Primary Care Leaders Research Articles

Ontario primary care reform and quality improvement activities: an environmental scan.

BackgroundQuality improvement is attracting the attention of the primary health care system as a means by which to achieve higher quality patient care. Ontario, Canada has demonstrated leadership in terms of its improvement in healthcare, but the province lacks a structured framework by which it can consistently evaluate its quality improvement initiatives specific to the primary healthcare system. The intent of this research was to complete an environmental scan and capacity map of quality improvement activities being built in and by the primary healthcare sector (QI-PHC) in Ontario as a first step to developing a coordinated and sustainable framework of primary healthcare for the province.MethodsData were collected between January and July 2011 in collaboration with an advisory group of stakeholder representatives and quality improvement leaders in primary health care. Twenty participants were interviewed by telephone, followed by review of relevant websites and documents identified in the interviews. Data were systematically examined using Framework Analysis augmented by Prior’s approach to document analysis in an iterative process.ResultsThe environmental scan identified many activities (n = 43) designed to strategically build QI-PHC capacity, identify promising QI-PHC practices and outcomes, scale up quality improvement-informed primary healthcare practice changes, and make quality improvement a core organizational strategy in health care delivery, which were grouped into clusters. Cluster 1 was composed of initiatives in the form of on-going programs that deliberately incorporated long-term quality improvement capacity building through province-wide reach. Cluster 2 represented activities that were time-limited (research, pilot, or demonstration projects) with the primary aim of research production. The activities of most primary health care practitioners, managers, stakeholder organizations and researchers involved in this scan demonstrated a shared vision of QI-PHC in Ontario. However, this vision was not necessarily collaboratively developed nor were activities necessarily strategically linked.ConclusionsWithin the scope of this research, the scan affirmed that there is currently no province-wide, integrated, and measured quality improvement program for the primary healthcare sector in Ontario. This could be improved by the development of a coordinated plan, an accompanying accountability framework, and an appropriate sustainable funding envelope for QI-PHC at the provincial level.

Clinical leadership in primary care

The article explores the concept of clinical leadership in primary health care. The definition of clinical leadership is wide-ranging but clearly relates to the leadership for clinical practice. In this article the focus of clinical leadership is on the improvement of patient care – safe, efficient, effective and person-centred care. The need for good clinical leadership has never been more important. With the major shifts in the UK health and social care policy agendas, clinical leaders will be working towards policy development, implementation and evaluation. However, clinical leadership does not only relate to the policy drivers (as important as these are), but to the (perhaps) less well-defined aspects of service and role developments that in themselves will enhance patient care. The development of the skills and attributes of clinical leadership is key to the continued enhancement and development of primary health care practice. The article points you to relevant resources and asks you to reflect on your own leadership in clinical practice, so that you can consider the aspects that you may wish to further develop.

Introducing a new series on effective writing and publishing of scientific papers

Introducing a new series on effective writing and publishing of scientific papers

Horizon’s Patient-Centered Medical Home Program Shows Practices Need Much More Than Payment Changes To Transform

Skyrocketing costs and the uneven quality of patient care challenge the US health care system. Some health insurance companies are exploring patient-centered medical homes as a way to change incentives and transform the health care delivery system by increasing primary care providers' accountability for care coordination and outcomes. Horizon Healthcare Services, Inc., New Jersey's oldest and largest health insurance company, developed medical home programs that include financial incentives with essential support tools. Our experience in implementing and evaluating various approaches indicates that medical homes require intensive and targeted patient care coordination supported by committed primary care leadership, as well as new payment structures that include a monthly care coordination fee and outcome-based payments. Our experience also indicates that considerable nonmonetary support-such as an education program for population care coordinators, a medical home guide that offers effective ways to transform a practice into a medical home, and useful data sharing-are needed to improve the quality of care and reduce costs.

The patient-centered medical home: Unprecedented workforce growth potential for professional psychology.

Changes in the health care system and a renewed focus on patient-centered medical homes, which integrate behavioral health services into primary care, present professional psychologists with unprecedented workforce and growth opportunities. However, the profession must act immediately to take full advantage of these emerging opportunities. Although many conceptualize integrated primary care as including mental health services in primary care, in practice, the role of the primary care behavioral professional extends far beyond mental health concerns. The authors suggest two key domains of action: First, in order to serve optimally as behavioral health professionals and leaders in primary care, psychologists must receive training in clinical health psychology. Second, psychologists need to increase knowledge and skills in the conduct of translational research in “real-world” clinical settings. The discussion centers on delineating the imperatives the profession must address and offers general suggestions for possible approaches, which ideally will form the basis for specific models of professional preparation. What is abundantly clear is that, as the face of health care changes, professional psychology must respond swiftly and appropriately not only to remain viable, but to thrive.

