Reorganization of Primary Care Services as a Tool for Changing Practices

Reorganization of Primary Care Services as a Tool for Changing Practices Michèle Aubin Lucie Bonin Jeannie Haggerty Yvan Leduc Diane Morin Daniel Reinharz Michèle St-Pierre André Tourigny With the assistance of: Zohra Benounissa Nathalie Houle June 2007 1565 Carling Avenue, Suite 700, Ottawa, Ontario K1Z 8R1 Tel: 613-728-2238 Fax: 613-728-3527

PRINCIPAL INVESTIGATORS Michèle Aubin Lucie Bonin Jeannie Haggerty Yvan Leduc Diane Morin Daniel Reinharz Michèle St-Pierre André Tourigny WITH THE ASSISTANCE OF: Zohra Benounissa Nathalie Houle FUNDING PROVIDED BY: Fonds de la recherche en santé du Québec Direction de l évaluation, Ministère de la Santé et des Services sociaux Agence de la santé et des services sociaux de la Capitale-Nationale Agence de la santé et des services sociaux de la Mauricie et du Centre-du-Québec Canadian Institutes of Health Research This document is available on the web site of the Canadian Health Services Research Foundation (). For more information about the, please contact us at: 1565 Carling Avenue, Suite 700 Ottawa ON K1Z 8R1 Tel.: 613-728-2238 Fax: 613-728-3527 E-mail: communications@chsrf.ca PLEASE CITE: Reinharz, D., Tourigny, A., Aubin, M., Bonin, L., Haggerty, J., Leduc, Y., Morin, D., St-Pierre, M., La réorganisation des services de première ligne comme outil de changement des pratiques, Université Laval, June 2007. Legal Deposit, Bibliothèque et Archives du Québec, 2007 ISBN-13: 978-2-922264-45-6

i KEY IMPLICATIONS FOR DECISION MAKERS In terms of the overall organization of services, the study revealed the following: family medicine groups (FMGs) encourage the networking of primary care medical resources and effective co-operation between doctors in private practice and the institutional system; this networking is made possible by a concurrent reform of the health system that enhances and strengthens the position of all doctors who support collective efforts to make primary care the cornerstone of services to the public; and FMGs give doctors in private practice, who once had little involvement in the orientation of the health system, real influence over how health services are structured in their region. The following points were noted concerning the actual practice within the FMGs under study: co-operation between doctors and nurses is enhanced by a shared commitment to a common goal of improving accessibility, continuity and quality of patient services; however, this co-operative relationship is a work in progress; in other words, it is a recent development and is regularly being tested, since the division of responsibilities is not always clearly defined, but the negotiating process to determine these responsibilities is viable as long as there is leadership; methods of co-operation vary depending on the location: they are influenced by the previous level of co-operation within and between professions, and they are enhanced by the sites and opportunities that exist for doctors and nurses to work co-operatively; inter-disciplinarity supports the development of protocols for co-operative work between doctors and nurses, but it is not essential to their implementation; multi-disciplinarity proves to be satisfactory once the division of duties has been well defined; and stakeholders believe that co-operation improves the quality of work and makes it more interesting, particularly by improving the continuity of care, and that it may have the secondary effect of having a positive impact on patient empowerment. Patients perceived impacts include the following: patients are willing to consult a nurse for the treatment of minor illnesses and for monitoring chronic illnesses; and the anticipated improvement in continuity of care is confirmed; the minimal change in accessibility is likely due to the continued shortage of medical and nursing resources. WHAT CAN BE LEARNED: FMGs are mainly a medical rather than inter-disciplinary tool, although they result in a high degree of satisfaction among professionals and patients. They lead to improvements in the continuity of services. However, there is less of an impact on accessibility, likely because of ongoing shortages in medical and nursing resources. Organizationally, FMGs enable doctors in private practice to gain a new authority that will give them real power to influence the way in which health services are structured in their region.

