providers of Healthcare and
Persons Receiving Care: This joint statement was developed by the Alberta Provincial Health
Ethics Network, with statements from the CHA, CMA, CAN and CHAC, and was approved on
June 8, 1998.

2.2. Planning Supports

Throughout the review of information collected, there were a number of planning supports
identified, including general ones (programs or guidelines for change), Health Councils, job
descriptions, performance management tools, and policies and procedures. This section also
includes initiatives from various national and/ or international groups.

General


British Columbia The College of Health Disciplines, University of British Columbia
The college is currently being restructured. Various inter-professional courses are available
including a population health approach, health care team development, health care ethics, etc.
For more information see http://www.health-disciplines.ubc.ca/index.php

Alberta Alberta Medical Association Practice Management Program
This program provides business related advice to family physicians as they develop Primary Care
Networks (PCN’s). It specifically provides information for developing physician leaders,

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governance structures, mitigating risk (legal, business, financial, tax), managing change and
letters of intent/business plans. For more information, see www.albertadoctors.org.

Source: CFPC Toolkit

Primary Health Care in Alberta
This planning document overviews Alberta's approach to PHC through local primary care
initiatives and includes indicators for measuring PHC. For more information see
http://www.health.gov.ab.ca/public/in_primary.pdf

Saskatchewan Guidelines for the Development of a Regional Health Authority Plan
for PHC Services:
The purpose of the guidelines is to help with the implementation of a regional primary health care
(PHC) plan. These guidelines discuss what PHC is, the planning steps required, action plan
including team formation, and implementation. For more information see
http://www.health.gov.sk.ca/ph_phs_publications/phs_pub_guidelines_%20for_dev.pdf.

Saskatchewan's Action Plan for Primary Health Care Service
This document contains definitional information, roles and responsibilities for various
stakeholders, and approach and strategies for implementation. For more information see
http://www.health.gov.sk.ca/ph_phs_publications/phs_action_plan_for_primary_health_care.pdf

Manitoba Nor'West Co-op Community Health Centre, Winnipeg, Manitoba: It is a non-profit
accredited health agency located in north Winnipeg established in 1972 by community members
as part of a co-operative community health centre. This community health centre has developed
several working plans, including an environmental, information management, and human
resources plans.
Environmental Plan Final Copy IM PLAN04-07 Overview - IM Plan and Priorities 05-06
HRPlan2006-2009


CAPC/CPNP People and Planning: A Human Resources Toolkit for CAPC/CPNP Projects:
Although this is not a primary health care specific, it provides a very good overview of
management and human resources functions, including strategic planning, evaluation, hiring,
orientation, training, supervision, etc. For more information see http://www.phac-aspc.gc.ca/dca-
dea/programs-mes/capc-cpnp_pphr_e.html.

United States John Hopkins Adjusted Clinical Group (ACG) Case-Mix System
This is a population based risk adjustment tool developed in the U.S. The ACG System creates a
common language for healthcare analysis and can be used to: predict high-risk users for
inclusion in care management; determine government- or employer-budgeted payment to health
plans; fairly allocate resources within programs; set capitation payments for provider groups;
evaluate access to care; assess the efficiency of provider practices; and improve quality and
monitor outcomes. It is used by the British Columbia government. For more information see
http://www.acg.jhsph.edu/

United Kingdom National Institute for Health and Clinical Excellence (NICE)
This is an independent organization responsible for providing national guidance on the promotion
of good health and the prevention and treatment of ill health. Many tools available on the site from
clinical practice guidelines to cost impact tools. For more information see http://www.nice.org.uk/

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New Zealand Resources for Primary Health Care Organizations
This New Zealand Web page contains information on funding guidelines, service specifications,
performance indicators, data elements, audit protocols, enrolment rules and guidelines, PHO
projects, etc. For more information see http://www.moh.govt.nz/pho

Health Councils


Alberta Health Sciences Council
The mission of the Health Sciences Council (HSC) is to champion interdisciplinary health
sciences research, education and community service at the University of Alberta. All Health
Science students at the University of Alberta are required to take a core interdisciplinary course.
This intensive course provides health science students with an overview of the theory and
application of working in teams. There is also clinical placements of teams. For more information
see http://www.healthscience.ualberta.ca/

Source: Facilitation Guide

Saskatchewan Health Quality Council Collaborative (HQCC) (SK) Borrowing from the
British Columbia model, the HQCC in Saskatchewan has played a lead role in implementing a
collaborative focus on chronic heart disease, diabetes and access. The HQCC takes a learn-by-
doing approach, supports the use of best evidence and brings a range of practitioners together to
share knowledge and test improvement of ideas. For more information see www.hcq.sk.ca

Scope of Practice/ Collaborative Practice

Source: EICP and CFPC Toolkit

CMA/CAN/CPA Joint Position Statement on Scopes of Practice
This statement overviews the principles and criteria for the determination of scopes of practices.
For more information see http://www.cna-
nurses.ca/CNA/documents/pdf/publications/PS66_Scopes_of_practice_June_2003_e.pdf

CMPA/CBPA The Canadian Medical Protective Agency (CMPA) and the Canadian Nurses
Protective Society (CNPS) have developed a joint statement on liability protection for nurse
practitioners and physicians in collaborative practice. It discusses liability risks, liability protection
and risk management. For more information see com_joint_statement-e.pdf

Job Descriptions


British Columbia Expanded Medical Office Assistant Role:
As part of the diabetes collaborative, the role of medical office assistants was enhanced to
include data recording, planning of office visits and related details of the visit (blood pressures,
height and weight, foot exams and self management). For more information see contact
Debbie.lewis@northernhealth.ca, Northern Health.

