Working Together:

Team-based Models of Primary Care

Dr Lucio Naccarella, PhDThe Australian Health Workforce Institute

General Practice Victoria

Collaboration: The Key to Better Health

22nd September, 2011

Remembering Our Elders

“Imagination is more important than

knowledge. Knowledge is limited. Imagination encircles

the world”Albert Einstein

Source: • Criminal Minds: Behavioural Analysis

Unit(18-12-1932 to 10–06-2011)

Team-based models of primary care workforce

have emerged to address health system challenges

• Context• Evidence

– Incentives for PHC Teams– Team-based Complex Care

Management

• Realist perspective• Implications – policy, practice &

research

Outline

• Primary (medical) care:– “the system of health care workers (predominantly

general practice, nursing and allied health professionals) which provide locally-based first contact care in the community setting”

• Team work:– “A group of professionals associated with treating

a particular patient, who are interdependent in their tasks, share responsibility for outcomes, and who work together to meet the changing needs of patients”

My perspective on concepts

The World Health Report 2008 Primary Health Care – Now More Than Ever

http://www.who.int/whr/2008/whr08_en.pdf

Team work – contextual influences

• Organisational context• Leadership• Shared culture• Support structures• Education & training• Financial arrangements• Regulatory frameworks• Workforce composition

Incentives for Primary Health Care Team Service Provision (2010)

Review Questions• What incentive approaches are being

used...?• What impact does funding, governance and

professional incentives have...?• How are funding, governance and profession

changes that aim to facilitate teamwork in PHC (i.e., incentives) interpreted and responded to by PHC professionals?

Key Findings

• Multiple interdependent incentive approaches exist:– payment, organizational, regulatory, profession,

infrastructure, workforce and education-based incentives

• No agreed upon definitions exist • Limited empirical evidence• Practice-level payment systems have potential but …• Regional level PHC organisations has potential to…• Practice level support and e-health infrastructure

systems• Inter-professional education is a means to…• Workforce reforms needed

Policy Options

• To provide Australians with access to cost-effective community-based primary care by supporting and strengthening a well-trained multidisciplinary team-based primary care

workforceNeed to:

• Prepare, support & sustain the PHC workforce to learn and work together

Source

• Naccarella, L.,Scott, A., Furler, J., Dwan, K., Savage, G., Meredith, R., Smith, F. (Jan, 2010). Narrative literature review of incentives for PHC team service provision. Report prepared for Australian Primary Health Care Research Institute, http://www.anu.edu.au/aphcri/Spokes_Research_Program/Stream_Thirteen.php

Theme 4: Working together - Team-based Models of Primary Medical Care:

• What’s working in Complex Care Management? Case Studies from Four Countries - US, Canada, UK, Australia (2010)

2011- Brisbane (IHWC)• http://rcpsc.medical.org/

publicpolicy/ihwc.php

Key Findings

• Health system reform processes and reform fatigue • Multidisciplinary trained primary care workforce • “Islands of innovation” - limited evaluative implementation

evidence• Cacophony of terms, concepts and definitions • Under-emphasis on workforce planning to support team-

based models of primary care for people with complex care needs.

Source:• Naccarella, L., LeBoutillier, S., Mulcahy, A., Nasmith, L., Creede, C., Kupka, S., Michener, L., Berkowitz, B., Oliveira,

J., Cook, J., Sutton, M. (2010). Theme 4: Working together - Team-based Models of Primary Medical Care: What’s working in Complex Care Management? Case Studies from Four Countries. http://rcpsc.medical.org/publicpolicy/imwc/2010-IMWC12/IMWCTeam-basedModelspaper2Apri2010.pdf

Next steps

• Policy levers to prepare, support and sustain

• Evaluative implementation evidence

• Evidence for inter-professional education & practice; and

• Improved workforce planning to support team-based models of primary care

Yes but...

“Evidence-based policy means integrating

experience, expertise and

judgement with the best available

external evidence from systematic

research” (Davies, 1999)

Realist Perspective:Team-based Models of Primary Care

Context + Mechanisms = Outcomes

•Multi-morbidity

• Workforce role expansion

+

• Relationships

• Communications

• Systems

Primary Care Functions

• First contact care

• Continuity

• Comprehensiveness

• Coordination of care

=

Context

Multi-morbidity is the most common reason for

presentation to primary care.

• Within general practice 3 in 10 people, and 1 in 4 Australians overall, have multi-morbidity

Source• Britt et al (2008). Prevalence and

patterns of multimorbidity in Australia. MJA, 189(2): 72-77.

Workforce role expansion within primary care can

maintain and even improve the quality of

care and the outcomes for patients.

Source

• Laurant et al (2010) Revision of professional roles and quality improvement: a review of the evidence. The Health Foundation http://www.pharmacienconsultant.org/wp-content/uploads/2010/03/The_Health_Foundation-Revision_of_professional_roles_and_quality_improvement.pdf

But Four Evidence Gaps

What

1.Educational policies and systems

2.Organisational and management policies and systems

3.Coordinating mechanisms; and

4.Support systems

are necessary to make expanded workforce roles work within team-based primary care?

Coordinating Mechanisms:Primary Care as Relational Work

• Primary care work is knowledge intensive, interdependent, uncertain and time-constrained - importance of relationships for coordinating the work

Theory of Relational Coordination • Coordination that occurs through frequent, timely and

problem solving communication supported by relationships of shared goals, shared knowledge and mutual respect will enable primary care practitioners to better achieve their desired outcomes

Source

• Gittel JH., Seidner R & Wimbush J (2009). A relational model of how high-performance work systems work. Organisation Science. 1-17.

• http://www.relationalcoordination.org

Coordinating Mechanisms:Team Boundary Spanning

• In response to increased complexity of work tasks, systems fragmentation, teams must increasingly:

“coordinate interdependent work efforts and bridge disconnected parties by actively managing relationships

external to the team itself” (Marrone, 2010 p. 911).

Source

• Marrone, JA (2010) ‘Team boundary spanning: A multilevel review of past research and proposals for the future’, Journal of Management, vol. 36, no. 4, pp. 911-939.

Leadership

systems

Systems thinking for Primary Care

Organisational systems

Educational systems

Capacity building dimensions

Implications

“The intuitive mind is a sacred gift and the rational mind is the faithful servant. We have created a society that honours the

servant and has forgotten the gift”

Albert Einstein

Source

• Wade Davis (2009) The Wayfinders: why ancient wisdom matters in the modern world. Chapter 4: Sacred Geography

• Dr Lucio Naccarella, PhD, The Australian Health Workforce Institute, The University of Melbourne.

Email: l.naccarella@unimelb.edu.au

Web: http://www.ahwi.edu.au

Thank You