Enhancing interprofessional collaboration for unattached patients in primary care

Abstract

This project explored an interprofessional collaboration initiative at Clinique Indigo which aimed to improve comprehensive care for unattached patients in Quebec’s primary care system. Throughout the project, physicians and non-physician health professionals alike became more actively engaged in the care of patients lacking a regular primary care provider. The project successfully demonstrated that defining a common vision for “well care” within the clinic and integrating diverse professionals could significantly improve quality of care for unattached patients, evidenced by an increase from 13% to 43% in comprehensive care provision. However, the initiative also faced challenges, including professional turnover and gaps in primary care training, suggesting critical areas for future improvement in healthcare policy and practice. These results support expanded interprofessional approaches in primary care to address systemic care disparities in universal healthcare settings such as this one caused by the differential or absence of attachment to a primary care provider.

Background

In Quebec, nearly one-third of patients report not having a regular primary care provider. Patients who are “attached” to a regular primary care provider receive more preventive care, use emergency services less frequently, and have better coordination, chronic disease, and health outcomes than those who are not.^1-5

Because access to high-quality comprehensive care is challenging for unattached patients, a single point of access pathway called the “GAP” (guichet d’accès en première ligne) was implemented in each region across the province by the Ministry of Health in 2022 to improve access and navigation while they wait on the centralized waiting list. The GAPs are based on a triage process that aims to refer patients to the right professional according to their need, with the goal of creating capacity in family physician’s schedules.

A second strategy implemented by the Ministry of Health was to incentivize groups of physicians to collectively attach patients to their clinic in a model of collective affiliation called Prise en charge collective (PECC). Collectively attached patients, however, still had to access care through the GAP and were not offered the same access to comprehensive care as regularly attached patients. In Quebec, accountability towards patients still revolves around attachment to individual family physicians and not to a regular place of care. Moreover, the dominant culture is to view the visits booked through the GAPs as urgent care visits, where physicians generally offer to manage a single issue. This contrasts to the comprehensive care type of visits offered to patients attached to an individual family doctor. Patients referred through the GAP, whether they were collectively attached or not, were therefore considered by our intervention team as “unattached” patients.

The family medicine group (groupe de médecine de famille, GMF) is the dominant primary healthcare model in Quebec since 2002. The model is based on multidisciplinary team practice serving non-geographically bound registered patients. It is financially supported by the government through a subsidy program; funding and human resources including registered nurses, social workers, pharmacists and physiotherapists or nutritionists provided by local health authorities (Centres intégrés universitaires de santé et services sociaux, CIUSSS) are allocated based on the number of attached patients. To be eligible, clinics must have a minimum of 6,000 attached patients, weighed for specific health issues and material deprivation indices. They must meet a certain standard of service and use certified Electronic Medical Records (EMRs). As of 2023, over 360 GMFs were serving more than 5 million patients, reflecting the model’s widespread adoption. Family physicians working in GMFs were incentivized in 2022-2024 to offer appointments for PECC and GAP patients.⁶

Despite the structured approach to care within GMFs, the engagement of non-physician professionals in the care of unattached patients has been limited. Recognizing the value of interprofessional collaboration in addressing complex health system challenges,^7,8 Clinique Indigo, a GMF located in Montreal, attempted to deconstruct the double standard of care facing attached and unattached patients by adopting a more integrated team approach for unattached patients referred by the GAP. Funding obtained through the Team Primary Care initiative financially supported the training and support required for the project’s deployment. It is important to note that no other organization currently provides funding for these types of activities in Quebec.

Project objective

The project named “Une équipe interprofessionnelle au service de la population orpheline” (EISPO project) aimed to showcase the potential of optimized interprofessional processes in enhancing the capacity of primary care teams to improve access and care comprehensiveness for unattached patients referred by the GAP. A secondary objective was to begin a deliberate transformation journey towards a more functional and efficient interprofessional team. The final objective was to document the facilitators and barriers to optimizing interdisciplinary care delivery.

Methods

The intervention approach undertaken over 11 months from May 2023 to March 2024 was multi-faceted.