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British Columbia Mid-Main Community Health Centre, Vancouver, BC
A job description for primary care nurse clinicians has been developed.
For more information see MMjob description NP

Mid-Main Community Health Centre, Vancouver, BC
Several documents are highlighted: a form that clarifies the job descriptions and relationships
within the community, the transferring of function from one discipline to another; the pharmacist's
prescriptive authority, and Warfarin monitoring physician authorization form that allows the
pharmacists to manage a patient's therapy.
For more information see Clarifying Job Descriptions and Related Tasks Transfer of Function
Pharmacist Prescriptive Authority Warfarin Authorization Form

Alberta Calgary Health Region, Home Care Program
This home care program offers a range of services from nursing, therapy, rehabilitation to
personal care. The program uses behavioral descriptive interview techniques to recruit new
members to its team. Highlighted is the applicant screening and behavior descriptive interview
package for community care coordinator positions. For more information see 1_BDI-CCC RN

Manitoba Nor'West Co-op Community Health Centre, Winnipeg, Manitoba
Job descriptions for the community development coordinator, family violence counselor,
aboriginal health outreach worker and the primary care registered nurse are highlighted.
For more information see CDCoordinator Position Family Violence Counselor Position Aboriginal
Health Outreach Primary Care Registered Nurse.

Newfoundland and Labrador Dr. Charles L. LeGrow Health Care Centre, Port aux Basques; A
job description has been developed for the PHC Coordinator. For more information see PHC
Coordinator.

Association Role Descriptions
Most professional associations have developed role descriptions for the disciplines of that
asscocation which can be accessed at the below web-sites.


Canadian Association of Occupational Therapists
http://www.otworks.ca/otworks_page.asp?pageid=824

Canadian Association of Social Workers
http://www.casw-acts.ca/

Canadian Association of Speech-Language Pathologists and Audiologists
http://www.caslpa.ca/english/careers/careers.asp

Canadian Nurses Association:
http://www.cnaaiic.ca/CNA/nursing/becoming/default_e.aspx
Nurse Practitioner at http://www.cnpi.ca/faq.asp
Advanced Nursing Practice at
http://www.cnaaiic.ca/CNA/documents/pdf/publications/PS60_Advanced_Nursing_Practice_June
_2002_e.pdf
Clinical Nurse Specialist at
http://www.cnaaiic.ca/CNA/documents/pdf/publications/PS65_Clinical_Nurse_Specialist_March_2
003_e.pdf

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Canadian Pharmacists Association
http://www.pharmacists.ca/content/about_cpha/about_pharmacy_in_can/how_to_become/index.c
fm

Canadian Physiotherapy Association
http://www.physiotherapy.ca/whatis.htm

Canadian Psychological Association
http://www.cpa.ca/cpasite/showPage.asp?id=1023&fr=##1
Psychologists and PHC

College of Family Physicians of Canada
http://www.cfpc.ca/local/files/Communications/Health%20Policy/FAMILY_MEDICINE_IN_CANAD
A_English.pdf

Dietitians of Canada
http://www.dietitians.ca/news/downloads/role_of_RD_french.pdf
http://www.dietitians.ca/news/downloads/role_of_RD_in_PHC.pdf

Performance Management

Manitoba Klinic Community Health Centre, Winnipeg, Manitoba
Performance appraisals are completes every two years at the Centre. It developed its own tool
that addresses soft skills such as teamwork, interpersonal conflict, etc. The performance
appraisal process involves team members listing their roles/responsibilities with the six top tasks
that want to be evaluated on. The process also includes peer review, self evaluation and includes
salaried physicians. For more information see Performance Appraisal Process

Policies and Procedures

Alberta Chinook Education Menu Booklet: This booklet includes resources to guide
orientation and training as well as to assist clinics in accessing available educational resources
and supports. These resources are available to family practice team members, as well as
physicians and existing office staff. For more information see Education-Menu-Booklet-II

Manitoba Nor'West Co-op Community Health Centre, Winnipeg, Manitoba
This Centre has a policy that overviews the functioning of the integrated goal sheets that are developed for
each client. For more information see P&P Integrated Goal Sheet I.pdf.

Population Health Approach

Public Health Agency of Canada
Population Health is an approach to health that aims to improve the health of the entire
population and to reduce health disparities among population groups. The Public Health Agency
of Canada has identified population health as a key concept and approach for policy and program
development aimed at improving the health of Canadians. In order to reach these objectives, the
Agency is looking at and acting upon the broad range of factors and conditions (determinants of
health) that have a strong influence on our health. This website provides a good overview of the
key elements and concepts that define a population health approach. For more information see
http://www.phac-aspc.gc.ca/ph-sp/phdd/.

19

Information and Communication


Health Canada eHealth Toolkit
eHealth is the use of information and communication technologies to support, educate, inform
and connect health care professionals and the people they serve. Health Canada's eHealth
Solutions Unit works to develop eHealth tools to support the use of health technology in Canada's
First Nations and Inuit communities to be connected, informed, and ultimately healthier. Their
overall aim is to enable front line health care providers working in First Nations and Inuit
communities to improve people's health through innovative eHealth partnerships, technologies,
tools and services. Tools are available in areas such as connectivity, telehealth, health
information systems, information for health providers, privacy protection and standards. For more
information see http://www.hc-sc.gc.ca/fnih-spni/services/ehealth-esante/index_e.html

CPA E-Therapeutics, The Canadian Pharmacists Association
This will be a resource for Canadian physicians, pharmacists, nurse practitioners and other
primary health care professionals to help make the right therapeutic decision. ETherapeutics+
provides a tool set based on CPhA's Therapeutic Choices and e- CPS plus references to create a
centralized drug resource for drug therapy information. For more information see
http://etherapeutics.pharmacists.ca/forms/index.asp?
dsp=template&act=view3&template_id=39&lang=e

REGULATION (Professional Organizations)

Source: EICP/ CFPC Toolkits

Access to information regarding regulations for some professional organizations are cited below.

Social Work National Scopes of Practice Statement www.caswacts.ca

Canadian Pharmacy Association Pharmacists
http://www.pharmacists.ca/content/about_cpha/about_pharmacy_in_can/ how_to
_become/index.cfm

Physiotherapy Competency Profile: Essential Competencies of Physiotherapy Support
Workers http://www.physiotherapy.ca/compprofile.htm

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Occupational Therapy Essential Competencies of Practice for Occupational Therapists
in Canada http://www.cotm.ca/publications.html.
http://www.otworks.ca/otworks_page.asp?pageid=824

Occupational Therapy Practice Guidelines for Occupational Therapists: Consulting to
Third Parties: Assist occupational therapists in recognizing and managing issues which arise
when the occupational therapist agrees to provide an assessment of a client to a third party.
http://www.cotm.ca/publications.html.

