Public experiences and perspectives of primary care in Canada: results from a cross-sectional survey.

BACKGROUND: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. METHODS: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. RESULTS: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. INTERPRETATION: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting.

Profiling patterns of patient experiences of access and continuity at team-based primary healthcare clinics (Canada): a latent class analysis.

BACKGROUND: Access to primary healthcare services is a core lever for reducing health inequalities. Population groups living with certain individual social characteristics are disproportionately more likely to experience barriers accessing care. This study identified profiles of access and continuity experiences of patients registered with a family physician working in team-based primary healthcare clinics and explored the associations of these profiles with individual and organizational characteristics. METHODS: A cross-sectional e-survey was conducted between September 2022 and April 2023. All registered adult patients with an email address at 104 team-based primary healthcare clinics in Quebec were invited to participate. Latent class analysis was used to identify patient profiles based on nine components of access to care and continuity experiences. Multinomial logistic regression models were fit to analyze each profile's association with ten characteristics related to individual sociodemographics, perceived heath status, chronic conditions and two related to clinic area and size. RESULTS: Based on 87,155 patients who reported on their experience, four profiles were identified. "Easy access and continuity" (42% of respondents) was characterized by ease in almost all access and continuity components. Three profiles were characterized by diverging access and/or continuity difficulties. "Challenging booking" (32%) was characterized by patients having to try several times to obtain an appointment at their clinic. "Challenging continuity" (9%) was characterized by patients having to repeat information that should have been in their file. "Access and continuity barriers" (16%) was characterized by difficulties with all access and continuity components. Female gender and poor perceived health significantly increased the risk of belonging to the three profiles associated with difficulties by 1.5. Being a recently arrived immigrant (p = 0.036), having less than a high school education (p = 0.002) and being registered at a large clinic (p < 0.001) were associated with experiencing booking difficulties. Having at least one chronic condition (p = 0.004) or poor perceived mental health (p = 0.048) were associated with experiencing continuity difficulties. CONCLUSIONS: These results highlight individual social and health characteristics associated with increased risk of experiencing healthcare access difficulties, such as immigration status and education level and/or continuity difficulties when having a chronic condition and poor perceived mental health. Facilitating appointment booking for recently arrived immigrants and patients with low education, integrating interprofessional collaboration practices for patients with chronic conditions and improving care coordination and communication for patients with mental health needs are recommended.

Co-designing a cardiac rehabilitation program with knowledge users for patients with cardiovascular disease from a remote area.

BACKGROUND: Cardiovascular disease is the leading cause of death worldwide. Cardiac rehabilitation (CR) programs are recognized as effective in reducing the burden of cardiovascular disease. However, CR programs are offered inequitably across regions and are available in less than 15% of remote areas worldwide. The main goal of this study was to design a CR program adapted to the contexts of remote areas to improve the service offered to patients. METHODS: We used an iterative user-centered design approach to understand the user context and services offered in cardiac rehabilitation in remote areas. We conducted two co-design processes with knowledge users in two remote regions. Two advisory committees were created in each of these regions, comprising managers (n = 6), healthcare professionals (n = 12) and patients (n = 2). We utilized the BACPR guidelines and the Hautes Autorités de santé operational model to support data collection in coding sessions to develop the CR program. We conducted four cycles of co-design with each of the committees to develop the cardiac rehabilitation program. Qualitative data were analyzed iteratively after each cycle. RESULTS: The co-design process resulted in developing a prototype cardiac rehabilitation program similar in both regions. It is based on a contextualized six-phase pathway of care designed for remote regions. For each phase 0 to 6 of the care pathway, knowledge users were asked to describe how to offer these phases in remote areas. Participants made structural changes to phases 0, 2, 3 and 4 in order to overcome staffing shortages in remote areas. These changes make it possible to decentralize cardiac rehabilitation expertise away from specialized centers, to ensure equity of service across the territory. Therapeutic patient education was integrated into phase 4 to meet patients' needs. Participants suggested that three follow-up offerings could come from nursing services to increase access to the cardiac rehabilitation program (primary care, home care, special chronic disease programs) in patients' home communities. CONCLUSION: The co-design process enables us to meet the needs of remote regions in program development. This final program can be the subject of future implementation research.

