A framework to support the progressive implementation of integrated team-based care for the management of COPD: a collective case study.

BACKGROUND: In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models, and there is limited empirical evidence to support this process in chronic disease management. We studied the supporting and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care. METHODS: We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program. RESULTS: We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors. CONCLUSIONS: This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study's focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.

Beyond implementation: A collective case study exploring the conceptions and facilitators of sustainability in a quality improvement collaborative.

Chronic Obstructive Pulmonary Disease (COPD) is a primary cause of adult hospitalizations and imposes substantial burdens on patients and healthcare systems. Initiatives that support providers and patients in addressing needs at each stage of this illness are needed. The INSPIRED COPD Outreach Program™ was introduced in 2010 in Halifax, Nova Scotia, Canada to improve care for those with advanced COPD. The huge success of the program led to its expansion to various contexts and geographic locations through a pan-Canadian quality improvement collaborative (QIC). Our study explored early elements of program planning and practice with an aim to understand factors that influence program sustainability. We evaluated the implementation process of 19 teams across Canada; post-collaborative team reports, focus groups, interviews and self-ratings of progress were collected from all teams. Analysis of data revealed three phases important to fostering sustainability (facilitating implementation, keeping the momentum, and securing sustainability) and each phase had unique supporting themes. Not surprisingly, teams that planned for sustainability early in the implementation process were more likely to successfully achieve program sustainability. However, teams also benefited more broadly from sustainability planning; this included being better able to plan for program spread as well as skill retention and knowledge transfer. This was also seen for quality improvement skills introduced early in the program that were more likely to be maintained and used through other contexts when sustainability planning was present. This study highlights that a QIC can be effective in not only influencing program sustainability but also beyond program implementation through improving knowledge and skill acquisition.