Occupational Therapy AAROT Guidelines for the Assignment/Delegation of
Occupational Therapy Services to Support Personnel
http://www.acot.ca/files/Support_Personnel_Guideline_
June_22.05_ACOT_VERSION_Final_Document.pdf.

Psychology Integration of Psychologists in Family Health Teams
IPEM - FHT tool kit-NOV24th2005.pdf.

Canadian Nurses Association Standards and Best Practices for Nurses
http://www.cna-nurses.ca/CNA/practice/standards/default_e.aspx.
Other useful links include:
• a description of Nurse practitioner see http://www.cnpi.ca/faq.asp
• a description of advanced nursing practice see
http://www.cna-aiic.ca/CNA/documents/pdf/publications/
PS60_Advanced_Nursing_Practice_June_2002_e.pdf
• a position description of Clinical Nurse Specialist
http://www.cna-aiic.ca/CNA/documents/pdf/publications/
PS65_Clinical_Nurse_Specialist_March_2003_e.pdf
• a statement about Registered Nurses and where they work at
http://www.cna-aiic.ca/CNA/nursing/becoming/default_e.aspx.

Interprofessional Education

McMaster University The Nursing and Health Care leadership courses/Management Distance
Education Program provides courses for nurses that include: Leadership/Management; Conflict
Management; Leading Effective Teams in Health Organizations; Decentralized Budgeting and
Total Quality Management. For more information see
www.fhs.mcmaster.ca/nursing/distance/distance.htm

Centre for Health Sciences Interprofessional Education (USA)
The Center for Health Sciences Interprofessional Education is dedicated to creating an
atmosphere of openness and commitment to interprofessional practice for the next century. It
offers courses on interprofessional competencies, issues in interdisciplinary health care,
interprofessional collaborative teams, etc. For more information see
http://interprofessional.washington.edu/about.asp

Centre for Interprofessional Practice (UK)
The centre is part of the Institute of Health at the University of East Anglia, Norwich, which is a
joint initiative across the Schools of Health to deliver teaching and research on interprofessional
learning. The Centre has team-based education packages that have been developed to support
active health/social care teams in enhancing their team working skills and improving their
understanding of the different professional roles involved in patient/client care. For more
information see http://www.uea.ac.uk/cipp/.

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Interdisciplinary Health Care Team Practice
This is a learning module for students (and others) from the District of Columbia AHEC (Area
Health Education Centre). It is a resource linked to the U.S. Department of Health and Human
Services site. The module contains learning on:
– Interdisciplinary Team Case
– Historical Background
– Models Of Team Practice
– The Interdisciplinary Teamwork System Model
– Interdisciplinary Team Building
– Members of the Health Care Team
For more information see http://dcahec.gwumc.edu/education/session3/.

The United Kingdom Centre for the Advancement of Interprofessional Education (CAIPE)
CAIPE's focus is on ways of enabling professions, in the university and the workplace, to learn
from and about each other, foster mutual respect, overcome barriers to collaboration and
engender action. It promotes interprofessional learning which actively involves service users and
local communities as essential partners. For more information see http://www.caipe.org.uk.

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3.0. PHC CHANGE: Inter-Professional Collaboration
This chapter provides an overview of PHC inter-professional collaboration processes and tools in
most jurisdictions, with some exceptions and limitations:
• Nunavut was unable to provide any information at this time nor could information
regarding their activities be identified on any of the websites or documents reviewed;
• Information for Manitoba is restricted to information gathered from the EICP/ CFPC
toolkits or Facilitation Guide as the environmental scan was not completed;
• Information regarding British Columbia regarding inter-professional collaboration is
included in the chapter on CDPM;
• There is some information areas missing for the Saskatchewan and Quebec sections;
and
• Ontario information is being completed by that jurisdiction.

3.1. Nunavut

No information was provided.



Services in the North West Territories are provided around six core service areas: diagnostic and
curative; rehabilitation services; mental health and addictions services; promotion and prevention
services; protection services and continuing care services. Services provided reflect the needs of
the client or family living within the team area.

The Department and Authorities work with other government departments such as: RCMP,
Justice, Education Culture and Employment, Housing and Municipal and Community Affairs to
address issues of common concern. Interagency Committees meet regularly in communities to
provide a forum to address intersectoral issues and concerns.

The eight health and social services authorities (HSSA or Authorities) and the Department of
Health and Social Services (DHSS or the Department) were involved in the development of the
Integrated Service Delivery Model (ISDM) for the Northwest Territories health and social services
system, which is based upon a Primary Community Care (PCC) approach. This model is one of
horizontal and vertical integration around the six core service areas as identified earlier. PCC
providers deliver core services to clients at the primary level.

The ISDM includes PCC teams at the primary level, regional support teams at the regional level,
and territorial health and social services caregivers with a mandate to serve the whole NWT. A
client's first point of contact is usually a member of the PCC team. Within the primary community
care team, care givers work in many different disciplines: physicians, nurse practitioners,
community health nurses, licensed practical nurses, midwives, social workers, mental health and
addictions counselors, community wellness workers, community health workers, and community
health representatives. They are supported by regional support teams (radiology, fluoroscopy,
rehabilitation, health promotion specialists, etc.), and territorial support teams that provide
specialized procedures and services (surgery, intensive care, psychiatric care; CT scan,
chemotherapy, etc.) and coordinate out of territory transfers.

Regional teams either travel to communities to provide service, or PCC providers arrange client
referrals to regional centres. PCC providers also coordinate referrals to Territorial services for
secondary or tertiary care services. More complex services not available in the NWT are
provided through Out of Territory referrals.

23

To work effectively on behalf of their clients, PCC providers collaborate with providers across the
horizontal levels, or up to the vertical levels of the HSSA system. They work with other health and
social services providers, and agencies and other sectors (Justice; Municipal and Community
Affairs; and Education Culture and Employment, etc.). The make up of the team is reflective of
the needs of the client.