Factors associated with patients' experience of access to their multidisciplinary primary health care clinic: A multilevel analysis.

BACKGROUND: Understanding patients' experiences accessing primary health care (PHC) is necessary to improve service organisation. This study aims to examine individual, organisational, and contextual factors associated with patients' experience of accessing the multidisciplinary PHC clinic to which they are attached. METHODS: This cross-sectional study builds on survey data collected in multidisciplinary PHC clinics located in 14 regions in the province of Quebec (Canada). Between September 2022 and June 2023, an online questionnaire was sent to patients with an email contact and attached to a family physician. Two patient-reported experience measures were assessed: (1) difficulty obtaining an appointment with their regular family physician or nurse practitioner and (2) perceived unmet healthcare needs. A self-reported online questionnaire based on the advanced access model was also sent to PHC professionals and administrative staff to assess the use of advanced access strategies in their practice. Multilevel logistic regression models were fit. Stratified analyses were conducted according to the number of consultations received. FINDINGS: In total, 122,397 patients and 847 family physicians, 97 nurse practitioners and 347 administrative staff nested into 104 clinics answered the survey. In the overall sample, having a chronic disorder was the only individual factor associated with the patient experience of access. Organizational factors including estimation of demand and supply, use of a referral algorithm, and strategies to optimise consultations were associated with a better access experience. Patients from medium size clinics compared to small clinics had better experiences of care for both outcomes. Stratified analysis indicated similar results for patients who consulted at the clinic 1-5 times in the last 12 months as observed in the overall sample. CONCLUSIONS: This study indicates that enhancing organizational processes can improve patients' access experiences.

Redirection of low-acuity emergency department patients to nearby medical clinics using an electronic medical support system: effects on emergency department performance indicators.

BACKGROUND: Overcrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators. METHODS: We performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding. RESULTS: Of 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p < 0.001), minus 20 min [-42;1] (p = 0.066) for patients assigned to triage 5 category. The rate of patients leaving without being seen decreased by 2% [-3;-2] (p < 0.001). CONCLUSION: Implementing a redirection process for low-acuity ED patients based on a clinical support system was associated with improvements in two of four ED performance indicators.

Care-seeking experiences of unattached patients in the Canadian health care system: Qualitative study.

OBJECTIVE: To understand how lack of attachment to a regular primary care provider influences patients' outlooks on primary care, ability to address their health care needs, and confidence in the health care system. DESIGN: Qualitative descriptive study using semistructured interviews. SETTING: Canadian provinces of Nova Scotia, Ontario, and Quebec. PARTICIPANTS: Patients aged 18 years or older who were unattached or had become attached within 1 year of being interviewed and who resided in the province in which they were interviewed. METHODS: Forty-one semistructured interviews were conducted, during which participants were asked to describe how they had become unattached, their searches to find new primary care providers, their perceptions of and experiences with the centralized waiting list in their province, their experiences seeking care while unattached, and the impact of being unattached on their health and on their perceptions of the health care system. Interviews were transcribed and analyzed using a thematic approach. MAIN FINDINGS: Two main themes were identified in interviews with unattached or recently attached patients: unmet needs of unattached patients and the impact of being unattached. Patients' perceived benefits of attachment included access to care, longitudinal relationships with health care providers, health history familiarity, and follow-up monitoring and care coordination. Being unattached was associated with negative effects on mental health, poor health outcomes, decreased confidence in the health care system, and greater pre-existing health inequities. CONCLUSION: Having a regular primary care provider is essential to having access to high-quality care and other health care services. Attachment also promotes health equity and confidence in the public health care system and has broader system-level, social, and policy implications.

Comparing the implementation of advanced access strategies among primary health care providers.

The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p = .001) and nurses (p < .001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p = .015) and nurses (p < .001). Nurses created more alternatives to in-person visits than family physicians (p < .001) and coordinated health and social services more than family physicians (p = .003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p = .003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended.

Enhancing interprofessional collaboration for unattached patients in primary care.

