Archives du mot-clé primary care

Translating research into practice: improving communication between patients and primary healthcare providers in Aotearoa New Zealand

CONFÉRENCIÈRE

Maria Stubbe PhD

Associate Professor and research lead, Department of Primary Health Care and General Practice, University of Otago, Wellington, New-Zealand and Director, Applied Research on Communication in Health Group

La conférence sera présentée en anglais

Résumé :

This talk will provide a brief outline of the health system and primary care research landscape in Aotearoa New Zealand, before presenting selected examples of translational work undertaken by the Applied Research on Communication in Health (ARCH) Group at Otago University.  The ARCH Group takes a multi-disciplinary approach, and aims to improve professional practice, health service delivery and equitable health outcomes by supporting reflective practice, empowering patients/service-users and developing open access digital resources for use in patient and health professional education. A particular research focus is direct observation of ‘real talk’ in video-recorded health interactions (using mixed qualitative methods such as conversation analysis and ethnography), and documenting patient perspectives in narratives of health experiences. More recently, ARCH Group members have been involved in several mixed methods health services research projects relating to youth mental health, vaccine delivery, and community knowledge and attitudes towards non-pharmaceutical interventions to reduce transmission of respiratory illnesses.

Le jeudi 25 avril 2024 de 16h00 à 17h00

Salle : R13.408 (et Zoom!)

Si vous souhaitez participer, veuillez contacter :



An essay by Jean Rochon: The health of primary care after the pandemic

This essay is part of a series of reflections on primary care during the pandemic presented by Réseau-1 Québec. The original essay published in French on May 11, 2020 is available here >>

Crises reveal both strengths and weaknesses. The French philosopher and sociologist Edgar Morin summarized the consequences clearly: “A crisis generates three different scenarios, but only the third should be encouraged: the desire to return to the world as it was, an escape into anything at all, and the emergence of new learning.”

It is crucial that we seize this opportunity, as another much more insidious and devastating crisis is unfolding because of the burden of chronic conditions and social inequalities in health. These also pose a threat to the economy and to social peace.

The crisis provoked by the COVID-19 pandemic has reminded us that complex situations require solutions validated by facts and science. It has also shown us the importance of having a broader conception of primary care, or the front line, in order to contain the emerging crisis.

Evolution of the front line

Fifty years ago, when the health and social services system was created, primary care was supposed to consist of family physicians and local health service centres (CLSCs), which would be the entry point to multidisciplinary team services for the treatment of individuals’ health problems, referral to specialized services when required, and a coordinated overall response to individuals’ needs. The rapid aging of the population and the rise in chronic conditions prompted the development of other services such as home care, adapted housing, and long-term care.

Over the following decades, the development of knowledge on the determinants of health demonstrated that three-quarters of a population’s health problems are influenced by environmental conditions, the quality of living environments, and healthy lifestyles. Research has shown that resulting chronic conditions can be prevented through a population-based approach that emphasizes disease prevention and health promotion through coordinated and integrated interventions. We now know that massive and sustained interventions starting in the first years of life, and timely responses to problems as they arise, can improve the life course of individuals and the health of the population.

Primary care can no longer be managed as simply the base level of a system whose resources are primarily invested in hospitals that provide specialized and superspecialized services. It needs to be conceptualized as a system in itself, serving a population in a given territory. This system is responsible for implementing government policies and programs at the local and regional levels by coordinating comprehensive and continuous services. The range of primary care services includes prevention and health promotion interventions within the provincial public health program, general health services, social services, community pharmacies, home care services, support for informal caregivers, housing adapted to support mobility and autonomy, and long-term care. The primary care system should refer patients to specialized services while providing support and care management over the medium and long term.

A new front line

From this standpoint, the primary care system should be conceived of as a consortium of public, socio-economic, and community partners, as well as citizens engaged in the community. This system is based on stakeholders’ geographic proximity and shared dynamics rather than on administrative boundaries. The territory constitutes a locus of network interaction and interdependencies among partners. Boundaries can shift depending on the deployment of activities. The consortium’s governance must make it possible to move from a sectoral, top-down approach to one that is territorial and interactive. It is the foundation for decentralizing decision-making and implementation powers to the local and regional levels.

Coordinating the consortium implies recognizing the partners’ specific responsibilities and expertise and identifying common problems. Its aim must be to develop objectives and actions collectively, and to seek solutions to common problems through collaborative means. As such, it needs to support the pooling of ways and means, as well as new resource allocation. The coordination of services and interventions ensures a smooth and harmonious process. In the Quebec context, the CLSC appears to be the entity that is qualified to undertake this coordination.

Individually, partners remain responsible and accountable for the outcomes of their specific activities. Together, they must aim for a collective impact on the health and well-being of the territory’s population. To this end, they require:

  • A shared action plan with concerted actions;
  • A common evaluation framework that involves sharing information;
  • Complementarity in their activities;
  • Ongoing communication based on a relationship of trust among the partners and with the community;
  • A method and the means for monitoring and for data collection;
  • A competent and dedicated team.