Progress toward implementation of the ISDM varies from region to region. Primary Health Care
Transition Fund (PHCTF) projects have helped to create some momentum, and the lessons
learned will benefit others as the NWT’s move toward full implementation of ISDM.

The following is a summary of Primary Health Care and PCC Teams within the PHCTF funded
projects:

YHSSA, Great Slave Community Health Clinic (GSLHC): The PCC team includes physicians,
nurse practitioner, public health nurse, licensed practical nurse, client advocate, mental health
worker, and support staff. The Authority will soon add a midwife. The GSCHC partners with the
Tree of Peace (a non-governmental organization) for addiction counseling and support services.
The YHSSA GSCHC, TCSA, Integrated Wellness Centre, and FSHSSA, Introducing Midwifery
Services project, and BDHSSA Beaufort Delta Wellness Teams are all co-located.

TCSA, Integrated Wellness Centre: The PCC team includes mental health counsellors,
addictions counsellors, social workers, and a public health nurse. They work closely with the
teachers in the two local schools, and the nurse practitioner and community health nurses in the
Marie Adele Bishop Health Centre in Behchoko (formerly Fort Rae).

FSHSSA, Introducing Midwifery Services project: The midwives work with the nurse
practitioner, physicians, general duty nurses, and public health nurses to provide prenatal and
postnatal care for women in the community. They also are linked to the Obstetricians and the
Coordinator of the STHA Northern Women’s Health Program.

STHA, Northern Women’s Health Program: The team includes the nurse coordinator,
physicians, an Obstetrician and a midwife who provide prenatal services for women, and support
PCC providers throughout the NWT involved in the provisions of prenatal care services for
women. Stanton Territorial Health Authority (STHA) Northern Women’s Health Program provides
coordination and support to PCC providers through a 1-800 call line and bi-monthly tele-health
sessions.

3.2.2. Teams and Services

All community care providers are part of the quot;teamquot;, with the client and family as part of the team
and the central focus. Primary Community Care (PCC) teams work with other agencies and
groups to address problems and create healthy communities.

The number of clients served is unknown. Populations served are those within the mandate of the
regional health and social services authority boundaries. Authorities use information from a
variety of sources to identify the health and social services needs of residents (health
assessments, health status reports, etc).

Within the NWT, inter-professional teams are located in 29 of 33 communities, consisting of 2 to 3
disciplines working together. The teams also include paraprofessionals such as community health
representatives, community health workers and community wellness workers.

In the NWT, PCC providers are deployed in teams located in the 31 communities across the
Territory. The teams range in size and number according to the size of the community. The
following teams have emerged through the NWT PHCTF initiative:

24

• BDHSSA, Beafort Delta Wellness Teams includes three teams working with clients
around 3 specific issues (rural);
• YHSSA, Yellowknife Community Health Clinic have assembled one interdisciplinary team
of providers; however, at times, smaller teams within the larger team work together to
case manage for complex clients (urban);
• TCSA, Integrated Wellness Centre project has one team; however, at times, smaller
teams within the larger team work together to case manage for complex clients (rural);
• FSHSSA, Introducing Midwifery Services project: the midwives work with other members
of the PCC team and STHA Northern Women’s Health Program to provide reproductive
health services for women (rural).


The NWT is early into the implementation of the ISDM, which is led by the Joint Senior
Management Committee (Authority Chief Executive Officers, DHSS Directors, Assistant Deputy
Ministers (2), and Deputy Minister).

The Department was able to make some progress through the PHCTF initiative to develop a plan
to support PCC providers with the transition toward ISDM. It has been unsuccessful in efforts to
find specific funding for “facilitation”. The authorities continue in their efforts to move forward with
leadership and support to staff.

Some authorities are establishing positions to lead implementation of ISDM and/or ISDM
Implementation Committees to sort out the issues related to roles and responsibilities and scopes
of practice. Of the eight authorities, there are four that have identified staff to lead implementation
of ISDM.


Multidisciplinary, inter-professional conferences (4 territorial and 1 regional) were held, with
change management workshops at the regional level, and teams of professionals have been
used to design and implement the new service delivery model. Resources and research has been
shared with authorities that have ISDM leads.

Project communications involved both formal and informal sharing networks to provide
information and get feedback. Project coordinators recognized that change takes time, and that
staff are more likely to support and maintain a change if they have input into the decision making
and feel their opinions are listened to, valued, and respected.
Some specific examples include:
• YHSSA had facilitated team building sessions for all staff, and a separate session for the
transition team tasked with establishing the Great Slave Community Health Clinic. They
also held a symposium for staff and stakeholders to get input. They will continue to orient
new staff to the NWT ISDM, emphasizing the PCC approach, and provide ongoing
training at the clinic.
• BDHSSA held team building ISDM workshops in all communities in the region; and
provided managers with training on ISDM and interdisciplinary practice.
• In the FSHSSA, the midwives gave presentations to staff on their roles and
responsibilities and scope of practice; and provided second attendant training to prepare
nurses to participate in deliveries. The Authority established an interdisciplinary maternity
care working group which has transitioned to a Maternity Care Committee. They have
recently established an ISDM Committee to clarify the roles, responsibilities, and
relationships of PCC Team Members in the provision of integrated services.
• The TCSA, Integrated Wellness Project identified their biggest challenges as lack of trust.
Clients needed reassurance that the personal issues they discussed during counseling
sessions at the Integrated Wellness Centre would not be disclosed in the community.

25

Significant strides have been made in building trust with clients, as evidenced by the
increasing number of clients accessing the services. Likewise, the staff at the Integrated
Wellness Centre needed to build trusting relationships with other service providers. A
strength of this project was the ongoing and frequent communication between service
providers, with communication working together with persistence and commitment to
build interdisciplinary teamwork.

Challenges stemmed from staff and service providers’ difficulties with adjusting to change,
limitations on human resources, the need for clear and effective communication, and finally,
shifting paradigms from an illness-centered approach to a wellness-centered one.