This project explored an interprofessional collaboration initiative at Clinique Indigo which aimed to improve comprehensive care for unattached patients in Quebec's primary care system. Throughout the project, physicians and non-physician health professionals alike became more actively engaged in the care of patients lacking a regular primary care provider. The project successfully demonstrated that defining a common vision for "well care" within the clinic and integrating diverse professionals could significantly improve quality of care for unattached patients, evidenced by an increase from 13% to 43% in comprehensive care provision. However, the initiative also faced challenges, including professional turnover and gaps in primary care training, suggesting critical areas for future improvement in healthcare policy and practice. These results support expanded interprofessional approaches in primary care to address systemic care disparities in universal healthcare settings such as this one caused by the differential or absence of attachment to a primary care provider.

When Bothering is Part of Professional Practice: Interprofessional Collaboration and Institutional Influences in Primary Care.

In Western healthcare systems, increasing numbers of nurse practitioners are practicing in primary care organizations, and their integration onto interprofessional teams can be somewhat bumpy. In this article, we rely on the institutional theory of organizational communication to investigate the situated communication challenges faced by NPs as they integrate onto primary health care teams (RQ1), and how these local challenges manifested institutional features (RQ2). We analyze interview data from NPs, their physician partners, clinical nurses, and a network administrator for NPs at five family medicine clinics in Quebec, Canada. We found three main challenges to IP communication between NPs and physicians, namely a lack of time, the professional necessity of bothering, and talking to - and like - a doctor. We present the solutions that participants found to overcome or workaround these challenges. We also interpreted the institutional features that inflected - or "moored" - the situated communication practices and challenges reported by our participants to better understand how the local experience of IP communication is shaped by broader institutional forces.

Nursing practice and teleconsultations in a pandemic context: A mixed-methods study.

AIM: To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic. BACKGROUND: Teleconsultation use increased rapidly during the COVID-19 pandemic. Its implementation has been documented for physicians and specialists, but knowledge is still limited in nursing practice. DESIGN: A sequential mixed-methods study. METHODS: Phase 1: A cross-sectional e-survey with 98 nurses (64 nurse clinicians [NCs] and 34 nurse practitioners [NPs]) was conducted in 2020 in 48 teaching primary care clinics in Quebec (Canada). Phase 2: Semi-structured interviews with four NCs and six NPs were conducted in 2021 in three primary care clinics. This study adheres to STROBE and COREQ guidelines. RESULTS: During the pandemic, telephone was the principal teleconsultation modality used by NPs and NCs compared to other teleconsultation modalities (text messages, email and video). The only variable associated with a higher likelihood of using teleconsultations was type of professional (NCs). Video consultation was almost absent from the modalities used. The majority of participants reported several facilitators to using teleconsultations in their work (e.g. web platforms and work-family balance) and for patients (e.g. rapid access). Some barriers to utilisation were identified (e.g. lack of physical resources) for successful integration of teleconsultations at the organisational, technological and systemic levels. Participants also reported positive (e.g. assessment of cognitive deficiency) and negative (e.g. rural population) impacts of using teleconsultations during a pandemic that made the use of teleconsultations complex. CONCLUSION: This study highlights the potential for nurses to use teleconsultations in primary care practice and suggests concrete solutions to encourage their implementation after the pandemic. RELEVANCE TO CLINICAL PRACTICE: Findings emphasize the need for updated nursing education, easy-to-use technology and the strengthening of policies for the sustainable use of teleconsultations in primary health care. IMPLICATIONS FOR THE PROFESSION: This study could promote the sustainable use of teleconsultations in nursing practice. REPORTING METHOD: The study adhered to relevant EQUATOR guidelines; the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as the study focused on the use of teleconsultation among health professionals, specifically primary care nurses.

Ten years later: A portrait of the implementation of the advanced access model in Quebec.

Since 2012, implementation of the advanced access model in primary care has been highly recommended across Canada to improve timely access. We present a portrait of the implementation of the advanced access model 10 years after its large-scale implementation across the province of Quebec. In total, 127 clinics participated in the study, with 999 family physicians and 107 nurse practitioners responding to the survey. Results show that opening schedules for appointments over a period of 2 to 4 weeks has largely been implemented. However, reserving consultation time for urgent or semi-urgent conditions was implemented by less than half and planning supply and demand for 20% or more of the upcoming year by fewer than one fifth of respondents. More strategies need to be put in place to react to imbalances when they occur. We demonstrate that strategies based on individual practice change are more often implemented than those requiring changes at the clinic.

