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Background: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment., Methods: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses., Results: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success., Conclusions: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.

Competing Interests: Competing interests: Ceara Cunningham and Judy Seidel are employees of Alberta Health Services (AHS). Brad Bahler is remunerated through a contract with AHS. He is the medical director for Primary Care Network Evolution in Alberta and the Alberta Medical Association Accelerated Change Transformation team. No other competing interests were declared.

Health systems across Canada are embarking on initiatives to enhance access to primary care services, with the intent of improving patient outcomes and mitigating escalating healthcare costs. However, it is important that such initiatives be carefully weighed with the evidence that the changes will indeed have the desired impact. In Alberta, part of the informative process involved an analysis to examine links between continuity with primary care and utilization of acute care services. The findings provide information regarding expectations for outcomes and potentially useful (and not so useful) measures for monitoring progress and performance., (Copyright © 2019 Longwoods Publishing.)

Introduction: Many jurisdictions in Canada are exploring the role of primary health care in mitigating the challenges of increasing and unsustainable reliance on acute care services. In the province of Alberta, several projects are underway to examine the links between use of primary health care services, patient outcomes and utilization of acute care services - work that may potentially inform policy direction. The current analysis examined the impact of continuity with primary health care services on acute care utilization among an inpatient population. Methods: Data were extracted from five administrative data sources for Alberta residents 18 years and older who were discharged to home after their first acute care inpatient encounter in 2016/17. Relational continuity was assessed in the 3 years prior to hospitalization, thus the sample was restricted to patients who were continuously registered with the Alberta Health Care Insurance Plan during that period. After exclusion of deaths in the 30 days post-discharge, 180,657 patients remained for this analyses. Continuity was calculated for patients with at least 3 physician visits using the Usual Provider Continuity (UPC) index, with the provider defined as a primary care clinic. Continuity was categorized as high (=80%), moderate (50-79%), low (<50%) and patients with <3 visits. Covariates included: age, sex, prior emergency and inpatient use, index admission type, region of residence, health status and history of medication use. Logistic regression models were used to examine associations between continuity and three outcomes; inpatient length of stay, emergency use and unplanned inpatient readmission in the 30 days post-discharge. Results: Most patients had high (50%) or moderate (33%) continuity; approximately 17% had low continuity or had <3 visits to a primary care provider in the 3 years prior to hospitalization. In the adjusted models, high continuity was significantly associated with reduced likelihood of an emergency visit in the 30 days post-discharge, compared to the low continuity group. Patients with high continuity also tended to be less likely to have inpatient stays over 30 days, although this association did not reach statistical significance. There was no apparent association between continuity and unplanned readmissions. Discussion and Conclusions: In the province of Alberta, most physicians still operate independently from the rest of the provincial health care system. These results suggest that continuity with primary care services may have a modest impact on emergency use, but further work is needed to assess primary care activities and mechanisms to improve coordination with acute care services. Lessons learned: Qualitative and survey data are needed to supplement administrative data sources to capture the full scope of activities in primary health care. Limitations: The continuity measure employed was limited to administrative sources that primarily cover physician services, thus access to other primary care providers was not captured. Suggestions for future research: A larger program of research is being planned that will include multiple modes of data collection and patient focus groups to gather evidence and identify solutions that will facilitate integration of primary health care with other sectors of the health system. [ABSTRACT FROM AUTHOR]