Primary care practice transformation: start with roles and relationships

Many countries are undertaking reforms to primary care as a result of recognizing that fragility in the primary care sector has undermined the functioning of the health care system (1). The Patient-Centered Medical Home (PCMH) model in the USA is one example of a framework for strengthening primary care (2). In Canada, similar reform efforts have been implemented and include alternative to fee-for-service physician payment methods, enrolment of patients, incentivized care, support for transition to electronic medical records and funding for inter-professional teams (3,4). The goals of both countries have been to solidify the primary care workforce and enable the delivery of quality care. Efforts to improve primary care in both countries have focused on the aforementioned structural reforms (4–6); however, such reforms are only part of the picture of how transformation of primary care practice happens. In this issue of Family Practice, Chase et al. describe the role of practice facilitators in achieving changes to the way family practices function (7). The study adds to the body of research on change processes in a group of US primary care practices being evaluated as they transition to the PCMH model (5,8). Nutting et al. (5), in their review of initial findings from the PCMH implementation noted that practices undergo the transition in their own way and through continual engaged learning by members of the team, and that there is no one size fits all approach. Similarly Chase et al. describe that the PCMH has specific aims for improving the care of patients, however there has been no single pathway or standardized approach to achieving the goals. Recognizing the complexity and magnitude of practice redesign and building on pilot studies of the effectiveness of outside facilitators, Chase et al. describe how a non-clinician coaching facilitator assisted health care professionals in overcoming obstacles during PCMH model implementation. The paper describes in-depth findings on the relationship between one particularly successful facilitator with a social science background, and six primary care practices. The facilitator employed coaching rather than consultative strategies in which she helped individuals and groups to develop skills through close and continual personal contact. She used varied approaches depending on needs and the goals of the individual or group, including encouraging new communications styles, teaching collaboration and teamwork, modelling and reinforcing facilitative leadership among physicians and ‘prodding’ practice leaders to articulate their vision. The paper’s findings illuminate an aspect of practice change that arises from, but is not dealt with, through structural reforms: roles and relationships in the practice. In what ways are these roles and relationships changing during practice transformation? Primary care is transforming to reflect a shift from individualized practice to a model where teamwork is emphasized. The teamwork model is based on research demonstrating that collaboration amongst professionals is linked to an increase in quality of care and improved patient and physician satisfaction (4,6). The benefits to this revolutionized collaborative relationship are 2-fold, improving both the patient and provider experience (6,9). One of the key achievements of the practice facilitator was to successfully coach practice members away from a ‘top-down model’ towards one of facilitative leadership where consensus on decision making and attention to group process emerged. When striving to achieve the benefits of teamwork, hierarchal structures discourage the formation of supportive relationships (5,6). Without power differentials in place, team members are able to trust and respect each other, mitigate internal and interpersonal conflicts and work as a cohesive unit with common goals (10). Early experience in Canada with primary care inter-professional teams has also shown that placing multiple professions together but maintaining the status quo of hierarchy in roles and relationships does not facilitate optimal collaborative teamwork in patient care (6). As a result of the coaching of the facilitator, physicians adopted a leadership style grounded not in dominant control over decision making, but in full team participation. The shift empowered team members to discover new workplace roles and enabled the formation of multidisciplinary teams. The facilitator described by Chase et al. enabled a change process by unravelling hierarchical structures, encouraging broad communication and helping practice members attain self-belief in discovering new practice roles. The authors further describe the introduction of ‘adaptive reserve’, defined as resilience and thriving in the midst of change (11), which lays the foundation for future changes by allowing health care providers to develop the skills associated with a collaborative working style. Perhaps the main benefit of adaptive reserve is the creation of an environment that nurtures change and permits teams to come up with creative solutions to problems. Often the new roles taken on by team members in the Chase et al. study related to project specific initiatives that were inclusive of multiple professions in the practice. It would be interesting to explore whether intentional collaboration on projects is a catalyst to greater trust and inter-professional collaboration in direct patient care. Structural changes to primary care have been necessary to provide the resource and inputs to enable change (12). It may be of equal importance to nurture health care providers to adopt the repertoire of skills needed to create a culture that can respond to changing health care demands, as opposed to returning to the drawing board for every new improvement initiative or structural reform. More research is needed on how to effectively support the process of optimizing roles and cultivating relationships in ways that are scalable, as such processes appear to be foundational in primary care transformation. We must also better understand how to translate the learning along the road to primary care transformation, into training the future generation of health care providers. Funding: none. Ethical approval: none. Conflict of interest: none.

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