Medicina de Família no Brasil e excelência acadêmica

An incredibly young and vibrant college. Who would not be impressed by the tremendous energy, enthusiasm, and dedication of general practitioner colleagues in Brazil – so many young doctors, so committed to Family Medicine. The Brazilian Society of Family and Community Medicine Conference (11th Brazilian Congress of Family and Community Medicine) was an uplifting experience and unique in its scale, youth, and vibrancy. With 4,000 delegates, it was the largest general practitioner conference I had ever attended and, with so few delegates over 40 years of age, it was the youngest one. Up to 18 parallel sessions came together effortlessly and there was no pharmaceutical involvement. I was also struck by the easy dialogue between speakers and the audience – this was a conversation of equals. I have never seen anything quite like that. Brazilians have the potential to be future leaders in primary care, but I do not think they quite appreciate their own potential.How can you build on this potential? In setting the agenda for the development of General Practice as an academic discipline, McWhinney outlined four principles: a unique field of action; a defined body of knowledge; an active area of research; and an intellectually rigorous training1,2. Of these, General Practice has identified a unique field of action; there is a consensus on the defined body of knowledge – as shown in some textbooks by authors, such as Bruce Duncan. Brazil has some excellent postgraduate General Practice training programmes. Not all general practitioners have undertaken this training and, as it evolves, it is important to integrate those who have not had formal training. The three main cornerstones of the academic discipline are already in place. However, like many academic disciplines, the difficulty is nurturing that final component: the research.Is research really necessary? Most of us are general practitioners because we are interested in people and their illnesses. Spending time in libraries and in laboratories and writing papers were not a priority. But, ask any family doctor if he/she is interested in finding out how illness affects his/her patients, how he/she might best treat them in the community, and how to provide the best healthcare, and he/she would undoubtedly agree. Research asks these very questions. If the discipline of General Practice is to flourish, research is not an option, it is a necessity. Asking how we can improve the healthcare for our patients is part of our discipline.Who should be involved in research? Others are already researching community healthcare in Brazil. A quick literature search shows that a lot of this is undertaken by hospital specialists. Therefore, it is important that general practitioners be part of this work. It is not enough to let others lead the way. It perpetuates the belief that General Practice is a second-class academic discipline and it will delay our acceptance as equals among the medical specialties. If General Practice is to be valued by peers in other branches of medicine, we must compete in the areas that they value. And, although we may not like it, the key criteria against which every academic discipline is measured, are academic endeavour, research publications, and higher degrees. For us to take our place as an academic discipline, there must be a vibrant General Practice research culture, which means that general practitioners will need to undertake university based Master’s and Doctoral level degrees and publish research. Not someone else – that means you.Will it be difficult to create a research culture? Yes, but you have huge advantages. You already have a university academic department of General Practice. Most of the other countries leading General Practice research had to fight this battle before you. You have a superb General Practice infrastructure with real time computerisation of the consultation and a huge strength in numbers. Accelerating to meet current level of international research is possible. But, academic research and publication in peer reviewed journals have their own rules and structure. Those interested in research should be encouraged to link with academic departments, and the College might fund fellowships and studentships to help doctors learn these skills. It is important to build international links through two-way international exchanges. Brazilian general practitioners could spend time at other universities and international academics could be invited to visit Brazil to work with local institutions.Is there anything to avoid? Try not to separate academic General Practice from the clinicians and from patients. Everyone must gain, but not everyone needs to be a leader or to be directly involved. Try to ensure that every general practitioner feels ownership of the research agenda and is proud to be part of it. But, most of all, make sure that the academics ask research questions that matter to patients.Do not focus on the problems, but look at your potential. Brazil could be a world leader.

