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Objective: To identify the processes that influence the evolution of family health teams (FHTs)., Design: Qualitative study using grounded theory methodology., Setting: Family health teams in Ontario., Participants: A total of 110 team members from 20 FHT sites in Ontario., Methods: Individual semistructured interviews were conducted and data were analyzed using initial coding, focused coding, and a constant comparison analysis., Main Findings: The analysis illuminated the complex and diverse nature of the FHTs' evolutionary trajectories, which were influenced by 7 discrete but interrelated processes: sharing a common philosophy about teamwork; having effective leadership; respecting each other's scopes of practice; sharing the physical environment; including team activities; supporting conflict resolution; and managing change. The status of each site's evolution was categorized as evolving, progressing, or stalled., Conclusion: The concept of evolution by its very definition does not imply stasis, and as the data revealed, change is always on the horizon. This study revealed 7 processes that influenced team evolution, and these processes were observed to be either optimally applied or noticeably limited in their execution, irrespective of team composition or configuration. These processes can be extrapolated to other primary health care teams to facilitate team evolution., (Copyright© the College of Family Physicians of Canada.)

Objective: To explore the process of the development of the patient-physician relationship in adult patients with severe or profound intellectual and developmental disabilities (IDD), from the perspective of the patients' caregivers., Design: Constructivist grounded theory., Setting: St John's, NL., Participants: Thirteen primary caregivers (5 males, 8 females) of 1 or more adults with severe or profound IDD., Methods: Data were collected via in-depth, semistructured interviews conducted in person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data., Main Findings: From the perspective of the caregivers, the core process in the development of the patient-physician relationship was protection. This process began as a result of the caregiver's recognition of the patient's vulnerability and moved through a number of stages before resulting in the development of a dynamic triangular interaction between the patient, caregiver, and family physician. First, the caregiver provides extreme nurturing to the patient, which results in the development of a strong bond between them. The patient and caregiver approached the family physician together as one unit, and then decided together on whether or not to open the patient-caregiver bond to the physician. The resultant dynamic triangular interaction formed the starting point from which 1 of 4 different relationship-development trajectories began. Which trajectory was taken and, therefore, the character of the relationships that developed was determined by how the caregiver and patient experienced their interaction with the family physician., Conclusion: Findings highlight the process of protection and the centrality of the patient-caregiver bond within the development of a triadic relationship involving the patient with IDD, the caregiver, and the family physician. How a physician approaches this bond can influence the trajectory of the resulting relationship., (Copyright© the College of Family Physicians of Canada.)

Objective: To gain a more comprehensive understanding of patients' perceptions of access to their primary care practice and how these relate to patient characteristics., Design: Cross-sectional study., Setting: Ontario., Participants: Adult primary care patients in Ontario (N = 1698) completing the Quality and Costs of Primary Care (QUALICOPC) Patient Experiences Survey., Main Outcome Measures: Responses to 11 access-related survey items, analyzed both individually and as a Composite Access Score (CAS)., Results: The mean (SD) CAS was 1.78 (0.16) (the highest possible CAS was 2 and the lowest was 1). Most patients (68%) waited more than 1 day for their appointment. By far most (96%) stated that it was easy to obtain their appointment and that they obtained that appointment as soon as they wanted to (87%). There were no statistically significant relationships between CAS and sex, language fluency, income, education, frequency of emergency department use, or chronic disease status. A higher CAS was associated with being older and being born in Canada, better self-reported health, and increased frequency of visits to a doctor., Conclusion: Despite criticisms of access to primary care, this study found that Ontario patients belonging to primary care practices have favourable impressions of their access. There were few statistically significant relationships between patient characteristics and access, and these relationships appeared to be weak., (Copyright© the College of Family Physicians of Canada.)

Objective: To examine family physicians' practices in and opinions on asking patients about their religious and spiritual beliefs, as well as physicians' comfort levels in asking., Design: Cross-sectional study using self-administered questionnaires., Setting: Kitchener-Waterloo, Ont., Participants: A total of 155 family physicians with office practices., Main Outcome Measures: Frequency of asking patients about their religious and spiritual beliefs and physicians' comfort levels in asking. Separate multiple linear regression analyses were conducted for each of these outcomes., Results: A total of 139 questionnaires were returned for a response rate of 89.7 %. Of the respondents, 51.8 % stated that they asked patients about their religious and spiritual beliefs sometimes. Physician opinion that it was important to ask patients about religious and spiritual beliefs (P = .001) and physician comfort level with asking (P < .001) were significantly associated with physicians' frequency of asking patients about their religious and spiritual beliefs. Comfort level with asking patients about their religious and spiritual beliefs was significantly associated with the opinions that it was important to ask (P = .004) and that it was their business to ask (P = .003), as well as with lack of training as the reason for not asking (P = .007)., Conclusion: This study found that family physicians were more likely to ask patients about their religious and spiritual beliefs if they had higher comfort levels in asking or if they believed that asking was important. Further, this study found that family physicians' comfort level with asking was higher if they believed that it was important to ask and that it was their business to ask about religious and spiritual beliefs. Physician comfort levels with asking patients about religious and spiritual beliefs can be addressed through adequate training and education., (Copyright© the College of Family Physicians of Canada.)

