Abstract
Objective To introduce the new Team-based care Evaluation and Adoption Model (TEAM) Framework.
Quality of evidence The initial TEAM Framework was derived from a series of reviews and consultations with academic and clinical experts. In a parallel process, team-based primary and community care evaluation in Canada was assessed through a structured review of academic literature, followed by a review of policy literature of existing primary care evaluation frameworks.
Main message The review of academic articles alongside an analysis of policy documents and existing evaluation frameworks in primary care resulted in the development of the 10-dimension TEAM Framework.
Conclusion Primary care transformation requires evaluation over time. The TEAM Framework provides a comprehensive framework for assessing evidence needed to support short- and long-term actionable improvements for team-based primary and community care in Canada. This framework will inform the development of an evaluation tool kit for primary care teams.
Primary care transformation in Canada has been positioned as the way to address increasing costs, improve access to primary care providers, and meet changing population needs.1 The Quadruple Aim has frequently been used as a framework for optimization of health system performance in 4 areas of focus: improving the health of populations, enhancing patient experience of care, enhancing provider experience, and reducing per capita costs of health care.2,3
In the published literature, there is widespread recognition of the potential of team-based primary and community care (TBPCC).4-8 Some studies have shown that TBPCC practices provide more appropriate care to their patients,8-10 with improved comprehensiveness, coordination, and efficiency of care,10,11 and lower burnout rates for providers.12 Previous studies of the transition to team-based practice have identified key change concepts for practice transformation: empanelment (attachment of patients to primary care providers); continuous and team-based relationships (linking patients to both providers and care teams, and support for longitudinal relationships); patient-centred interactions; engaged leadership; quality improvement strategies; enhanced access; care coordination; and evidence-based care.1,8,9,13
The Patient’s Medical Home (PMH) model is a building block of TBPCC in Canada, and has been launched, with variation, in multiple jurisdictions across North America.11,13-15 The College of Family Physicians of Canada defines the Patient’s Medical Home as the place patients feel most comfortable presenting and discussing their personal and family health and medical concerns.14 The PMH model is defined by a framework that includes foundations (appropriate infrastructure, connected care, administration of funding), functions (comprehensive team-based care with family physician leadership; community adaptiveness and social accountability; accessible care; patient- and family-centred care; and continuity of care), and ongoing development (measurement and continuous quality improvement and research, as well as training, education, and continuing professional development). Despite the widespread use of the language of PMHs and the creation of high-level implementation guides,14 there has been little focus on comprehensive evaluation in the context of TBPCC.
There are few models for evaluation that can both assess existing TBPCC and guide improvement. Those in use are often regionally specific (eg, Ontario’s family health team model, implemented in 2005).16 Transformation of health systems is complex17,18 and progress in Canada varies from province to province.19-21 Dr Julia M. Langton and colleagues emphasize the importance of congruence between “a primary care performance measurement system and accepted conceptual frameworks that articulate important features of high-quality primary care systems.”18 This article presents the Team-based care Evaluation and Adoption Model (TEAM) Framework as a coordinated approach to evaluation and an umbrella under which key principles can be standardized.
Objective
The TEAM Framework was developed to provide a comprehensive, evidence-based structure to guide planning and evaluation in primary care for regions and jurisdictions that are adopting or enhancing TBPCC. To reach the goal of creating an evidence-informed framework to guide TBPCC planning, adoption, and evaluation, a multimethod, iterative approach was undertaken (Figure 1).
TEAM Framework development process
Quality of evidence
Initial draft of the TEAM Framework. We first conducted a rapid review and synthesis of peer-reviewed academic literature related to team-based primary care and evaluation using MEDLINE (Ovid and PubMed) and then conducted an advanced search with Google Scholar (limited to title field only) using the search terms primary care and evaluation and team or team-based care. These initial reviews informed the development of a draft 8-dimension evaluation model, built against the backdrop of the World Health Organization (WHO) partnership pentagon,22 which defines key partners to engage in health systems transformation.
