55 Rainbow lessons: scaling an intervention to improve access to primary health care in Alberta, Canada

Context Embedded in a Canadian provincial health system that is committed to delivering Primary Health Care (PHC) through teams of providers, the Crowfoot Village Family Practice (CVFP) is a full-service primary care clinic in Calgary, Alberta. CVFP is financed through an alternative relationship plan (ARP) that pays a salary, derived from blended capitation, to physicians.PROBLEM In 2023 CVFP had more than 4000 potential patients on its waiting list, each hoping to be attached to a clinic physician. ASSESSMENT: In an effort to reduce this waiting list and improve access to team-based PHC, CVFP medical leaders and staff at the clinic began creating a new care delivery model named Project Rainbow (Rainbow). ROOT CAUSE ANALYSIS: Rainbow’s designers began with the assumption that family physician time and availability were the major rate-limiting factors that were preventing patients from becoming attached to CVFP’s multi-disciplinary team of PHC providers. INTERVENTION: In a provincial system that generally equates physician access with PHC access, Rainbow innovated by making non-physician health care professionals the first point of contact for new patients. PATIENT INVOLVEMENT: A sub-set of patients on the waiting list were directly engaged about their willingness to participate in Rainbow, with a volunteer from that subgroup invited to serve on an advisory committee for the project. STRATEGY FOR CHANGE AND OUTCOMES: A robust data collection program shows the waiting list reduced significantly, as CVFP nurses – under the supervision of physicians – became first points of contact.This poster does not describe the specific interventions or the data collection activities that the CVFP team undertook in partnership with patients to ease the bottleneck and create a non-physician first point of contact. Both activities are ongoing and highly specific to CVFP’s finances, operations, and team structures. Instead, we draw out more broadly applicable lessons.We report on key facilitators of, and barriers to, Rainbow thriving in the clinic and scaling beyond its home ARP environment into the predominant fee-for-service financing of the provincial system. What follows is based on qualitative observation and interview data gathered by an embedded health services action researcher who worked alongside the CVPF team during the design and early implementation of Rainbow between August 2023 and February 2024. Understanding these facilitators and barriers is important to scaling Rainbow’s successes to meet the challenge of a nation-wide crisis in access to PHC.A FACILITATOR of Rainbow’s local success – one also aimed at enabling its spread beyond the CVFP – was the collection and use of data. Data were purposively collected to course-correct internally as well as to drive awareness and excitement about Rainbow in the external policy environment. Key BARRIERS to achieving local QI goals and scaling Rainbow beyond the clinic included workforce Human Resource (HR) issues, cultural/governance issues, and finance model issues.HR ISSUES It is unclear how existing efforts to improve physician recruitment and retention can be extended and leveraged to ensure not just family physicians, but the full range of PHC team members, are attracted to and sustainably integrated into programs like Rainbow. CULTURAL/GOVERNANCE ISSUES: Implementing Rainbow required the enactment of a culture of innovation and multi-disciplinary teamwork. Understanding how that culture and mental models that support novel distributions of professional authority and autonomy can be transmitted and supported with policy is central to achieving spread and scale. Amendments to scopes of practice, monopoly and competition frameworks, and learning environments that rewrite cultural norms by deconstructing hierarchical mental models to facilitate truly multi-disciplinary interaction require consideration. FINANCE MODEL ISSUES: Spreading CVFP’s ARP model is likely a necessary condition to enable scaling. Simply ‘fixing’ the finances, however, is unlikely to be sufficient. How to reform finances so that they support the resolution of workforce and cultural/governance issues remains an open question.KEY MESSAGES HR, Culture, and Finance issues are intertwined barriers to scaling a PHC access improving program in Alberta, Canada. More generally, embedded qualitative action researchers can help QI teams seeking to scale programs by co-identifying facilitators and barriers that go beyond the local.Conflicts of Interest This work was funded by the Alberta Innovates Health Solutions Fund, and the Canadian Institutes of Health Research. The authors declare no conflicts of interest.Ethics Approval Ethics approval was obtained from the University of Calgary Research Ethics Board (REB22-1385)The authors acknowledge that they have seen and agree to the license applied to conference abstracts published by BMJ.

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