Some authorities have provided training for employees on change management, conflict
resolution, and verbal judo. Committees have been tasked with addressing scope of practice
issues (e.g. Nurse Practitioner Implementation Committee, Midwifery Implementation
Committee).

Information has been shared regarding the web-based learning provided through the Atlantic
team training modules (Building a Better Tomorrow modules). A workshop on the Facilitation
Guide was facilitated in Yellowknife, with a few of the authorities sending participants. The Guide
will be distributed to HSSA authorities when the DHSS receives copies.

STHA’s project coordinator encountered resistance from physicians who felt they were the only
providers that can look after prenatal patients. This was overcome by working closely with the
physicians and allowing them to observe the care that women were receiving.


The characteristics, philosophy, principles, and approach are described in the NWT's Integrated
Service Delivery Model (ISPM).

Tools used to ID population served include:
Authority designed Client Needs Surveys
NWT Client Satisfaction Survey
DHSS The NWT Health Status Report 2005
Epi North Newsletters
DHSS special reports on Cancer, Injuries, Addictions
Strategic Directions reports addressing specific issues such as Sexually Transmitted Infections,
and Respite Care.
NWT Bureau of Statistics demographic reports.

For more information see
http://www.hlthss.gov.nt.ca/Features/Programs_and_Services/isdm/default.asp

See the Nova Scotia section regarding BBTI modules.

See the NL section re Facilitation Guide.

3.2.5. Other Facilitators

To further support changes, the strategic plan and action plan are based on ISDM (key
components are collaboration and integration), and physician contracts reflect expectations for
collaboration. Electronic Medical Records (EMR) pilots are interdisciplinary (for Family Physicians
and Nurse Practitioners). In addition, internet services are available in all communities.

YHSSA reported that with co-location, providers are able to access each other and consult on
client cases in a more personal and often more timely basis. Co-location has also resulted in an

26

increased understanding, appreciation, and respect for professional scopes of practice which
promotes collaborative practice and has given occasion to discuss common concerns with
respect to shared care, e.g. confidentiality and liability issues.


Recruitment and retention of professionals are outstanding barriers. Job ads, information
regarding bursaries, orientation materials and support programs for competency development are
on the website to help manage this challenge.

3.2.7. Evaluation

Information regarding evaluation is not available at this time.


HSSA has used internal operational funding (present staff within the Authority). Most physicians
are remunerated by salary (not fee for service) through a negotiated contract. All other providers
are Government of NWT employees.

3.3. Yukon

See Chapter 4.


See Chapters 4 and 5.

3.5. Alberta


By dispersing money to third party organizations to develop and implement innovative primary
health care initiatives, projects funded through the PHCTF were diverse in scope. Most initiatives
were involved to some extent in the development of teams of health care providers working
collaboratively.

There were 9 Capacity Building Fund initiatives funded that encompassed either regional service
changes or changes within individual clinics.

The key vehicle driving primary health care renewal in Alberta is the Primary Care Initiative (PCI),
which was negotiated as part of the Tri-lateral Master Agreement between the Alberta Medical
Association, the Regional Health Authorities (RHA’s) and Alberta Health and Wellness as equal
partners in the agreement. The primary mechanism for implementing the PCI is the Primary Care
Network (PCN). PCN's are formal (contractual) arrangements between physicians and RHA’s,
and are created for the purpose of providing comprehensive primary care services to a defined
population of patients. PCN’s serve the general population, but implement other programs and
services that are needed by their patient populations.

Agencies involved in inter-professional collaboration (IPC) for change were Capital Health,
Calgary Health Region, Chinook Regional Health Authority, Palliser Health Authority, David
Thompson Regional Health Authority, East Central Health, Aspen Regional Health Authority,
Peace County Health, Northern Lights Health Region, the Associate Clinic of Pincher Creek, and
various Primary Care Networks.

27

Projects funded through the PHCTF were diverse in scope. Some projects (e.g. Health First
Strathcona, an after-hours primary care clinic) were based on needs assessments for the general
population in a specific geographical area.

3.5.2. Teams

One of the goals that Alberta’s Primary Care Networks work to achieve is to foster a team
approach to providing primary health care.

Teams include participants from many different health disciplines. Roles and functions are divided
according to the skills and scope of practice associated with each discipline or profession.

PCN’s serve diverse population groups in rural and urban areas across the province. The team
comprises of between 80 and 90 staff members, including physicians, registered nurses,
occupation therapists, public health nurses, lab technicians and mental health workers. The size
and scope of teams in PCN’s vary depending on patient needs and programs currently being
implemented. Individual initiatives identified team numbers and composition.

Some specific initiatives include:

Interdisciplinary Primary Health Care Team Initiative: The team serves the general population.
An average of 858 patients visits the Centre each month.

Health First Strathcona: The Centre is staffed by rotating physicians who work 1 or 2 shifts per
month, a registered nurse, a licensed practical nurse, a respiratory therapist and an orthopaedic
technician.

Pincher Creek Rural Primary Care Initiative: The team is comprised of a registered nurse,
registered dietician, clinical pharmacist, registered social worker and the patient’s physician. The
extended surgical team is comprised of two visiting surgeons from Calgary, one local surgeon,
three local physicians providing anesthesiology services, family physicians and operating room
staff.

Taber: There is a regional population of 160,000. Examples of client groups served include: 4%
of population are participating in the Diabetes program, referrals are accepted from the Home
Care program and physician offices, and 350 clients per year are supported by the Palliative Care
program. Family Practice Teams (FPT’s) focus around the patient roster of each physician.
Program service teams (Geriatrics and Palliative Care) teams focus on assisting Family Practices
and Home Care nursing with complex cases. FPT’s in the clinic revolve around pods of 4 Family
Physicians each. They include 4 medical office assistants (for rooming pts, ordering labs, etc), 2
Licensed Practical Nurses (managing disease prevention screening and chronic disease
surveillance), 1 Registered Nurse (managing complex disease surveillance), and 1 Nurse
Practitioner (managing Family Physician patients when each physician is on holidays).


