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.8 | Improving Primary Health Care Through Collaboration: Briefing 2—October 2012Inadequate InterprofessionalEducation and TrainingOne of the barriers to effective interprofessional collaborationis team members’ lack of competency in interprofessionalcollaboration due to lack of or inadequateinterprofessional education and training. 51 According toDrummond and others, the primary goal of interprofessionaleducation and training 52 is “to help studentsbecome collaborative practitioners in an effectivefashion.” 53 They reported that the available evidencearound interprofessional education is mostly not of highquality, resulting in uncertainty about its valueand the key features for training professionals to worktogether effectively. 54 A 2008 systematic review byReeves and others found mixed results on the effectivenessof interprofessional education interventions, especiallywithin a primary care setting; however, due tosmall sample sizes and number of studies, the resultsmay not be reliable. 55 Drummond and others recentlyexamined the status and processes of interprofessionalwork environments and implications for interprofessionaleducation in a sample of family medicine teaching clinicsin Alberta. 56 They found that not one teaching clinic inthe study had a clear and explicit focus on providing interprofessionaleducation and training. 57 They note that“to ensure future collaborations in the health care workplaceare effective, opportunities for students to engagewith students from other professionals are required.” 58The implications of inadequate interprofessional educationand training are reduced quality of collaboration andteam effectiveness. 5951 Drummond and others, “Interprofessional Primary Carein Academic Family Medicine Clinics.”52 Educational, training, teaching or learning sessions where two ormore health and social care professions are learning and trainingtogether interactively.53 Drummond and others, “Interprofessional Primary Carein Academic Family Medicine Clinics.”54 Reeves and others, Inter-Professional Education.55 Ibid.56 Drummond and others, “Interprofessional Primary Carein Academic Family Medicine Clinics.”57 Ibid.58 Ibid.59 Ibid.Sub-Optimal Funding ModelsA significant operational challenge for IPC teams isgetting the mechanism of payment right for health providersand teams in order to promote greater team effectivenessand better health outcomes for patients. Thechallenge is to determine the appropriate remunerationmodel and financial incentives to promote increasedand improved interprofessional collaboration, optimizeindividual scopes of practice, and improve recruitmentand retention of health human resources.One interprofessional collaboration barrier is teammembers’ lack of interprofessional competency due toinadequate interprofessional education and training.RemunerationPayment mechanisms for physicians vary across IPC teammodels and between and within provincial/territorial jurisdictions.The works by Wranick and Durier-Copp 60 andLéger 61 provide good overviews of the advantages anddisadvantages of the different alternative physician paymentmodels. Physicians in alternative payment models(salary, capitation, blended) may be more incentivisedto participate in team meetings than physicians in fee-forservicemodels. Most of the current IPC team modelsemploy a blended payment model of capitation or salarywith fee-for-service for physicians. Non-physician IPCteam members are paid in different ways, depending onthe type of IPC team model; however, for the most partthey are paid on salary. In some jurisdictions, such asOntario, extra funds are available from the Ministryof Health to pay salaries for non-physician IPC teammembers in the family health team model. Communityhealth centres are often provided line budgets to remuneratestaff in all disciplines by salary, sessional fees, orcapitation. 62 There is little research on the impact offunding and remuneration schemes for non-physicianIPC team members. Documentation shows that whencompensation rates and benefits are non-competitive for60 Wranick and Durier-Copp. “Physician Remuneration Methodsfor Family Physicians in Canada.”61 Léger, Physician Payment Mechanisms.62 Canadian Alliance of Community Health Centre Associations,Characteristics of CHCs.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 | 9IPC team members, compared with other employmentsettings, including hospitals and the private sector, thechallenge lies in recruitment and retention. 63Referral policies create another barrier in interprofessionalcollaboration that can be misaligned with the goals ofinterprofessional primary care to improve access andbetter health outcomes. For example, as in other parts ofCanada, Ontario’s nurse practitioners have an expandedscope of practice that allows them to screen for and diagnosediseases and refer patients to medical specialistsand for diagnostic tests. One of the challenges of optimizingthe role of the nurse practitioner within IPCmodels is that there is a higher rate of remunerationpaid to physician specialists for patient referrals made bya physician. 64 Without a referral from another physician,the specialist is allowed to claim only the medical-specificassessment fee, and not the consultation, which resultsin a 24 to 39 per cent lower payment. 65 Since specialistsare not obligated to accept referrals from nurse practitioners,there is a financial disincentive to see patientsreferred by non-physician providers. Even if specialistsdo take a referral from a nurse practitioner, they are notrequired to provide a care plan to the referring providerwithout a consultative fee, thus limiting optimal coordinationof care. 66 The nurse practitioner-led clinics inOntario currently deal with this challenge by includinga collaborating physician on the team in order to facilitatespecialist referrals. 67 Ultimately, this strategy does notcontribute to an efficient use of the health care system.Lack of Appropriate Monitoring andEvaluation to Inform ChangeOne of the greatest and most important challenges inthe optimization of IPC teams is the lack of consistentlycollected, reported, and meaningful performance data.63 Silversides and Laupacis, Lower Pay Hampers Nurse PractitionerRecruitment in Primary Care; Osmond, Policy Barriers to Recruitmentand Retention of Health Professionals in Rural Areas of Nova Scotia;Grosso, Meeting the Demographic and Retirement Challenge.64 Donald and others, “The Primary Healthcare Nurse PractitionerRole in Canada.”65 Nurse Practitioners’ Association of Ontario, Position Statement.66 Ibid.67 Donald and others, “The Primary Healthcare Nurse PractitionerRole in Canada.”As a result of limited monitoring and evaluation, weknow little about the health and economic impacts ofpast and current reforms to the primary health care system.A preliminary review of the literature around theeffectiveness and cost-effectiveness of IPC teams inCanada was conducted to inform the subsequent briefingin this report series. The majority of published evidenceon IPC teams describes changes in practices, asopposed to impacts on health outcomes. This findingis similar to the conclusions drawn in the systematicreview by Tieman and others. 68The Canadian Institute for Health Information hasstated that “the effectiveness of primary care remainslargely a black box.” 69 In terms of indicators for interprofessionalcollaboration, there is a need to capturemore comprehensive primary care provider and organizationaldata. The development and consistent implementationof rigorous evaluation processes for currentIPC team models is needed to assess team functioningand its direct impact on clinical/health and economicoutcomes. Without evidence of effectiveness and efficiency,it is difficult to assess the trade-off between thecosts of IPC teams and their benefits—such as improvedhealth, increased productivity, and reduced costs to theacute care system. It is equally important that the evaluationindicators are meaningful in that they can provideinsights on what works, what doesn’t, and why, in orderto inform changes required for improving performance.ConclusionThe previous briefing established that IPC team modelsvary in terms of structure, function, funding, governance,and level of maturity, which influences the quantity andquality of interprofessional collaboration within theseteams. IPC teams can be optimized, in that opportunitiesand resources can be better used to promote and supportinterprofessional collaboration that can increase access68 Tieman and others, “Integration, Coordination andMultidisciplinary Care.”69 Canadian Institute for Health Information, Health Carein Canada 2009.Find this briefing and other Conference Board research at www.e-library.ca
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