Interprofessional team creation and stabilization

Initially, the project focused on broadening the clinic’s interprofessional team, drawing from a diverse pool of healthcare professionals. Innovative partnerships with external service providers such as private physiotherapy clinics and mindfulness providers were created to broaden the spectrum of care offerings. Early on, the clinic elected to pool the funds allocated to physicians for offering appointments to collectively attached patients to fund the new professional services. It was decided that family physicians who wished to offer appointments to collectively attached patients at the clinic would have to adhere to this vision to access the extra remuneration through the pooled money. Building this service offering was crucial in addressing prevalent and unmet health concerns for unattached patients, particularly in musculoskeletal and mental healthcare.

Improving collaboration among healthcare workers

The subsequent phase involved team workshops aimed at fostering shared goals among team members, including administrative staff, professionals, and family physicians. These sessions, facilitated by quality improvement specialists acting as coaches, focused on developing a unified vision for the provision of “well care” and comprehensive care. Overall, a significant emphasis was placed on communication, understanding professional roles, and coordinating care pathways. Our team engaged in three facilitated workshops centred around different themes (Table 1).

Table 1.

Interprofessional collaboration workshop descriptions.

Theme	Purpose
Project launch and common vision building (September-2023)	• Gather the team and discuss project objective, apprehensions and excitement towards the project
	• Develop a common vision for “well care” delivery services for unattached patients
	• Present the interprofessional team to physicians: Physiotherapist, nurse, mindfulness course
Consolidation of the “well care” vision for unattached patients (December-2023)	• Refine and agree on the common vision for “well care” delivery services for unattached patients (i.e., screening and counselling)
	• Encourage physicians to offer age-appropriate screening to unattached patients and to refer to nurses for counselling (diet and smoking cessation) and screening (Pap tests)
	• Categorize and prioritize possible sub-projects in an effort/impact matrix
Roles and communication styles in collaboration (January-2024)	• Understanding roles and communication styles in the context of collaboration with others. All team members were asked to complete the Winning Colours personality test. Winning Colours, is an approach rooted in the idea that behaviour produces results
	• Discuss the different personality types, share who falls into what personality category, discuss the dos and don’ts of communicating with each personality type, and practice effective communication

In parallel to this work, a sub-committee composed of diverse team members was formed with the responsibility of implementing prioritized “well care” initiatives. Under the guidance of the improvement coach, the sub-committee met frequently to implement, test, refine, and assess the initiatives, ensuring a structured approach to change. They developed an intake questionnaire to identify patients’ “well care” needs (age-appropriate screening, counselling for chronic disease prevention, and smoking cessation). A pathway was identified to refer patients who qualified for a pap test directly to the clinical nurse who could provide that service.

To complete the workshops and better understand each professional’s scope of practice, we implemented bi-monthly professional lunch and learn sessions. Each lunch (four in total) was focused on one role: nurse, social worker, pharmacist, and physiotherapist. During the lunches, the professional shared a brief presentation on his or her role and scope of practice, what patients and conditions they could care for and how to refer. A discussion period took place in which the professionals and team shared thoughts and ideas of how to collaborate more effectively. Of note, this part of the intervention was completed at the project’s end—therefore it was unfortunately not possible to include the impact of these sessions on collaboration improvement in this piece.

Key measures and outcomes

The project employed a multi-dimensional evaluation strategy to assess its impact. Quantitative data, including emergency medical record analyses and chart reviews, offered insights into the extent of interprofessional engagement and the comprehensiveness of care provided. Qualitative assessments, through project journaling and collaboration with local health authorities, helped identify operational and structural challenges and opportunities for improvement.

Increase in interprofessional collaboration

Following engagement in the interventions, we measured an increased involvement of professionals other than family physicians in the care of unattached patients: a total of 279 professional visits for the same number of unattached patients were realized between September 2023 and February 2024, compared to none prior to the start of training between June 2023 and August 2023 despite the professionals being available to receive patients. Despite this promising result, nearly 50% of professional appointments reserved for unattached patients remained unfilled.