Primary Care Interdisciplinary Initiative: The initiative is governed by a Steering Committee that
comprises of all organizations and agencies involved in the project. An Interdisciplinary Working
Group, including representation from the different professionals that are part of the
interdisciplinary team, is involved in the planning process and provides leadership for the
development of interdisciplinary teams.

Health First Strathcona: A Strategic Steering Committee comprised of Capital Health staff meet to
discuss new practices, protocols and roles. Participating physicians and other clinical staff often
meet with the Committee for these discussions.

28

Pincher Creek Rural Primary Care Initiative: This initiative is led by a group of eight physicians at
the Associated Medical Clinic in Pincher Creek. One physician is lead liaison with the project
staff.

Taber: Physician leaders are involved in a Governance Committee, and a Local Improvement
Committee (LIC). A Clinical Care Coordinator (Masters of Nursing) was hired for the clinic.


Different strategies were used in each project to facilitate the implementation of teams. Some
projects, such as the Primary Care Interdisciplinary Initiative at Okotoks, developed an orientation
manual for staff, held an orientation session and carried out monthly sharing sessions. The
Capacity Building Fund has demonstrated that co-location, when possible, is an important
strategy to help build effective health care teams.

Two general categories of tools were developed for the implementation of health care teams.
First, tools were developed for providers, such as orientation manuals and clinical guides. As
well, one project developed an interdisciplinary training manual for health care providers involved
in Alberta’s Primary Care Networks. Second, tools were developed to assist patients during the
implementation and use of health teams, such as personal logbooks for patients to identify which
providers are involved in their care and health trackers to manage healthy living.

The Interdisciplinary Training program developed a training manual for the development of teams
in PCN’s. As well, the Office Improvement Project is assisting PCN’s to establish teams to
implement a more integrated approach to the delivery of primary care services in physicians’
offices and to determine what team members are appropriate for physicians’ patient populations.

A Practice Needs Assessment is available for clinics who are interested in projects for Advanced
Access.


Taber: A community needs assessment was completed to identify the population needs.

The Local Improvement Committee includes participation from clinic and reception staff, as well
as physicians.

Championship Teams, a process presented by the Institute of Healthcare Improvement, were
formed. Championship Teams modules were completed, and provided support for the Advanced
Access initiatives in the area.

The Family Practice teams have been developed using Work Flow Mapping process, facilitated
by a department at the Alberta Medical Association called Toward Optimized Practice (TOP).
A Program Budget and Marginal Analysis (PBMA), which is a priority setting framework
developed by economists at the University of Calgary (Cam Donaldson and Craig Mitton), was
used to prioritize needs and programs.

For more information regarding any of the above see http://www.health.gov.ab.ca/key/phc.html.

Source: Facilitation Manual

Engaging PCN Teams in Change: A workshop, held in June 2006, supported by Alberta Health
and Wellness, for leaders from health regions and Primary Care Networks, with significant
participation from primary care physicians, gave a boost to team development. On-going support
to PCN teams is offered through the Alberta Medical Association program Towards Optimized

29

Practice. For further information, contact: doug.stich@topalbertadoctors.org Toward Optimized
Practice.

Team Development in Primary Care Networks: Supported by Alberta Health and Wellness,
Capital Health and Calgary Health Regions hosted a project to develop a manual which supports
interdisciplinary teamwork in Primary Care Networks across Alberta. It includes learning activities
and resources on system context, using evidence, building teams, collaboration and scope of
practice and sustaining team facilitators. For further information contact:
Kelly.Holmes@gov.ab.ca, Alberta Health and Wellness.

Source: EICP

A Joint Statement on Resolving Ethical Conflicts Between Providers of Healthcare and
Persons Receiving Care, was developed by the Alberta Provincial Health Ethics Network,
statement from the CHA, CMA, CAN and CHAC, June 8, 1998. For further information see
http://www.phen.ab.ca/pcons/jsrc.html.

Chinook Primary Care Network Communications Plan: The Chinook Health Region in
southwestern Alberta has prepared a comprehensive communications plan to get its messages
about primary health care out to multiple stakeholder groups. For further information see CPCN
comm plan 2006.

Chinook Primary Care Network Evaluation Workplan: The Chinook Health Region in
southwestern Alberta has prepared a service evaluation plan to assess effectiveness in five key
PHC areas. For further information see CPCN Evaluation Workplan.


Health First Strathcona has implemented e-triage that is used by all Emergency Departments in
the region to ensure more accurate reporting.

Pincher Creek Rural Health Care Initiative has integrated the clinic’s electronic medical record.
The medical record includes electronic access to radiology reports and electronic lab results.
Also, the initiative has created a registry to track chronic disease patients and electronic
reminders for physicians about patients in the medical record.

Taber: Data support for decision making was obtained from the local clinic Electronic Medical
Record, regional Medi-Tech, and provincial AHW data.


Learnings from Capacity Building Fund (CBF) projects show that developing a multidisciplinary
team is a slow process. Furthermore, delays in facility construction and limited office space often
provided barriers to co-location. In developing multi-disciplinary teams, it is important that all team
members have a common understanding of who the members of “their” team are, particularly for
those who are members of more than one team. Learnings from Capacity Building Fund
initiatives suggest that the more intense the interaction between team members on a daily basis
the quicker they will feel as part of a team. Most importantly, teams take time to develop.
Potential strategies to build a team include co-location, unstructured opportunities to relationship
build (coffee breaks, etc), mutual dependency in providing effective patient care, and a stable
team membership.

Taber: Regional programs sometimes feel their turf is infringed upon, and their professional roles
are being usurped, leading to suspicion and obstruction at management levels. The silos and
acute care focus remains a major issue to manage.

30

3.5.7. Evaluation

A ‘Team Functioning’ survey was developed by external evaluators to assess team processes in
Capacity Building Fund initiatives, including communication, orientation, leadership, feedback and
coordination. The evaluation determined that facilitators to team satisfaction are good
communication, co-location, knowledge and respect for others’ abilities, shared vision and values,
strong leadership and mutual trust. On the other hand, barriers to team satisfaction included lack
of structured and unstructured opportunities to work together, lack of role clarity, forced team
participation, and lack of stability in team membership.

