1. Working Together : Team-based Models of Primary Care Dr Lucio Naccarella, PhD The Australian Health Workforce Institute General Practice Victoria Collaboration: The Key to Better Health 22nd September, 2011

2. Remembering Our Elders “Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world” Albert Einstein Source: Criminal Minds: Behavioural Analysis Unit (18-12-1932 to 10–06-2011)

3. Team-based models of primary care workforce have emerged to address health system challenges Context Evidence –Incentives for PHC Teams –Team-based Complex Care Management Realist perspective Implications – policy, practice & research Outline

4. Primary (medical) care: –“the system of health care workers (predominantly general practice, nursing and allied health professionals) which provide locally-based first contact care in the community setting” Team work: –“A group of professionals associated with treating a particular patient, who are interdependent in their tasks, share responsibility for outcomes, and who work together to meet the changing needs of patients” My perspective on concepts

5. The World Health Report 2008 Primary Health Care – Now More Than Ever http://www.who.int/whr/2008/whr08_en.pdf

6. Team work – contextual influences Organisational context Leadership Shared culture Support structures Education & training Financial arrangements Regulatory frameworks Workforce composition

7. Incentives for Primary Health Care Team Service Provision (2010) Review Questions What incentive approaches are being used...? What impact does funding, governance and professional incentives have...? How are funding, governance and profession changes that aim to facilitate teamwork in PHC (i.e., incentives) interpreted and responded to by PHC professionals?

8. Key Findings Multiple interdependent incentive approaches exist: –payment, organizational, regulatory, profession, infrastructure, workforce and education-based incentives No agreed upon definitions exist Limited empirical evidence Practice-level payment systems have potential but … Regional level PHC organisations has potential to… Practice level support and e-health infrastructure systems Inter-professional education is a means to… Workforce reforms needed

9. Policy Options To provide Australians with access to cost- effective community-based primary care by supporting and strengthening a well- trained multidisciplinary team-based primary care workforce Need to: Prepare, support & sustain the PHC workforce to learn and work together Source Naccarella, L.,Scott, A., Furler, J., Dwan, K., Savage, G., Meredith, R., Smith, F. (Jan, 2010). Narrative literature review of incentives for PHC team service provision. Report prepared for Australian Primary Health Care Research Institute, http://www.anu.edu.au/aphcri/Spokes_Research_Program/Stream_Thirteen.php http://www.anu.edu.au/aphcri/Spokes_Research_Program/Stream_Thirteen.php

10. Theme 4: Working together - Team- based Models of Primary Medical Care: What’s working in Complex Care Management? Case Studies from Four Countries - US, Canada, UK, Australia (2010) 2011- Brisbane (IHWC) http://rcpsc.medical.org/publ icpolicy/ihwc.phphttp://rcpsc.medical.org/publ icpolicy/ihwc.php

11. Key Findings Health system reform processes and reform fatigue Multidisciplinary trained primary care workforce “Islands of innovation” - limited evaluative implementation evidence Cacophony of terms, concepts and definitions Under-emphasis on workforce planning to support team- based models of primary care for people with complex care needs. Source: Naccarella, L., LeBoutillier, S., Mulcahy, A., Nasmith, L., Creede, C., Kupka, S., Michener, L., Berkowitz, B., Oliveira, J., Cook, J., Sutton, M. (2010). Theme 4: Working together - Team-based Models of Primary Medical Care: What’s working in Complex Care Management? Case Studies from Four Countries. http://rcpsc.medical.org/publicpolicy/imwc/2010-IMWC12/IMWCTeam-basedModelspaper2Apri2010.pdf http://rcpsc.medical.org/publicpolicy/imwc/2010-IMWC12/IMWCTeam-basedModelspaper2Apri2010.pdf

12. Next steps Policy levers to prepare, support and sustain Evaluative implementation evidence Evidence for inter-professional education & practice; and Improved workforce planning to support team-based models of primary care

13. Yes but... “Evidence-based policy means integrating experience, expertise and judgement with the best available external evidence from systematic research” (Davies, 1999)

14. Realist Perspective: Team-based Models of Primary Care Context + Mechanisms = Outcomes Multi-morbidity Workforce role expansion + Relationships Communications Systems Primary Care Functions First contact care Continuity Comprehensiveness Coordination of care =

15. Context Multi-morbidity is the most common reason for presentation to primary care. Within general practice 3 in 10 people, and 1 in 4 Australians overall, have multi-morbidity Source Britt et al (2008). Prevalence and patterns of multimorbidity in Australia. MJA, 189(2): 72-77. Workforce role expansion within primary care can maintain and even improve the quality of care and the outcomes for patients. Source Laurant et al (2010) Revision of professional roles and quality improvement: a review of the evidence. The Health Foundation http://www.pharmacienconsultant.org/wp- content/uploads/2010/03/The_Health_Found ation- Revision_of_professional_roles_and_quality _improvement.pdf http://www.pharmacienconsultant.org/wp- content/uploads/2010/03/The_Health_Found ation- Revision_of_professional_roles_and_quality _improvement.pdf

16. But Four Evidence Gaps What 1.Educational policies and systems 2.Organisational and management policies and systems 3.Coordinating mechanisms; and 4.Support systems are necessary to make expanded workforce roles work within team-based primary care?

17. Coordinating Mechanisms: Primary Care as Relational Work Primary care work is knowledge intensive, interdependent, uncertain and time-constrained - importance of relationships for coordinating the work Theory of Relational Coordination Coordination that occurs through frequent, timely and problem solving communication supported by relationships of shared goals, shared knowledge and mutual respect will enable primary care practitioners to better achieve their desired outcomes Source Gittel JH., Seidner R & Wimbush J (2009). A relational model of how high-performance work systems work. Organisation Science. 1-17. http://www.relationalcoordination.org

19. Coordinating Mechanisms: Team Boundary Spanning In response to increased complexity of work tasks, systems fragmentation, teams must increasingly: “coordinate interdependent work efforts and bridge disconnected parties by actively managing relationships external to the team itself” (Marrone, 2010 p. 911). Source Marrone, JA (2010) ‘Team boundary spanning: A multilevel review of past research and proposals for the future’, Journal of Management, vol. 36, no. 4, pp. 911-939.

20. Community (People, Patients) Coordination systems Support systems Leadership systems Systems thinking for Primary Care Organisational systems Educational systems

21. Capacity building dimensions Individual level workforce roles, skills & competencies Organizational level leadership & interactions System level infrastructure

22. Implications Policy Implement policy frameworks that promote working together underpinned by evaluation Practice Implement models & strategies that promote working together underpinned by evaluation Research How to strengthen an expanded workforce to work within team-based primary care? How to optimise relational coordination in primary care? How can a team in primary care span boundaries effectively ?

23. “The intuitive mind is a sacred gift and the rational mind is the faithful servant. We have created a society that honours the servant and has forgotten the gift” Albert Einstein Source Wade Davis (2009) The Wayfinders: why ancient wisdom matters in the modern world. Chapter 4: Sacred Geography

24. Dr Lucio Naccarella, PhD, The Australian Health Workforce Institute, The University of Melbourne. Email: l.naccarella@unimelb.edu.au l.naccarella@unimelb.edu.au Web: http://www.ahwi.edu.auhttp://www.ahwi.edu.au Thank You