Single points of access to fill the "GAP" for unattached patients in primary care: what makes paediatric users more likely to require a medical appointment?

Unattachment to a regular primary care professional can affect children's and adolescents' well-being, considering their unique health needs. Having no alternative, many turn to emergency departments for non-urgent conditions. To help unattached patients access healthcare services while on waitlists, Quebec's government implemented single access points in each administrative region across the province. Our study aimed to describe the paediatric population using single access points and identify associations between their characteristics and need for a medical appointment. Clinical-administrative data of 1,323 paediatric access point users in the Montérégie region from November 2022 to March 2023 were utilized to conduct bivariate and multivariable regression analyses. Our study showed that young age, assessment trajectory, and specific reasons for calling were more likely to necessitate a medical appointment. While access points improve accessibility to doctors, questions remain regarding the relevance of medical consultations, inequities, and possible security issues resulting from the overall process.

The Impact of COVID-19 on Primary Care Teamwork: a Qualitative Study in Two States.

BACKGROUND: The emergence of coronavirus disease 2019 (COVID-19) disrupted how primary care physicians (PCPs) and their staff delivered team-based care. OBJECTIVE: To explore PCPs' perspectives about the impact of stay-at-home orders and the increased use of telemedicine on interactions and working relationships with their practice staff during the first 9 months of the pandemic. DESIGN: Qualitative research. PARTICIPANTS: Participants included PCPs from family and community medicine, general internal medicine, and pediatrics. APPROACH: One-on-one, semi-structured video interviews with 42 PCPs were conducted between July and December 2020. Physicians were recruited from 30 primary care practices in Massachusetts and Ohio using a combination of purposeful, convenience, and snowball sampling. Interview questions focused on work changes and work relationships with other staff members during the pandemic as well as their experiences delivering telemedicine. All interviews were audio-recorded, transcribed verbatim, and coded using deductive and inductive approaches. KEY RESULTS: Across respondents and states, the context of the pandemic was reported to have four major impacts on primary care teamwork: (1) staff members' roles were repurposed to support telemedicine; (2) PCPs felt disconnected from staff; (3) PCPs had difficulty communicating with staff; and (4) many PCPs were demoralized during the pandemic. CONCLUSIONS: The lack of in-person contact, and less synchronous communication, negatively impacted PCP-staff teamwork and morale during the pandemic. These challenges further highlight the importance for practice leaders to recognize and attend to clinicians' relational and work-related needs as the pandemic continues.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Transitions de soins pharmaceutiques chez les personnes âgées : une évaluation de la mise en place.

Background : Pharmacist-led transitions of care between hospital and community settings have been associated with decreased hospitalizations. Little data is available on the optimal conditions for their implantation.Purpose of research : The study aims to analyze the implementation of a pharmacist-led transition of care intervention among older adults with drug-related problems. The objectives are to describe the main characteristics of the intervention and to identify the facilitators and the barriers to its implementation.Methods : A single case study design including individual interviews (n = 10 interviews) and document analysis was preferred. Damschroder’s conceptual implementation framework guided the analysis.Results : The main characteristics of the intervention are the interdisciplinary collaboration and clarity of the involved professional’s roles, the time dedicated to the intervention and the improvement of interdisciplinary communication mechanisms. The implementation facilitators include the availability of leaders and clinical champion, as well as the perception and collaboration of professionals. The Barriers include the limitations in integrating the intervention into routine care in terms of time and resources, the adoption and lack of skills in using an electronic medical record and the difficult access to some patients for follow-ups.Conclusions : The analysis of the main characteristics of the intervention, the facilitators and the barriers to its implementation demonstrate the feasibility of this pharmacist-led transition of care intervention and the issues associated with its integration into routine care in the Canadian health system.

Les soins primaires face à la COVID-19 : une comparaison Belgique, France, Québec et Suisse.