3.5.8. Funding sources

The Capacity Building Fund provided support for the development of multidisciplinary teams in
the various initiatives. Regional Health Authorities fund the operation of teams and most often pay
providers’ salaries. As well, other sources of funding have been used, such as the Medical
Services Delivery Fund that provides funding for alternate payment plans for physicians.

Physicians involved in these teams are largely paid by fee for service billing for the health
services they provide. In Health First Strathcona, the physicians are on an alternate payment plan
rather than fee for service. In other projects, including the Chronic Disease Prevention and
Management Network, PHC Chronic Disease Management, the Shared Mental Health Care
Network, physicians receive payment through an alternate payment plan in addition to fee for
service to cover other services for the initiative, such as planning or tool development. Other team
members, such as nurses, are paid a salary by the initiatives.

Health Link Alberta, Capacity Building Fund initiatives and other provincial coordination activities
were funded through the PHCTF, Health Canada.

PCN’s are funded through the Primary Care Initiative Agreement.

The Physician Office Support Program (POSP) was part of the last negotiation between
government and the Alberta Medical Association, providing funding for hardware and software in
physician offices. It was responsible for the 65%+ computerization of physician offices in the
province.

3.6. Saskatchewan


Saskatchewan’s Action Plan for Primary Health Care (PHC) is an integrated system of health
services available on a 24-hour, 7-day-a-week basis through Regional Health Authority (RHA)
managed networks and teams of health care providers. The goal of the plan is to have networks
and teams established in all regions with accessibility to 100% of the population by the end of 10
years. It is based on a collaborative, interdisciplinary team approach to service planning and
delivery.

Each Regional Health Authority (RHA) is mandated to develop a network of care provider teams
to deliver primary health care services, and to provide case management to coordinate services.
Primary health care networks throughout the province will offer a full range of core primary health
care services.

A network within a Health Region consists of all the teams that interact with each other. This may
include program teams, central teams, satellite and visiting teams. RHAs will generally be a
network as specialized program teams may service the whole region.

31

The team extends to include representatives from the community and other human service
sectors such as Education, Social Services, Justice and Municipal Government, as well as the
public.

3.6.2. Teams

Clients who live within the PHC team area, or within a physician practice, are provided service by
the team.

Primary health care networks and team structures vary depending on the geographic or social
needs of the population. Teams vary in size and complement depending upon the assessed
needs of the community and availability of resources.

Program Teams

Program teams form part of the network. There may be one or several of each program team in a
Health Region depending on the population served. Some examples of these teams may be
mental health, specialized programs, public health (population based i.e. Medical Health Officer,
nutritionist, etc.), emergency response teams, and chronic disease management teams (e.g.
diabetic management team). These teams would link to all teams in the network.

Teams would exist in institutions as well. Much of what happens in a hospital or Emergency
Room is considered primary health care. The management of many medical conditions involves
some time in hospital. The hospital and emergency room teams must be linked to the community
teams. Further, most of the health care needs that are being met in special care homes are
primary health care services. Teams that provide service in special care homes should function
on primary health care principles.

Central Team

A central team is envisioned to have at a minimum a group of 3 - 4 physicians and a primary care
nurse practitioner serving a population of approximately 5,000 including satellite and visiting
locations. In urban areas physician groups may be larger, with 5 - 10 physicians and with 1 or 2
primary care nurse practitioners, and therefore serve a larger population. Although co-location
may be desirable for all team members in most cases, this may not be immediately attainable. At
a minimum, the nurse practitioner should be co-located with the physician group.

An urban centre may have many central teams serving different communities within the urban
boundaries.

A central team may provide visiting services to satellite and visiting locations and provide needed
support to smaller teams.

An urban centre may have several central locations and team members may be by way of a
virtual team. The key idea is the core team members know each other well and can share the
responsibilities of clinical management, proactive care, or health promotion and injury prevention.

Satellite Teams

The satellite team will be connected to a central team and receive visiting services from the
central team. A satellite location is envisioned as a community where resident staff or visiting staff
offers health promotion and prevention services, clinical services and access to emergency
services. A range of basic services is delivered to meet the health needs of the individual, family

32

and community closer to home.

A satellite location will at a minimum have the following services on site:
a primary care nurse practitioner; and
a primary care physician (visiting).

The following services would be offered by visiting staff:
laboratory (specimen collection abilities) visiting or part time services;
public health;
home care;
therapies; and/ or
emergency services based on geographic needs.

The client/ patient would generally need to travel for other services.


There are Directors of PHC in all of the regions, and Facilitators in place to support changes in
the PHC team areas.


There were formalized processes and tools developed to support PHC changes in the team areas
including:
• Focus groups were held to determine potential facilitators and barriers to team
development;
• Train the trainer sessions for formal Facilitators were held in the team areas;
• Team workshops were delivered by the Facilitators to team members in their areas;
• Guidelines were provided for the development of RHA plans; and
• Provincial PHC Services Branch was established with the following objectives:
o to support and facilitate the process of implementing Saskatchewan’s Action Plan
for Primary Health Care;
o to develop the policy framework for Regional Health Authorities (RHAs) to plan
and organize their primary health care service delivery within regions; and
o to develop a strategy to control diabetes across the province.

In 2005 the University of Saskatchewan was successful in a submission to Health Canada for a
3-year $1.196 M project entitled, quot;Patient-Centred Inter-professional Team Experiencesquot;. For
more information see (P-CITE). http://www.pcite.ca/

The overall goal of the P-CITE Program is to improve the health of communities, families and
individuals across the province through engagement of communities and academic institutions in
implementing and evaluating inter-professional teams for patient-centred health care.

The objectives are to:
develop innovative inter-professional patient-centred education programs and settings and
evaluate their benefits;
• stimulate spread of best approaches to inter-professional patient-centred education; and
• increase health professionals exposure to inter-professional patient-centred education.

33



Team Facilitator Training: This training has been developed to support the development of team
facilitators in Saskatchewan. For more information see www.health.gov.sk.ca/ph_br_phs.html.

