Improving Primary Health Care Through Collaboration: Briefing 2 ...

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For the exclusive use of Mona Lesage, mlesage@wrha.mb.ca, Winnipeg Regional Health Authority.2 | Improving Primary Health Care Through Collaboration: Briefing 2—October 2012coordination of care. 3 When chronic diseases are wellmanaged, health system, economic, and societal benefitsresult in the form of reduced emergency department visitsand hospitalizations, increased productivity, and lowerpremature mortality. 4 Although significant reforms toprimary care have been implemented over the past decade,barriers to optimizing IPC teams in Canada remain.Based on a review of the literature, this second briefingof the series Improving Primary Health Care ThroughCollaboration highlights some of the important barriersto interprofessional collaboration in IPC teams. Thereis emphasis on those barriers to optimize what can bechanged at the individual, practice, and system levels,and that are relevant to the Canadian context. Althoughthere is abundant literature on the barriers to IPC teamoptimization, it remains unclear as to how these barrierscan be overcome.What Is an Interprofessional Primary Care Team?Interprofessional primary care (IPC) teams come in theform of physician-led practices, nurse practitioner-ledpractices, community-led practices, and integrated networks.An IPC team is a group of professionals fromdifferent disciplines who communicate and work togetherin a formal arrangement to care for a patient populationin a primary care setting. Examples of common primarycare settings are family physicians’ offices or practicesand community health centres. IPC teams often comprisefamily physicians or general practitioners; nurse practitioners;other nurses; and other professionals, includingdietitians, nutritionists, social workers, mental health counsellors,psychologists, pharmacists, exercise physiologists,physical therapists, chiropractors, and physician assistants.Barriers to InterProfessionalCollaboration in Primary CareThe content presented in this briefing is based on areview of the literature on interprofessional collaborationin primary care published in the past decade.The first briefing in this series provided an overview ofwhat is currently known about IPC teams in Canada. 5The main findings were that IPC teams vary across andwithin jurisdictions in terms of structure, function, funding,governance, and maturity. This, in turn, influencesthe quantity and quality of interprofessional collaborationin primary care. The third briefing will examine thehealth and economic impacts of IPC teams and the implicationsof improved access to them for the chronicallyill, using the examples of diabetes and depression. Thefourth and final briefing will provide recommendationsfor policy changes that can lead to more successfulinterprofessional collaboration in primary care.The content presented in this briefing is based on areview of the literature on interprofessional collaborationin primary care published in the past decade. Duringthat time, significant primary care reforms were implementedin Canada and comparable countries such asAustralia, England, and the Netherlands. 6 We identifiedrelevant literature using electronic databases (Medlineand Allied and Complementary Medicine); reports publishedby selected organizations and initiatives, (includingEnhancing Interdisciplinary Collaboration in PrimaryHealth Care (EICP), the Canadian Health ServicesResearch Foundation (CHSRF), the Health Council ofCanada, and Health Canada); and selected bibliographies.The review included traditional qualitative and interventionstudies, systematic reviews, and commissioned reports.Individual-Level Barriers toInterprofessional Collaboration3 Goldman and others, “Inter-Professional Collaboration in FamilyHealth Teams.”4 Thériault, Stonebridge, and Browarski, The Canadian Heart HealthStrategy; Hermus and others, Cost Risk Analysis for ChronicLung Disease in Canada; Ohinmaa and others, “The Projection ofPrevalence and Cost of Diabetes in Canada.”5 Dinh, Improving Primary Health Care Through Collaboration.Briefing 1.This section highlights some of the important individual-levelbarriers to interprofessional collaboration inIPC teams. They include a lack of role clarity and trust,and a perceived and projected professional hierarchywithin the team.6 The Commonwealth Fund, Strengthening Primary Care.Find this briefing and other Conference Board research at www.e-library.ca