To encourage thinking about the evolution of indicators and outcomes over time in primary care evaluation, we developed an adoption model parallel to the evaluation model, as part of the TEAM Framework. The adoption model focuses on the context of primary care transformation and was adapted from the Clinical Adoption Meta-Model, a temporal model that was developed to describe processes and possible challenges with clinical adoption and decision making.23
First expert review. Following initial development, the TEAM Framework was reviewed by a focus group and through 1-to-1 consultations with expert stakeholders in British Columbia (BC). Stakeholders were identified through evaluation working groups at the BC Ministry of Health, the Department of Family Practice at the University of British Columbia (UBC) in Vancouver, and the UBC School of Population and Public Health, and included policy makers, TBPCC project leaders in communities, and researchers with relevant expertise.
Review of content and comprehensiveness. To further confirm the content and comprehensiveness of the TEAM Framework, we engaged in 2 additional literature reviews. The first was a structured review of peer-reviewed literature, registered using the Covidence platform and focused on the current state of evaluation of TBPCC in Canada. We reviewed the MEDLINE (Ovid and PubMed), CINAHL, Embase, SPORTDiscus, and PsycInfo databases, and did an advanced search with Google Scholar (title field only) with the search terms Canada and primary care and team. We excluded reviews, opinion papers, laboratory-based studies, and studies based outside of Canada. Forty-five publications met our inclusion criteria. These articles were then mapped to the Quadruple Aim and to the initial TEAM Framework to ascertain the aspects of TBPCC that are currently being evaluated in Canada and where they fit in the initial framework.
We then conducted a review of gray literature (provincial, national, and international policy documents), using the general search terms primary care and evaluation and framework, as well as province and primary care and evaluation and policy, to develop a list of primary care evaluation frameworks that are currently being used to support evaluation in Canada and internationally. Our search resulted in a list of 14 frameworks, which we narrowed down to 10 after excluding frameworks that did not include enough detail or referred only to specific subpopulations.3,7,9,14,24-29 These 10 frameworks were analyzed and compared to develop a list of key areas that have typically been included in primary care evaluation. The key areas were then mapped to the initial TEAM Framework to ensure the framework was comprehensive.
Second expert review. The framework then went through several revisions with the authors and other expert collaborators from the stakeholder groups identified in the WHO partnership pentagon,22 to clarify the aspects included in the evaluation model and refine the dimension definitions. Stakeholder groups included primary care providers, academics with expertise in primary care evaluation, and policy makers. A series of constructive workshops and 1-to-1 consultations were conducted with key stakeholders, designed to engage participants in confirming definitions and assessing the comprehensiveness of the framework. This phase also included additional framework mapping by the authors and research team.
Final TEAM Framework. The framework mapping process and second round of expert review led to the addition of 2 dimensions to the evaluation model that had previously been incorporated in other dimensions, resulting in a 10-dimension model. The adoption model was also expanded to incorporate the EPIS (Exploration, Preparation, Implementation, Sustainment) framework.30 The EPIS framework has been widely applied in implementation research30,31 and provides a comprehensive framework that explores the fit between evidence-based practice, innovation, and the settings in which innovations occur.31
Ethics approval. Discussion with the UBC Office of Research Ethics confirmed that research ethics board approval was not required.
Main message
The TEAM Framework incorporates a 10-dimension evaluation model (Figure 2) and an adoption model (Figure 3) to evaluate TBPCC. Together, these models comprise the TEAM Framework.
Evaluation model of the TEAM Framework
Adoption model of the TEAM framework
The 10 dimensions of the evaluation model are as follows: relationship-centred care, patient experience, provider experience, team function, quality-of-care process, capacity and access, TBPCC foundations, governance and accountability, health of the population, and health care costs. The definitions of each dimension are outlined in Table 1,3,7,9,14,24-29,32-38 while descriptions of the aspects included in each dimension can be found in the supplementary material, available from CFPlus.*
TEAM Framework evaluation model dimensions
The transformation of primary care is a process that occurs over time and requires a focus on formative evaluation (early-stage evaluation, creating opportunities for feedback, learning, and iterative improvements) as well as summative evaluation (longer-term and bigger-picture outcome-focused evaluation). Assessing the long-term benefits of systems change requires 5 to 10 years17,39; however, shorter-term evaluation is needed to support decision makers, continuous quality improvement, adaptation, and the flexibility to ensure the process is relevant to specific contexts and communities. In the context of considering change in complex systems, Drs Morgan Price and Francis Lau highlight that adoption models
have a number of common features ... a) they describe a number of dimensions related to adoption; b) they are designed for a specific audience; [and] c) they allow for variability in assessment.23
The TEAM Framework includes an adoption model to encourage thinking on the evolution of indicators over time, from measuring baseline and early intention to change, through to observable behaviour and, finally, long-term outcomes (Figure 3).