ii EXECUTIVE SUMMARY In 2002, the Quebec Ministry of Health and Social Services launched a reform of health services centred on a key concept: family medicine groups (FMGs). The goal of the reform was to establish structures that brought together doctors in private practice and nurses, who co-ordinate their services with the CLSCs, under the responsibility of regional agencies mandated to organize the provision of services. As is the case elsewhere in Canada and abroad, the main purpose of reorganizing primary care services is to encourage professionals to adopt new approaches in this instance co-operation within and between professions as well as within and between organizations to ensure that the objectives of improved accessibility, continuity, co-ordination and comprehensiveness of services are achieved. The purpose of this study is to examine how and to what extent FMGs are likely to encourage doctors, particularly those in private practice, to co-operate more fully with the institutional network and with other professionals, particularly nurses. The study also links findings with the changes observed in the provision of service and with the patients perceived impacts. This study focused on the following questions: Do FMGs encourage doctors, particularly those in private practice, to co-operate more with other resources in the health system? Do FMGs foster greater co-operation between nurses and doctors with regard to providing patient services? Do FMGs have an impact on the accessibility, continuity and comprehensiveness of services provided to users and on the use of services? METHODOLOGY The study consists of three sections. The first two an organizational analysis and an analysis of inter-professional co-operation are composed of several case studies, while the third section is composed of a cohort study. The case study is based on the analysis of existing documents and the content analysis of 46 individual interviews. These interviews were designed to bring out aspects of the two theoretical frameworks used. The first, which was used for the organizational analysis, was based on two conceptual frameworks: Gamson s concept of coalitions and the archetypes of Hinings and Greenwood. The first framework was used to determine the critical factors that, in the organizational dynamic of the system under study, influence the establishment and implementation of a major change in a structure such as the health system. The conceptual framework of D Amour, Goulet et al. was used for the section on inter-professional

iii co-operation. To measure the impacts perceived by patients, a survey was conducted using a random sample representative of adult clients (18 years and older) registered in each of the five FMGs in the study. A sample of 1,046 individuals was followed over an 18-month period, with T0 being the establishment of the FMG in the fall of 2004, and T1 being the spring of 2006. Two telephone interviews were conducted using a survey developed and validated by Haggerty et al. concerning various aspects of primary care services. RESULTS AND IMPLICATIONS From an organizational perspective, the approach definitely enhanced the integration of FMGs medical practices, particularly private practices, within the health network. However, integration occurred mainly in the area of primary care. It was made possible by institutionalizing the practices of FMGs to a certain degree. This outcome is remarkable given that most of the doctors associated with an FMG work alone in private practice. This concession by doctors in private practice is compensated by the advantage that they derive from it: a very strong voice in the structuring of services in the region. In return for their institutionalization, FMGs gain greater authority that will enable them to participate in the structuring of medical services. On a more internal level, the structure of FMGs still appears to be primarily medical rather than multi-disciplinary. It should be noted that co-operative efforts between doctors and nurses is growing to varying degrees, depending on the FMG. The conditions that foster this co-operation for example, the persons concerned knew each other prior to the FMG, or opportunities have been created for them to get to know each other are not always present. But co-operative processes are taking shape at the FMGs and will develop in ways that suit the specific characteristics of the individual FMG. As for impacts, service providers have the impression that there is an improvement in the provision of patient services. Patients see positive effects, particularly on continuity, but little or no impact on accessibility. Patients are very open to meeting with a nurse for such services as monitoring chronic illnesses. We can conclude that FMGs have brought about definite changes to practice, and these changes now affect all aspects of primary care. Services are better integrated and the level of satisfaction among professionals and patients is high. One of the main objectives of the FMG approach has therefore been achieved. However, there are still key issues to address. The first issue is the problem of improving accessibility. This study confirms that it is difficult for one organizational approach to improve the continuity and accessibility of

iv primary services in an environment where resources are extremely limited. The second issue concerns the future of inter-organizational co-operation. As a result of consolidation, FMGs are now calling for the ability to offer services that they have been lacking rather than turn to partners with whom they have co-operative relationships. This issue takes on even greater importance given that, in many regions, FMGs have become influential voices regarding the structuring of services. This major change will be at the heart of future debates. FMGs have become a centre for a practice that was once relatively on the margins of the decision-making process concerning the structure of health services. The fact that FMGs involve primarily an office-based practice may have some impact. In the coming years, this issue will likely benefit from further examination. 1565 Carling Avenue, Suite 700, Ottawa, Ontario K1Z 8R1 Tel: 613-728-2238 Fax: 613-728-3527