© The Conference Board of Canada. All rights reserved. Please contact cboc.ca/ip with questions or concerns about the use of this material.The Conference Board of Canada | 3Lack of Role Clarity and TrustRole clarity and trust are crucial in the development andoptimization of interprofessional collaboration, especiallywithin teams where professional silos previouslyexisted. 7 Barriers that inhibit role clarity and trust can,in part, be attributable to limited knowledge and understandingof other team members’ knowledge, skills, andscopes of practice, making it difficult to manage andoptimize roles within the team. 8,9 The roles of individualteam members in relation to the traditional physicianledmodel can be looked at in two ways: 1) task substitutionand 2) supplementation. 10 Task substitution occurswhen one health professional assumes specific tasks ofanother health professional, with the intention of meetingthe needs of clients (patients) and alleviating workload,workforce shortages, and costs. 11 Supplementationdescribes the working and shared-role relationshipbetween physicians and other health professionalswithin a team as complementary, interdependent, andaimed at improving quality of care, as opposed tofocusing on process efficiency or cost reduction. 12Supplementation seems to be more acceptable amongprofessional groups and is most commonly practicedin high-collaborating IPC teams. 13Some professional groups have overlapping competenciesor variations of similar competencies. The first briefingin this series examined similar services provided acrossIPC team models that were sometimes delivered by differentproviders. For example, depending on the jurisdiction,physicians and nurse practitioners can make7 Gotlib Conn and others, “Creating Sustainable Change in theInterprofessional Academic Family Practice Setting.”8 Scope of practice ”[is] the range of activities that a qualified practitionerof an occupation may undertake; establishes the boundariesof an occupation, especially in relation to other occupations wheresimilar activities may be performed; may be established throughgoverning legislation or through internal regulations adopted by aregulatory body.”9 The College of Family Physicians of Canada, CFPC VisionStatement on Inter-Professional Care.10 Hefford and others, Practice Nurse Cost Benefit Analysis.11 Ibid.12 Ibid.13 The College of Family Physicians of Canada, CFPC VisionStatement on Inter-Professional Care; Dinh, Improving PrimaryHealth Care Through Collaboration. Briefing 1.primary diagnoses, make referrals to specialists, and prescribemedications. Similarly, various providers, includingdietitians, nutritionists, and nurses, can provide educationsuch as nutrition counselling to support self-managementof chronic diseases. Mental health counselling may beoffered by social workers, mental health counsellors, orpsychologists. Overlapping skills can create difficultiesin formally establishing defined roles within an IPC team.For IPC teams to be effective in team functioning andimproving patient outcomes, team member roles in theplanning and delivery of care must be clearly expressedand negotiated. 14 This process is often overlooked duringteam development and transformation. A lack of roleclarity when care is shared creates confusion withinthe team, and can cause conflict and sub-optimal carefor patients. 15Perceived and Projected HierarchicalRoles and RelationshipsTeam effectiveness and collaboration can be compromisedwhen team members perceive and/or project a professionalhierarchical order of importance or power. 16A study by Gotlibb Conn and others suggests that it isvery difficult to eliminate hierarchy in a primary careteam. Because of the medico-legal responsibilities thatthey hold, physicians often assume important medicaldecision-making. 17 Nonetheless, non-physician team memberscan feel disappointment and reduced job satisfactionwhen their involvement in decision-making is limited. 18In their study of a family health team in Ontario, GotlibConn and others found that language was critical in creatinga work environment where both providers andpatients understand and value the unique roles and contributionsof all members of the team. 19 They noted that,after two years of implementing an appreciative inquiryintervention to promote and support interprofessional14 Mitchell, Tieman, and Shelby-James, “Multidisciplinary CarePlanning and Teamwork in Primary Care.”15 Ibid.16 Gotlib Conn and others, “Creating Sustainable Change in theInterprofessional Academic Family Practice Setting.”17 Ibid.18 Shaw, de Lusignan, and Rowlands, “Do Primary CareProfessionals Work as a Team.”19 Gotlib Conn and others, “Creating Sustainable Change inthe Interprofessional Academic Family Practice Setting.”Find this briefing and other Conference Board research at www.e-library.ca
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