The goal of the adoption model is to support meaningful evaluation in TBPCC projects throughout their life cycle so that evaluation informs the change, identifies unintended consequences, and guides meaningful continuous quality improvement. The adoption model highlights that timing for different indicators is important and that we should not be looking for long-term outcomes in the first weeks following implementation. While 1 set of curves is shown in Figure 3, adoption is more iterative, so some elements of TBPCC may be implemented at different rates; therefore, flexibility in evaluation is important.
Considering where a team is along the stages of adoption (eg, exploring, planning, implementing, sustaining) and applying the adoption model to evaluation planning and quality improvement efforts across each of the evaluation model’s dimensions will support the comprehensive planning and implementation of evaluation at both a practice and systems level, across dimensions that are relevant and feasible to measure.
Next steps. We are currently working with communities and jurisdictions across BC on the application of the framework. Next steps are as follows: develop and validate (with expert stakeholders, in line with the WHO partnership model22) the indicators for each dimension of the framework; review and adapt existing tools to support the comprehensive measurement of each dimension that meets community needs; and pilot the recommended tools in communities. The TEAM Framework provides a model to support the development of comprehensive evaluation plans for communities engaged in primary care transformation.
Conclusion
This article shares the new TEAM Framework, which has been developed through a synthesis of international evaluation models and Canadian evaluation studies in primary care. The review process that informed the development of the TEAM Framework highlighted 10 key dimensions that need to be considered in the assessment and evaluation of shorter- and longer-term outcomes of the transformation of primary care and transition to team-based care. The evidence clearly underscores the value of relationships, visionary leadership, efforts to support enhanced collaboration, shared understanding, and clear communication in the transition to TBPCC. By encouraging a focus on formative as well as summative evaluation, the TEAM Framework provides a comprehensive approach to assessing the evidence needed to support actionable improvements for TBPCC in Canada and is currently informing the development of an evaluation tool kit for primary care teams in BC.
A key strength of the TEAM Framework is the iterative process that has resulted in its development. Over the course of its development, a number of experts, as well as communities engaged in primary care transformation efforts in BC, have had the opportunity to work with and provide feedback on the development of the framework. This review process has been limited to those working in the BC context, and the structured review of evaluation of team-based care in primary care that was conducted as part of this work was focused specifically on the Canadian context. Future work in this area could include validation of the framework in international contexts.
Notes
Editor’s key points
▸ Primary care transformation in Canada has been positioned as the way to address increasing costs, improve access to primary care providers, and address changing population needs.
▸ However, primary care transformation requires evaluation, both formative and summative, over time. To date, there has been little focus on comprehensive evaluation of transformation efforts in the context of team-based primary and community care.
▸ The new Team-based care Evaluation and Adoption Model Framework described in this article provides a comprehensive framework for assessing evidence needed to support short- and long-term actionable improvements for team-based primary and community care in Canada.
Points de repère du rédacteur
▸ La transformation des soins primaires au Canada a été positionnée comme étant la façon de s’attaquer à l’augmentation des coûts, d’améliorer l’accès aux professionnels des soins de première ligne et de répondre aux besoins changeants de la population.
▸ Par ailleurs, la transformation des soins primaires exige une évaluation au fil du temps à la fois formative et sommative. Jusqu’à présent, l’évaluation exhaustive des efforts de transformation dans le contexte des soins primaires et communautaires en équipe a suscité peu d’intérêt.
▸ Le nouveau cadre modèle d’évaluation et d’adoption des soins en équipe TEAM (Team-based care Evaluation and Adoption Model) décrit dans cet article présente une ensemble complet de paramètres pour évaluer les données factuelles nécessaires pour appuyer des améliorations réalisables à court et à long terme dans les soins primaires et communautaires en équipe au Canada.
Footnotes
* The supplementary material is available from www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
All authors contributed to the literature review and interpretation, and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © 2021 the College of Family Physicians of Canada
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