INTRODUCTION: Facing COVID-19, most of health care system first responded with the confinement of the population and an increase of intensive care resources. Primary care was then mobilized variably and more or less coordinated. PURPOSE OF RESEARCH: Comparing the involvement of primary care in four francophone regions with similar primary care to draw lessons for reforms directions in light of the COVID experience. RESULTS: Mobilization of primary care actors was important, heterogeneous and linked to local context and previous dynamics at the territorial level or the practice level except in Quebec where primary care is governed by health authorities. The creation of COVID centers was systematic as "warm practices" in Quebec or left to the initiative of local stakeholders more or less supported by health authorities. Teleconsultation, largely dominated by the use of the telephone, was implemented everywhere, generally supported by flexible and adapted pricing. The performance of diagnostic tests such as vaccination by new professionals within a legal, financial and simple training framework is a major area for improvement. Information systems to assess local needs were insufficient everywhere. CONCLUSION: The definition of primary care governance methods and, in particular, the link between professionals and public health operators in the four areas studied is a priority area for improvement at both local and national levels.

Orthopedist involvement in the management of clinical activities: a case study.

BACKGROUND: The rapid shift in hospital governance in the past few years suggests greater orthopedist involvement in management roles, would have wide-reaching benefits for the efficiency and effectiveness of healthcare delivery. This paper analyzes the dynamics of orthopedist involvement in the management of clinical activities for three orthopedic care pathways, by examining orthopedists' level of involvement, describing the implications of such involvement, and indicating the main responses of other healthcare workers to such orthopedist involvement. METHODS: We selected four contrasting cases according to their level of governance in a Canadian university hospital center. We documented the institutional dynamics of orthopedist involvement in the management of clinical activities using semi-structured interviews until data saturation was reached at the 37th interview. RESULTS: Our findings show four levels (Inactive, Reactive, Contributory and Active) of orthopedist involvement in clinical activities. With the underlying nature of orthopedic surgeries, there are: (i) some activities for which decisions cannot be programmed in advance, and (ii) others for which decisions can be programmed. The management of unforeseen events requires a higher level of orthopedist involvement than the management of events that can be programmed. CONCLUSIONS: Beyond simply identifying the underlying dynamics of orthopedists' involvement in clinical activities, this study analyzed how such involvement impacts management activities and the quality-of-care results for patients.

Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec.

BACKGROUND: In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences. METHODS: We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation. RESULTS: Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability. INTERPRETATION: Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

Expectations and needs of socially vulnerable patients for navigational support of primary health care services.

BACKGROUND: Primary healthcare is the main entry to the health care system for most of the population. In 2008, it was estimated that about 26% of the population in Quebec (Canada) did not have a regular family physician. In early 2017, about 10 years after the introduction of a centralized waiting list for patients without a family physician, Québec had 25% of its population without a family physician and nearly 33% of these or 540,000, many of whom were socially vulnerable (SV), remained registered on the list. SV patients often have more health problems. They also face access inequities or may lack the skills needed to navigate a constantly evolving and complex healthcare system. Navigation interventions show promise for improving access to primary health care for SV patients. This study aimed to describe and understand the expectations and needs of SV patients. METHODS: A descriptive qualitative study rooted in a participatory study on navigation interventions implemented in Montérégie (Quebec) addressed to SV patients. Semi-structured individual face-to-face and telephone interviews were conducted with patients recruited in three primary health care clinics, some of whom received the navigation intervention. A thematic analysis was performed using NVivo 11 software. RESULTS: Sixteen patients living in socially deprived contexts agreed to participate in this qualitative study. Three main expectations and needs of patients for navigation interventions were identified: communication expectations (support to understand providers and to be understood by them, discuss about medical visit, and bridge the communication cap between patients and PHC providers); relational expectations regarding emotional or psychosocial support; and pragmatic expectations (information on available resources, information about the clinic, and physical support to navigate the health care system). CONCLUSIONS: Our study contributes to the literature by identifying expectations and needs specified to SV patients accessing primary health care services, that relate to navigation interventions. This information can be used by decision makers for navigation interventions design and inform health care organizational policies.

Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services.

BACKGROUND: The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS: Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION: Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.