Fostering the Next Generation of Primary Care Physician Leaders

In Reply: We greatly appreciate the opinion of Mr. Van Ramshorst and wholeheartedly support student interest in primary care and primary care leadership, especially given the tremendous need for additional primary care providers. Although the focus of our call to action was leadership in primary health care for the underserved, we certainly agree with the need to foster additional student interest in both primary care and medical leadership in general. In support of these goals, our blueprint included a call to increase opportunities for trainees in underserved primary care settings, develop regional and national leadership training programs, and identify new funding mechanisms for medical education in community health centers. These steps would benefit all parties involved, including medical students interested in primary care and medical leadership in any setting. While we agree that providing focused leadership training and mentorship for medical students is important, our experience suggests that many primary care physician leaders still enter their roles feeling unprepared, in some cases even after completing various prior training programs.1 This would seem in congruence with adult learning principles, suggesting that learners often may not be ready to truly incorporate lessons from leadership training until they are immersed in a leadership role. This is why we also continue to strongly advocate timely training and mentorship of those physicians entering into leadership roles in their postgraduate careers, and the development of more robust and integrated support systems in academics, government, and the private sector. Jeffrey F. Markuns, MD, EdM Assistant professor, Department of Family Medicine, Boston University School of Medicine, Boston, Massachusetts; [email protected]. Larry Culpepper, MD, MPH Chair, Department of Family Medicine, Boston University School of Medicine, and chief, Department of Family Medicine, Boston Medical Center; both in Boston, Massachusetts. William J. Halpin, Jr. Chief executive officer, South Boston Community Health Center, South Boston, Massachusetts.

Addressing the Primary Care Deficit: Building Primary Care Leaders for Tomorrow

Addressing the Primary Care Deficit: Building Primary Care Leaders for Tomorrow

Leadership and Teambuilding in primary careLeadership and Teambuilding in Primary Care Clare Mullins Graham Constable Radcliffe 2007 168 £21.95 9781846191053 184619105X

This book is a timely text indeed, as these elements of management are of paramount significance in the current primary care setting. Primary care in the UK is rapidly evolving. Ever changing targets and shifting goal posts have led to an increase of workload and resulting pressure levels not previously experienced by staff in this area. Efficient teamwork between medical, nursing and clerical staff is central to providing a good service to clients in the community, and good leadership is key to developing and maintaining strong teams.

Inspiring leaders in primary care

Liam Benison reports from the first event of the Working in Partnership Programme’s roadshow for practice nurses

Nurse leadership within primary care: the perceptions of community nurses, GPs, policy makers and members of the public

The aim of this section of a wider study was to seek the views of community nurses, general practitioners, members of the public and policy makers on nursing leadership in primary care. The wider study aimed to review the role and function of primary care services and community nursing with reference to developments in practice, education, research and policy. Key messages, challenges and opportunities for leaders within nursing have been highlighted in the literature and in turn emphasis placed on the positive effect this would have on improved quality of services [Department of Health and Social Services (1998) Valuing Diversity...A Way Forward. Department of Health and Social Service, Belfast]. In order to grasp these opportunities, nursing has to invest in the development of leaders. A two round Delphi technique was employed using a focus group approach in round one and a postal questionnaire in round two. Semi-structured interviews were carried out with senior policy makers. Findings show that there was agreement that strong leadership was needed for the development of community nursing but that at present there is confusion and disagreement over whether it exists currently. Other findings focus on problems inherent in identifying future nurse leaders. The traditional subservient culture of community nursing is blamed for the perceived inability to nurture strong leaders. Recommendations are made for the development of nurse leaders.

Primary care at a crossroads.

In response to concerns about the future of primary care, the Robert Wood Johnson Foundation sponsored a meeting in October 2001 in Glen Cove, New York, of 45 leaders in primary care and other health sectors. The purpose was to discuss the current and future challenges to primary care and to develop new and innovative ideas about how primary care might meet the needs of our current and future population. The premise of the meeting was that primary care is at a crossroads, which could lead to a new renaissance or a continued decline. Principles and ideas need to be identified to construct new primary care systems. As background for the meeting, 15 papers were written by experts in health care policy and primary care. Included in this supplement are revised versions of 4 of these papers, which present an overview of the current crisis, the implications of patients' views of primary care, the Chronic Illness Model as one possible solution, and a prediction of a tiering in the way primary care is delivered in the future. The final paper presents ideas and suggestions, based in part on the discussions at the meeting, about opportunities to move toward another renaissance of primary care.

A primary care leadership programme

A primary care leadership programme

Community-oriented primary care: new relevance in a changing world.

Since its inception in rural, pre-apartheid South Africa, community-oriented primary care (COPC) has intrigued and informed public health and primary care leaders worldwide. COPC has influenced such programs as the US community health center movement, the general practice movement in the United Kingdom, and recent reforms in the public health system of South Africa. We provide a global overview of COPC, tracing its conceptual roots, reviewing its many manifestations, and exploring its future prospects as an organizational paradigm for the democratic organization of community health services. We examine the pitfalls and paradoxes of COPC and suggest its future utility. COPC has important values and methods to offer disparate but powerful movements in public health worldwide.