Facilitator Network: This provincial forum supports the work of provincial team facilitators through
quarterly meetings guided by a systems-thinking approach. It offers support with orientation of
new facilitators, continuing education, information and resource sharing, regional and provincial
updates, and updates on facilitation work/initiatives in other areas of the country. For more
information, contact Primary Health Services Branch, Saskatchewan Health or gary.n@pnrh.ca,
Saskatchewan Health.

Comprehensive Community Information System (CCIS): CCIS is an innovative vehicle for sharing
resources, information, tools and knowledge, for sparking curiosity, identifying key wellness
issues and determining priorities. It also promotes evidence-based research, programming, policy
development and evaluation. CCIS is also a community-based tool that fosters empowerment
through the sharing of information and through a collaborative, holistic and humanistic approach
to the ongoing process of community wellness. For more information, visit
http://ccis.cronustech.com.

Source: EICP/ CFPC Tool-kits

Pilot Project in PHC Team Development: Saskatchewan Health, through a partnership
with Med-Emerg International and the Centre for Strategic Management (CSM), developed a pilot
project on interdisciplinary primary health care teams. It contains team effectiveness tools, team
charter templates, and team facilitator workshops. As a result of team development project there
were also funded team facilitators in each of RHAs. The team focus developed in Saskatchewan
was based on systems thinking. CSM uses a five step approach quot;ABCDEquot; model to lead
organizations through change and team development. For more information see
http://www.health.gov.sk.ca/ps_phs_teamdev.pdf.

Team Charters: A team charter (team mandate or terms of reference) is a working document that
defines the team and its scope of work. The charter is a useful foundation document that supports
a team discussion on purpose, roles and elements of team functioning. For more information
contact the Saskatoon Health Region.

Facilitationforum: To support the sharing of information between colleagues, an internet-based
group page has been established where facilitators can dialogue about their work.
Facilitationforum has been set up through Yahoo! Groups, a free service that offers a convenient
way to connect with others who share the same interests and ideas. For more information
contact: saskatoonhealthregion.ca, Saskatoon Health Region.

Team Facilitator Training: This training has been developed to support the development of team
facilitators in Saskatchewan. For more information see www.health.gov.sk.ca/ph_br_phs.html


No information is available at this time.



34

3.6.7. Evaluation

There was a formal evaluation completed for the team development process.

3.6.8. Funding

The PHCTF provided funds for some of the change activities, and team development.

3.7. Manitoba



3.7.2. Teams





The processes and tolls included were identified through the Facilitation Guide.


Primary Health Care Lens: This easy-to-use tool encourages reflection on the degree to which
PHC is integrated into provider’s work. It has been used with communities and staff as a means
to evaluate existing programs and design new ones so that they are aligned with the principles of
PHC. For more information, contact: bkozak@arha.ca, Assiniboine Regional Health Authority.

Move to PHC: The NOR-MAN RHA has facilitated a PHC change process focused on building
capacity, encouraging collaboration, working within a common vision and using communication
processes to validate change. By providing a clear, collective and individual understanding of
PHC concepts imperative to success, this process changed the way NOR-MAN RHA operates.
For more information, contact: mgray@normanrha.mb.ca, NOR-MAN Regional Health Authority.

Change Management Workshop: It is crucial to recognize that staff members are at different
points in the change cycle. As part of their move-to-PHC plan, NOR/MAN RHA, staff collaborated
to offer a session to assist staff with the change process. For more information, contact:
mgray@normanrha.mb.ca, NOR-MAN Regional Health Authority.

One Window Approach: This tool was developed to provide a continuum of service among
service providers (within the health care system and with community partners). It is both a tool
and a process to assess current programs and create a plan for action to make necessary
improvements in: collaborative work, information sharing and referrals, aligning resources,
capacity building, assessment, tracking, monitoring and evaluation and communication and
connections. For more information, contact: bkozak@arha.ca, Assiniboine Regional Health
Authority.



35



3.7.7. Evaluation


3.7.8. Funding


3.8. Quebec


One of the models that has been given priority for the integration of health care is the introduction
and development of the Family Medicine Groups (FMG’s) over the next few years. Patient
management, which involves both continuity and accessibility, requires the creation of medical
teams that include nurses. A formal agreement is signed with a local health and social services
network development (CSSS’s) agency. The FMG’s offer of services must comply with the
regional plan for the organization of general medical services, as assessed by the regional
department of general medicine.

In exchange, this agreement with the agency calls for technical and financial support to be
provided to support the organization of FMS services proportional to the number of individuals
who are registered (9 000, 12 000, 15 000, 19 000, 24 000 or 30 000 individuals). Technical
support includes the computerization of the FMGs, in particular, access to test results and data
on medications. Computerization of the FMGs is done in compliance with the Ministry’s general
plan for the computerization of the health care network.

The agency is also responsible for supporting the FMGs and the CSSSs in their efforts to
establish functional links, thereby promoting access to diagnostic services and specialized
services.

The FMG is defined as an organization made up of family physicians who work as a group, in
close cooperation with nurses and other professionals such as pharmacists and social workers.
The FMG offers a range of primary care services with an adapted 24/7 service for patients who
voluntarily register with a physician who is a member of the FMG. The FMG enters into
agreements with other partners (e.g. CSSS’s, pharmacists, etc.) in order to provide a complete
range of services. These activities must be a part of the agency’s regional plan for the
organization of general medical services (RPOS).

The FMG primarily provides a structure for the family physician’s primary care activities, in the
office on an appointment or drop-in basis, or in the home for individuals whose mobility is
severely limited, during business hours on weekdays and on a drop-in basis on weekends. The
physicians also work in several other settings (emergency care, long-term hospital care, short-
term hospital care, palliative care, etc.) that do not fall within the scope of the FMG but with which
integration objectives are being pursued.

3.8.2. Teams

In June 2004, 1995 local service networks were created across the province to bring services to
the population and to enhance service accessibility, coordination, and continuity. To achieve the
objectives of accessibility, continuity, and quality, all of the CSSS’s, with partners in their local

36

Juanitas Final April 29 2007

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