Introduction
Canada and Australia are two of many countries trying to improve their systems for delivering primary health care. Despite a number of dedicated efforts, many consumers are still unable to access quality health care. Access is particularly troublesome for people who are sick, people who are poor, or those who are otherwise disadvantaged. Poor primary health care access leads to overloaded emergency departments, avoidable hospitalisations, increased costs and poor health outcomes in the long run.
The Innovative Models Promoting Access-to-Care Transformation (IMPACT) initiative was a five-year research program that provided an opportunity to build upon partnerships, programs, and research to co-create models of care that enhance access for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three sites in Canada and three sites in Australia provided the foundation for these collaborative activities (see Appendix A for more information on the IMPACT program). Meaningful engagement, knowledge exchange, and collaboration among stakeholders were critical to the achievement of our objectives.
The methodological foundation for our approach was participatory action research. Each regional team worked with each network to identify regional access priorities. Next, after scoping relevant organisational innovations, they consulted with communities and conducted realist reviews to examine the feasibility of implementing relevant access-related organisational innovations within the regions. Finally, selected organisational innovations were implemented and evaluations were conducted to inform sustainability and uptake in other communities. The team used deliberative processes within the research team and with different stakeholders, including community members, to inform key decisions related to IMPACT. We viewed deliberative processes as a way to allow different stakeholders with different backgrounds, experiences and values to support informed decision-making. Our approach was built on the fundamental principle that on-going knowledge exchange with community-based stakeholders and researchers is an essential component of sustainable organisational innovation and, ultimately, community impact.
This guide was originally developed in 2014 as a general template for establishing LIPs and carrying out related research program activities in the IMPACT program of research. It was designed to help coordinate major developments in all the LIPs to fit a harmonised timeline while allowing each LIP to adapt and reflect the unique circumstances of each context. As we applied the guide, reality did not always align with the plan.
The IMPACT Reality
In this version of the guide, we provide a glimpse into the actual implementation of a multi-site, international research project designed to improve access to primary healthcare. We provide the fundamental requirements that are consistent for developing partnerships, but we also describe how our program deviated from the original protocol in order to highlight the fact that differences can arise in partnerships across different contexts (e.g., use of different terms/names for committees, structures, documentation requirements, additional or adapted processes to respond to and meet local needs).
Each healthcare intervention is unique based on the context within which it exists. People involved in partnerships are encouraged to continuously learn from what works and what doesn’t as well as from experiences of others to make timely adaptations to ensure that partnerships remain responsive to the needs of those involved. We hope that this guide will continue to evolve as it is applied to broader contexts and encourage users to contact us with suggestions and to let us know how they are using the guide in their practice.
the consequence of the interface between the five dimensions of consumer ability and five dimensions of service accessibility (Levesque, Harris & Russell, 2013)
Access is a consequence of a dynamic process. See proposed primary health care model (Levesque et al., 2013 & Obrist et al., 2007).
Contextual and demographic factors are assumed to influence the service and consumer dimensions and need to be measured/monitored in each partnership.
The 5 dimensions of accessibility of services:
1) Approachability;
2) Acceptability;
3) Availability and accommodation;
4) Affordability;
5) Appropriateness.
The 5 dimensions of ability of consumers:
1) Ability to perceive;
2) Ability to seek;
3) Ability to reach;
4) Ability to pay;
5) Ability to engage.
Access to community-based primary health care is indicated by first-contact accessibility (primary indicator of access): The ease with which a person can obtain needed community-based primary health care (including advice and support) within a time frame appropriate to the urgency of the problem (Haggerty et al., 2007).
At a population level, access to community-based primary health care is indicated by assumed outcomes of poor access (secondary indicator of access): high rates of emergency department visits, avoidable hospitalizations and emergency department presentations for Ambulatory Care Sensitive Conditions.
a novel set of behaviours or routines implemented through planned and coordinated actions (based on Greenhalgh, 2004)
Excludes innovation aimed at individual practitioner behaviour changes (e.g., clinical practice, treatment innovation) if they are not intended to address one of the dimensions of service accessibility
Excludes innovations aimed at community members (e.g., general health literacy strategies)
Requires action to be planned and coordinated
May include behaviours or routines provided off-site or externally that improves accessibility of the community-based primary health care organisation (e.g., routine access to telephone translation services).