Funding for the consortium and its partners should be multi-year, in three to five year cycles, to ensure sustainability. Financial and technical support should promote the development of workers’ competencies and foster innovation to ensure continuous adaptation and improvement in response to changing needs, opportunities, and outcomes.

Perspective 

The deployment of a primary care system as outlined above is a major undertaking, but several experiences in Quebec and elsewhere have established foundations on which we could build. It would be risky to focus only on a few isolated parts of the consortium concept, such as family medicine groups (FMGs) or seniors’ residences. As with a chain, the system will only be as strong as its weakest link.

Another concern is the competition for available resources that can be expected after the crisis, including the risk of austerity policies due to short-term pressures. Yet investing in health promotion, disease prevention, and front-line services will have a significant positive economic impact in the medium to long term. However, we have both the means and the capacity to pursue a sustainable development path to meet the needs of the population today and to protect the future for generations to come.

This will require foresight and political will.

Jean Rochon, Professor emeritus, Université Laval, former Minister of Health and Social Services of Québec (1994–1998)



COVID-19—A pivotal moment in community care

This essay is part of a series of reflections on primary care during the pandemic presented by Réseau-1 Québec. The original essay was published in The BMJ Opinion on April 7, 2020. A French translation is available here >>

As primary care physicians and community practitioners, we are first hand witnesses of the covid crisis and its impact on our communities. The pandemic wave is just hitting Canada and we have benefited from the experience of other countries to implement early measures of containment, preparation, and care management. As elsewhere, we are uncertain about the outcomes for our patients, our communities, our colleagues, our families, and ourselves. But as we navigate the changing landscape of community care in downtown Montreal, we are observing the most rapid and profound healthcare transformation of our entire careers. This crisis is changing our teams, our relationships, and ourselves. 

Teams are changing

Our spirit has switched from “me, myself and my patients”, to “we’re all in this together.” Within a week, primary care practice has changed from exclusive face-to-face meetings to about 95% phone consultations. Accessibility—an intractable problem of Canadian primary care reforms over the past 20 years—has markedly increased within a few days. The “bureaucratically frozen public health system” we thought we inhabited has unfrozen and massive improvement has been achieved without adding a single professional. Hierarchies have been shaken and we have mobilized the intelligence and creativity of our full team in transforming the way we work together. A team which includes receptionists, cleaning staff, equipment suppliers, and managers as well as hands on health professionals.

We have rapidly adopted “new” technologies (ie. phone, emails, and internet) for prescriptions, document exchange and video-conferences. We are questioning the value of every diagnostic test, referral, and treatment, asking ourselves if our interventions do more harm than good (ex. balancing the risk of in-hospital investigation for chest pain in people at high-risk of covid complications, given local epidemic data of the day). We are also increasing capacity by postponing a number of screening tests and chronic care follow-up, all of which needs to be carefully balanced in order to minimize indirect pandemic impacts on other major health conditions. And we are sharing uncertainty collectively rather than individually. As one of our colleagues said: “We don’t always know where we are going, but we are going together.”

Relationships and collaborations are changing

We are realizing that patients, citizens and community members can be trusted as caregivers. Mothers and fathers have become our eyes and ears when assessing a child’s illness over the phone. The majority of our patients with COVID (and other conditions) are caring for themselves, by themselves, at home, with help from neighbours, family and friends. We have been impressed by how resilient many of our patients are. They are embracing change, offering constructive suggestions, mobilizing their knowledge and inner resources to adapt to the crisis, showing appreciation of the and reassurance of being remaining connected with a trusted team of health professionals who know them. Experienced patient partners working closely with our primary care team coach and support other patients to help them find practical solutions to their new life. 

Collaborators on paper have become real partners, as community organizations and health professionals seek joint solutions to common practical challenges. We see narrow professional roles and silos suddenly giving way and new ways of working adopted. Volunteers from all ages (kids, teenagers, adults and seniors) are reducing the health impacts of social isolation by maintaining contact with people confined at home. Community organizations, peer-support workers, social care and volunteers are acknowledged as key players to address the huge needs for psychosocial, material, food and economic support. Local initiatives with the health care system and municipalities are being invented to respond to the needs of the most vulnerable individuals in our communities (eg. turning old buildings into individual rooms for home isolation of homeless people). Professional turf wars have been abandoned, as we realize our inter-dependence with colleagues working in the intensive care units, hospitals, emergency rooms, other primary care clinics, home care, long-term care, palliative care, public health, not-for-profit community organizations and informal social support networks. 

Changing ourselves

Society is no more divided into healthcare workers and others. We suddenly realize the common vulnerability. We are all at risk of illness and death. We are deeply reminded of our own interdependence and personal need for support. We are deeply shaken in our professional limits, facing a disease for which no specific treatment yet exists. We have reintegrated within the community we serve; reciprocally acting as care-givers and care-receivers. We are grateful to the teenagers delivering food to our parents, the neighbours giving us lasagna and a smile after a long day of work, the child care workers helping with our kids. 