Mental health problems in primary care: a research agenda.

The NAPCRG Task Force on Mental Health Problems was commissioned to explore critical research and policy issues in mental health and to develop a primary care research agenda for review and action by NAPCRG. This "White Paper" presents the key findings and recommendations of the Task Force. A comprehensive review of the primary care mental health literature, using MEDLINE searches with manual follow up, and personal communications with many active researchers in the field were performed by the authors; Task Force members participated in the editing and refinement of the White Paper in a series of email and face-to-face meetings. Although primary care researchers have made major contributions to our growing understanding of mental health problems as they exist in the "real world" of primary care, rapid changes in the U.S. health care environment threaten to undo the integration of mental and physical health that is at the heart of primary care. It will be necessary for the primary care leaders in this field to step forward to guide policy-makers, purchasers, and the public as primary care is reengineered for the next generation. Efforts to operationalize episode of care and comorbidity recording with EMR systems, particularly in cooperation with managed care corporations and/or primary care research networks, may represent the most effective strategy for promoting the integration of mental health services into primary care. The most promising area for research in the immediate future may be descriptive studies that capture and explore the clinical epidemiology of common mental health problems as they occur in routine practice.

"Bimodal" medical schools: excelling in research and primary care.

The authors studied four "bimodal" medical schools--those ranked in the top 20% by the Association of American Medical Colleges both in production of primary care physicians and in receiving research grants from the National Institutes of Health. A descriptive, anthropologic method was used to describe the cultures of these schools and to determine common factors in their success. The four schools are at the University of Washington, the University of North Carolina, the University of California, San Francisco, and the University of California, San Diego. These common factors ranged from characteristics of the schools to characteristics of their external environments. All four are part of large, state-supported universities. They are relatively new schools in areas of the country that have blossomed in biotechnology, aerospace, and computer industries. The schools' missions, admission committees, and educational programs reflect their dual role: to meet the health care needs of their states and to advance basic science knowledge in medicine. Each state has a strong Academy of Family Practice, and the medical schools have been in the forefront of residency training in this specialty. Federal- and state-funded Area Health Education Centers and private foundations have provided seed money for educational programs in community and rural settings that attract medical students to primary care. Research-intensive medical schools can encourage students to enter primary care specialties if they have strong primary care leaders and programs and if they support medical education programs outside the academic, tertiary-care center. A culture of mutual respect and commitment to community service is also essential to achieving this bimodal success.

An Evaluation of the First Public Health Service Primary Care Policy Fellowship

In June 1991, the U.S. Public Health Service sponsored a 3-week Primary Care Policy Fellowship to establish an interdisciplinary cadre of primary care leaders. The fellowship was designed to introduce senior-level practitioners, academicians, researchers, and adrninistrators to the dynamics of primary care policy development, the legislative process, and resource identification. An evaluation was conducted to determine expectations and reasons whyfellows participated in the fellowship, analyze the degree ofperceived learning, identify the sessions of most value, and describe the personal goals achieved by thefellows relating to their future leadership responsibilities in primary care. The 18 fellows most highly valued the networking across primary care disciplines, the sessions with constituency groups, and discussions about influencing decision makers. The leadership skills development activities particularly met their expectations. Theirskills were improved in identifying ways to influence policymakers, in locating resources for primary care research, and in networking with primary care leaders.

Caring for people with AIDS and HIV infection in hospital-based primary care practice

The future health care needs of individuals with HIV infection are uncertain but clearly growing. Through close teamwork and the integration of patients infected with HIV into mainstream care, the practice we describe has attempted to establish a framework for care that can be adapted and expanded to meet future needs. This capacity is becoming even more important as care for those in the early stages of HIV infection is extended, requiring regular follow-up. As the AIDS epidemic continues, it is important to monitor this and similar efforts closely. Ultimately, we may need to build programs on the strengths of existing and interested institutions without regard to whether they are AIDS-specific or decentralized. Our goal should be to insure that each, regardless of structure, be evaluated with respect to the quality of care provided. Given the growing primary care needs of people with HIV infection, national leaders in primary care must consider how to incorporate the capacity to meet these needs into their programs.

Program Funded to Prepare Nurses for Academic Leadership in Primary Care

Program Funded to Prepare Nurses for Academic Leadership in Primary Care