Editorial | By Ivy Lynn Bourgeault, Ivy Oandasan, Jasbir Sunner, Dale McMurchy

Introduction

Primary care is the foundation of the health care system in Canada. Yet over six million Canadians do not have access to a regular primary care provider. Nearly one in six family doctors in Canada are nearing retirement and given the pandemic many more are taking early retirement.

The question is how we will address the crisis we face. Is it simply a need to produce more? Or do we also need to think and work differently and optimize the use of the incredible assets we have in our health workforce. Evidence shows that when healthcare providers truly work interprofessionally particularly when faced with complexity, improved patient outcomes, improved efficiencies (less ER visits, improved access) improved work satisfaction (less burnout) and that’s better for the healthcare system overall.

Comprehensive team-based primary care training is not happening right now – or is not robust enough and aligned to get the right outcomes – Team Primary Care (TPC) was an initiative created to do this. Our inspiration is a quote from the Romanow Commission in 2002, “If health care providers are expected to work together … it makes sense that their education & training should prepare them for this type of working arrangement.” (p. 109)

Vision, Mission, Principles

Our collective vision is an integrated health system in which every individual receives equitable, high quality, comprehensive care from a well-trained, well-supported and optimally utilized primary care team. To achieve this vision, our mission is to transform primary care training and education, equipping Canada’s workforce for effective team-based care. These are in support of the four primary care core functions of (Starfield et al., 2005):

First contact – access and use of health services whenever necessary;
Comprehensiveness – promotion, prevention, treatment and rehabilitation appropriate to the PC context;
Coordination – the integration of all the care the user receives and needs with the other health services;
Continuity – a professional-subject-of-care temporal relationship, leading to the establishment of strong mutual trust.

TPC also proposed that primary care education in Canada should embed a commitment to five core principles of interprofessionalism, equity, diversity inclusion and accessibility, truth and reconciliation, psychological health and safety and social accountability (1).

Implementation Framework

Putting this collective mission into action and embedding these principles was a work in progress – whilst our various partners were building parts of the plane and flying it. In Figure 1, we depict how the different pieces came together.

Noting how training is essential for successful primary care practice and primary care reform, we started at the foundation – the training for the different practitioners that could contribute to comprehensive primary care. We delineated between those projects focused at the pre-licensure level in colleges and universities and those at the post-licensure level organized by professional associations and other partners. We brought both of those projects together at the Interprofessional Collaborative Table (IP Table) – creating a meta-curricular project to support the alignment across the different partners and projects.

Because we must affect change not just for those in training but also those in practice, team-focused training was also accelerated through team training projects across Canada. These were brought together to share lessons learned at the Team Optimization Table (TO Table). Across all these activities, we ensured training would be informed by the TPC principles and that ultimately, organizational culture, leadership and process that support change towards the goal of more coordinated and comprehensive team-based primary care.

Cutting across the IP and TO tables was an embedded developmental evaluation structure and process.

Interprofessional Collaborative Table

The Interprofessional Collaborative Table was created as a forum to share and align curricula across more than 20 different primary care practitioners to advance comprehensive team-based primary care, enhancing knowledge of each other’s roles & contributions. This was an unprecedentedly inclusive initiative that enabled each practitioner project to learn about, from and with each other.

With enthusiastic training partners across all comprehensive primary care domains, and detailed agendas, strategic dialogues, and reflective ‘homework’, we set out to strategically build a foundation for alignment across a series of meetings. This started first with building relationships where promising practices tools and methodologies were shared across partners. We then identified the range of services included in comprehensive primary care based on an inclusive synthesis domains drafted by Dale McMurtry for which all the primary care providers contributed and could see themselves. This was to help promote greater breadth and alignment in training. Next, we had each partner detail their scope of practice and competency profile that mapped onto these domains. We highlighted three in particular to do a deep dive which resulted in many ‘ah-ha’ moments of the partners.

The next step was to move towards alignment of the learning objectives, core competencies and accreditation standards. We began an engagement process with accreditors to provide context for our activities at TPC and discuss how they could help contributed to this overarching alignment process. These dialogues were highlighted as critical to support spread and scale.

Team Optimization Table

The Team Optimisation table brought together over 14 team-based training projects, most of whom were successful at securing funding through an internal competition led by the Foundation for Advancing Family Medicine. One of the strategic goals of these competitively awarded projects was to advance learning about, from and with existing and new practitioners in team-based practice models. Teams were spread across the country and the activities within each of the team training projects were clustered in four different ways:

One cluster of team-training projects focused on bringing new skill sets into existing primary care teams.
Another cluster focused on improving interprofessional teams already working together.
Some teams focused on providing training for enhanced skills, including Internationally Educated Health Practitioners and those in rural practice.
Finally, another cluster of team-training projects focused on the expansion of skills to engage in specific communities or populations.

Cross Cutting Theme Table

The Cross Cutting Table brought together the projects focused on interprofessionalism and interprofessional training tools led by the Centre for Advancing Collaborative Healthcare & Education (CACHE) team, a range of EDIA tools developed by those at the Equity in Health Systems Lab (EqHS), and tools to support the psychological health and safety of teams and training programs co-developed by the Canadian Health Workforce Network (CHWN) and Mental Health Commission of Canada (MHCC). In addition, Indigenous health and primary care resources compiled on the TPC website. Finally, another cross-cutting team focused on applying an interprofessional approach to the planning for team-based primary care through a case study in Toronto.

Legacy & Next Steps

Part of the Team Primary Care legacy is the collection and curation of resources from across the practitioner and team-based training projects, and the cross-cutting support teams including webinar videos on the TPC website and CHWN YouTube channel. Some of the teams are represented in the papers in this special issue.

As we closed out the Team Primary Care initiative on March 31, 2024, we also developed a Call to Action that was presented to Ministers. Our collective ask was to urge governments to ensure that investments used for primary care teams include the required training reforms and infrastructure, guided by interprofessional tables convened to support effective team-based comprehensive primary care. In return the over 770 signatories commit to supporting governments, using our spheres of influence, bringing our collective voices, collaborative energy, and expertise to redesign and deliver the training needed to create the interprofessional primary health care workforce Canada needs.

Lastly, TPC developed an Acceleration Agenda that illustrated a framework for further action across four foci to help equip Canada’s workforce for effective team-based primary care:

Mobilizing knowledge and lessons from Team Primary Care;
Focusing on team-based primary care training and practices for all, especially populations experiencing the greatest health inequities;
Building coalitions to advance team based primary care education and practice; and,
Advocating for policies, practices and infrastructure needed for team based primary care to thrive.

References:

Starfield B, Shi L and Macinko J (2005) Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 83, 457–502.

Special Issue of Healthcare Management Forum