Comprehensive care enhancement for unattached patients

We observed a noteworthy rise in age-appropriate “well care”¹ delivery, with percentages of patients being offered services increasing from 13% to 43% within 3 months of the intervention (Figure 1).

Figure 1.

Proportion of unattached patients who received age-appropriate “well care.”

Structural facilitators and obstacles documentation

Throughout the project, journal entries were recorded by the project’s co-leads and the research coordinator. This journaling approach was used to document challenges encountered during the project’s span. It helped the identification of several significant political, administrative, and logistical barriers. Most significant is the documentation of primary care training gaps and issues related to the availability of professionals and the stability of teams (Table 2).

Table 2.

Documented challenges to improved interprofessional collaboration.

Theme	Impact points
Unfilled positions and general team instability impact negatively activities and processes put in place to improve collaboration	• High professional turnover rates: Relationships key to more effective collaboration are lost and constantly need to be rebuilt
	• Positions left unfilled for several months: Absence of professionals to develop collaboration with or loss of established collaboration pathways
Primary care training deficiencies for professionals cause delays in interprofessional care team integration and care delivery	• Absence of a structured primary care curriculum for nurses prior to them entering the primary care professional workforce
	• Lack of training translates into delays in full scope of practice of up to a year as training occurs while the nurse has already obtained her position
Significant systemic barriers limit the autonomy of primary care clinics to improve interprofessional collaboration	• Professionals are hired by the local health authorities, based on seniority alone without criteria on primary care competency
	• Professionals are therefore on loan of service to GMFs, limiting GMFs ability to replace extended leaves of absence or to put in place measures to ensure better team stability
	• CIUSSS delays in hiring certain categories of professionals such as physiotherapists due to lack of competitiveness in salary offering

Lack of stability of the professional workforce “loaned” to GMFs

The project demonstrated a high turnover and absence rate among health professionals provided to GMFs by the local health authorities (CIUSSS). During the project period, 10 months from June 2023 until end of March 2024, the nursing team was working at incomplete capacity 23% of the time. The social worker role was vacant 55% of the time, and the physiotherapist role, 38% of the time.

Capacity for consultations in GMFs still rely heavily on family physicians

Family physicians at Clinique Indigo still provided most of the care within the GMF with over 80% of total consultations offered over the project year. This heavily depends on the availability of professionals during a given year. Physician appointments were always filled at capacity whereas in contrast, other professionals often filled up only 50-60% of their appointment capacity. The physiotherapist stood out by filling 89% of the time. On-boarding and primary care competency training time explain a large proportion of these findings. The turnover in administrative staff and their own training delays in learning the scope of practice of professionals working in primary care settings and the referral pathways also hindered appropriate bookings with the right professional.

Training deficit of professionals in primary care

There is a lack of primary care training for many healthcare professionals working in primary care settings. Notably, nurses require up to 12 months while on the job to reach their full scope of practice. Of the 77% at complete capacity, nurses were not fully trained in primary care 26% of the time, which translates into an approximate 3-month period of total absence of care delivery.

Key learnings

Team stability is critical to establishing effective interprofessional collaboration

Team stability significantly influences the effectiveness and sustainability of collaboration. High turnover rates and hiring practices that prioritize seniority over core primary care competencies are major obstacles to achieving cohesive teamwork.

Generalized phenomena like a high prevalence of medical leaves and workforce shortages explain part of the finding. The rigidity and maladaptation to the realities of primary care in GMFs of established hiring and other administrative processes within local health authorities (CIUSSS) explain the remaining. Elements like delays related to fixed job posting dates that do not correspond to the clinic’s funding financial year, for example, systematically create a period where the professional will be absent. Inability to modify a position to fit the preference of a candidate despite a scarcity of resources also hindered hiring. Furthermore, as a large employer, the CIUSSS provides numerous opportunities for the unionized healthcare professionals contributing to the high turnover rate of nurses who once trained on the job as effective clinical nurses in primary care, move on to managerial positions, go on to pursue nurse practitioner studies in primary care, or move on to other positions. Finally, salaries lower than the private sector appeared as a significant barrier to hiring particularly for physiotherapists.