And we are more intensely aware of our privileges. We are all in the same boat, but not all of us have access to lifeboats. “Health inequalities” and “social determinants of health” have turned from abstract concepts to real patients, friends and community members who have fallen ill, have lost their jobs, are unable to pay for rent or groceries, are living alone, or cannot implement “home isolation” because they have no home, living in crowded shelters or in the streets. 

These lived experiences mobilize the health professional in us, caring for one patient at time, but also the human beings in us, caring about each other in connection with our communities. Communities that have always been there, sometimes without our awareness, but that we see and value more clearly now. 

Witnesses and actors of a history in writing 

This is not a movie we are watching on TV but a history we are writing together. We are at a crossroad that could tear us apart or make us stronger as teams, health systems, and communities. What we are witnessing at the moment is being written, imprinted, in our experience and memory. Who knows which turn we will take next, and which of these changes will last. But these choices are likely to shape our individual and collective future.

Antoine Boivin​, Family Physician and Canada Research Chair in Patient and Public Partnership, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Île-de-Montréal.
Manuel Penafiel​, Community organizer, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Île-de-Montréal.
Ghislaine Rouly​, Patient-partner and co-lead of the Caring Community research-action project, Montreal.
Valérie Lahaie​, Public Health and Partnership Coordinator, Centre intégré universitaire de santé et de services sociaux du Centre-Ouest de l’île de Montréal.
Marie-Pierre Codsi​, MD, home care services, Notre-Dame Family Medicine Group, Montreal.
Mathieu Isabel​, Medical Director of homeless services, Faubourgs Community Health Center, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Île-de- Montréal.
Brian White-Guay​, Medical Coordinator of the Notre-Dame Family Medicine Group COVID response team, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Île-de-Montréal.

Original text published in The BMJ Opinion, April 7, 2020.



Primary care, a public priority even in a time of crisis

This essay is part of a series of reflections on primary care during the pandemic presented by Réseau-1 Québec. The original essay published in French on April 27, 2020 is available here. The essay was also reproduced in l’Actualité on May 29, 2020.

The COVID-19 crisis has reminded the general public of the relevance of public health and shown that, from the government’s perspective, the hospital remains the central institution of the health and social services system. The focus on hospitals and intensive care services at the beginning of the pandemic has unfortunately delayed preparedness in other sectors, which partly explains the profound crisis currently ravaging long-term care hospitals (CHSLDs) and, to a lesser extent for now, home care services. What does this portend for primary care services in the aftermath of the pandemic?

A strong primary care system (medical clinics, community groups, emergency departments, Info-santé, etc.) has and will continue to respond quickly to the ongoing needs of the population before, during, and after the pandemic, just as it is responding to the ongoing needs of the majority of people affected by COVID-19.

The smoke and mirrors of media reports exposed the confusion in public opinion regarding primary care or front-line services. Microbiologists and other respirologists have been called the front line, while the actual front line has not received as much attention, except for public information lines (811), ad hoc screening clinics, and emergency departments. It goes without saying that hospitals, specialists, and emergency physicians are among the most vital players in such a context. There is no question of minimizing their importance. It is equally obvious that the primary care system is not set up to receive a mass of contagious or potentially contagious people. Still, to be effective, public health, the 811 service, screening clinics, and emergency departments depend on primary care, primary medical care in particular, which plays a crucial role. The overall effectiveness of the health and social services system in general, and the fight against COVID in particular, depends on it. Thus, the imperative of adapting and enhancing the front line’s capacity to meet the challenges of the next phase of endemicity is key to a sustainable strategy against COVID-19.

Public policies relating to emergency or pandemic measures should be reviewed to better foresee what conditions will ensure that primary care remains central, so it can continue to play an indispensable role in caring for the most vulnerable clienteles, in terms of not only physical and mental health, but also social issues. A number of conditions are required for primary care to play this role fully.

In a pandemic, and then an endemic context, i.e., after a gradual return to normal life but with SARS-COV-2 still present, these include:

  • Making protective equipment and other resources needed for primary care management of the illness available in sufficient quantities, at all stages of the pandemic.
  • Continuing to act on both the chronic conditions that were present prior to COVID-19 and their psychosocial effects on patients.
  • Maintaining continuity of care for the entire population.
  • Anticipating and managing the significant reverberations that will affect, over a long period of time, those clienteles whose follow-up has been delayed or altered.
  • Ensuring that decision-making units during the crisis include expert primary care and chronic disease counsellors at all levels.
  • Providing specialist and managerial support for front-line clinicians’ decisions when necessary.
  • Developing and supporting a good-quality, sustainable teleconsultation strategy.
  • Planning the contributions of all community resources.

To support the hospital’s essential, acute care role in the context of a pandemic, it is imperative to continue developing a health and social services system in which primary care ensures access to and continuity of services for the most vulnerable people in times of crisis, whether in the community, at home, or in medical clinics. Primary care must remain a public priority; even more so in these difficult pandemic times.

Yves Couturier, Scientific Director, Réseau-1 Québec

Catherine Hudon, Associate Scientific Director, Réseau-1 Québec