An unstable workforce is incompatible with optimized interprofessional work and care delivery. This statement seems obvious; however, it bears to be recognized explicitly by healthcare leaders as a prominent barrier to the establishment of effective interprofessional teams. The healthcare system will need to rely heavily on the effectiveness of these interprofessional teams to deliver high-quality care to more patients if we wish to offer primary care unconditionally to all.

Critical gaps in healthcare professionals’ primary care training delay establishment of effective teams

Unlike family physicians, other professionals lack dedicated primary care training and exposure. Nurses require up to 12 months of on-the-job training in a GMF setting to fully develop their primary care skills as primary care is not part of their curriculum in school or stage. Other projects funded under the TPC umbrella analyzed this topic and proposed initial curricula to begin bridging this gap. More work will be required however to include clinical skills in primary care training. This delay in reaching full competency restricts their ability to take on a full range of patient care responsibilities from the outset, hindering the development of effective interprofessional teamwork within clinics.

This is mostly explained by the hiring processes that prioritize seniority over primary care competencies. Most nurses acquire their clinical experience in hospital settings, where they gain their seniority. Since, furthermore, most academic training of nurses focusses on hospital type care, it is almost impossible for a nurse to arrive in her position trained to the full breadth of family medicine.

Establishing effective collaboration among professionals involves more than their mere presence in a primary care team

The project underscored the extensive timeframe and energy required to improve interprofessional collaboration. Despite increased referrals 6 months into the project, professionals were still not operating at full capacity. This underutilization of capacity is in part due to the staff’s incomplete primary care training and absences for parts of the project. It also highlighted that it takes longer than 18 months to optimize professional roles within a team, a timeline that challenged the constraints of project funding in this case. Attention must continuously be devoted to improving collaboration pathways. Due to limited project duration, it was impossible to see if the team improved its functioning after the lunch and learns specifically addressing professional’s roles. Previous literature has shown that once a team is in place, trained, and stable, training geared at better understanding each other’s role improves collaboration pathways leading to further gains in efficiency.

Primary care in Quebec continues to rely heavily on family physicians despite multidisciplinary teams in GMFs. The ratio of nursing and other professionals to family physicians remains low in primary care. High level policy changes and funding will be required to transform this aspect and increase the proportion of other professionals within primary care teams.

Interprofessional teamwork does provide improved comprehensiveness of care for unattached patients

Despite the significant challenges noted above, the creation of an interprofessional team within a GMF to support physician consultations booked from the GAP did improve the provision of “well care” services for unattached patients. Patients who were otherwise booked for acute issues were offered more comprehensive care than they would have otherwise received had the interprofessional team not been in place. Given the challenge of affiliating more patients to family physicians in Quebec due to a shortage of these professionals, increasing support towards interdisciplinary teams presents a promising avenue towards achieving equitable and comprehensive care access for everyone.

Conclusion

In a universal healthcare system, unattached patients should have access to the same quality of care as patients attached to a regular family physician. This project underscored the opportunity of interprofessional collaboration to enhance comprehensiveness of care for patients. Considering the family physician shortage and the goal of achieving universal patient attachment, the role of other healthcare professionals and their teams in driving primary care transformation will become increasingly critical. To achieve this, it will take adequate primary care training, optimized human resource allocation processes, and training and coaching of teams to learn to collaborate. The project highlighted several opportunities for policy-makers and primary care leaders to better support interprofessional work in primary care.

Footnotes

Acknowledgements

We extend our sincere gratitude to our esteemed collaborators from the Quebec Ministry of Health, Philippe Lachance, Director of Access and Integrated Primary Care Services Organization, and Dominique Perron, Advisor Access and Integrated Primary Care Services Organization, whose insights and expertise as knowledge users have enriched our work, ensuring its relevance and impact on health policy and practice.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: Team Primary Care was supported by Employment and Social Development Canada through a grant to the Foundation for advancing Family Medicine, co-led by the College of Family Physicians of Canada and the Canadian Health Workforce Network.

Ethical approval

Institutional Review Board approval was not required.

ORCID iDs

Elise Boulanger

Isabelle Gaboury

Mylaine Breton

Note

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