Objective: Enhancing maternal and child health are key Millennium Development Goals (MDGs). This study examined whether increased utilization of recommended maternal health care (MHC), is associated with factors that improve children's health; specifically, complete immunization and appropriate care for fever and diarrhoea in Ghana., Design: Data from the 1998, 2003, and 2008 Ghana Demographic and Health Surveys were pooled for a nationally representative sample of 6786 women aged 15-49 years who had a child in the previous 5 years. Children aged 12-23 months were considered fully immunized if they received all eight basic immunizations. Appropriate care for children under-five was receipt of medical treatment for fever or oral rehydration therapy for diarrhoea. The effect of recommended MHC utilization (characterized as poor, intermediate or best use) on immunization and appropriate care for fever and diarrhoea was determined through logistic regression with Andersen's Behavioural Model guiding co-variate selection., Results: Increased MHC utilization (reference: intermediate MHC use) increased the odds of immunization [poor use: odds ratio (OR) = 0.54, 95% confidence interval (CI): 0.42-0.69; best use: OR = 1.29, 95% CI: 1.01-1.67], as well as appropriate care for fever (poor use: OR = 0.55, 95% CI: 0.35-0.88; best use: OR = 1.72, 95% CI: 1.17-2.52) and diarrhoea (poor use: OR = 0.63, 95% CI: 0.43-0.93). Survey year and region also predicted each outcome. Other determinants of immunization were maternal education, ethnicity, religion, media exposure, wealth and birth weight. Determinants of appropriate care for fever included paternal education, media exposure and wealth, and for diarrhoea, child's age and birth weight., Conclusion: This study proposes a linkage between MDGs; initiatives to improve maternal health through promoting increased use of recommended MHC may enhance children's health-related care. This could be useful for countries with limited resources in achieving MDGs, especially in sub-Saharan Africa where under-five mortality is the highest., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

This article describes the triangulation of qualitative dimensions, reflecting high functioning teams, with the results of standardized teamwork measures. The study used a mixed methods design using qualitative and quantitative approaches to assess teamwork in 19 Family Health Teams in Ontario, Canada. This article describes dimensions from the qualitative phase using grounded theory to explore the issues and challenges to teamwork. Two quantitative measures were used in the study, the Team Climate Inventory (TCI) and the Providing Effective Resources and Knowledge (PERK) scale. For the triangulation analysis, the mean scores of these measures were compared with the qualitatively derived ratings for the dimensions. The final sample for the qualitative component was 107 participants. The qualitative analysis identified 9 dimensions related to high team functioning such as common philosophy, scope of practice, conflict resolution, change management, leadership, and team evolution. From these dimensions, teams were categorized numerically as high, moderate, or low functioning. Three hundred seventeen team members completed the survey measures. Mean site scores for the TCI and PERK were 3.87 and 3.88, respectively (of 5). The TCI was associated will all dimensions except for team location, space allocation, and executive director leadership. The PERK was associated with all dimensions except team location. Data triangulation provided qualitative and quantitative evidence of what constitutes teamwork. Leadership was pivotal in forging a common philosophy and encouraging team collaboration. Teams used conflict resolution strategies and adapted to the changes they encountered. These dimensions advanced the team's evolution toward a high functioning team., ((c) 2015 APA, all rights reserved).)

A recent report of the Health Council of Canada implies that patient-centred care is related to higher costs. This paper draws the opposite conclusion. A study of 311 family practice patients revealed that the costs for diagnostic tests decreased over four quartiles of patient-centred scores; the more patient-centred the visit, the less the cost for diagnostic testing in the two-month follow-up period. Projecting to the Canadian population, if all family physicians were patient-centred at the level of the highest quartile, one-third of these diagnostic costs would be saved. The paper makes four recommendations and concludes that patient-centred care has a role to play in delivering not only effective but also efficient healthcare services.

Objective: To evaluate a new program, Integrating Physician Services in the Home (IPSITH), to integrate family practice and home care for acutely ill patients., Design: Causal model, mixed-method, multi-measures design including comparison of IPSITH and non-IPSITH patients. Data were collected through chart reviews and through surveys of IPSITH and non-IPSITH patients, caregivers, family physicians, and community nurses., Setting: London, Ont, and surrounding communities, where home care is coordinated through the Community Care Access Centre., Participants: A total of 82 patients receiving the new IPSITH program of care (including 29 family physicians and 1 nurse practitioner), 82 non-randomized matched patients receiving usual care (and their physicians), community nurses, and caregivers., Main Outcome Measures: Emergency department (ED) visits and satisfaction with care. Analysis included a process evaluation of the IPSITH program and an outcomes evaluation comparing IPSITH and non-IPSITH patients., Results: Patients and family physicians were very satisfied with the addition of a nurse practitioner to the IPSITH team. Controlling for symptom severity, a significantly smaller proportion of IPSITH patients had ED visits (3.7% versus 20.7%; P = .002), and IPSITH patients and their caregivers, family physicians, and community nurses had significantly higher levels of satisfaction (P < .05). There was no difference in caregiver burden between groups., Conclusion: Family physicians can be integrated into acute home care when appropriately supported by a team including a nurse practitioner. This integrated team was associated with better patient and system outcomes. The gains for the health system are reduced strain on hospital EDs and more satisfied patients.

Objective: To understand the flow of family physicians from region to region across Canada. To discover how many leave a region after residency, how many stay, and how many flow into a region from other regions., Design: Cross-sectional study using descriptive statistics., Setting: Various regions across Canada., Participants: A weighted sample (N = 14,332) of all family physicians who completed the College of Family Physicians of Canada's 2001 National Family Physician Workforce Survey. This survey asked where physicians had done their family medicine residency., Main Outcome Measures: The proportion of family physicians whose current region of practice was the same as their place of residency ("staying"), the proportion of family physicians who trained in one region and who now practise in a different region ("outflow"), the proportion of family physicians who practise in a region but were trained in another region ("inflow"), and the number of family physicians flowing in and out of regions., Results: Half of Canadian family physicians were practising in regions different from the regions where they did their residency programs. This percentage varied by region, however, with only Ontario's percentage resembling the Canadian figure. In the Atlantic and Prairie regions, few stayed (13.8% and 24.7%, respectively), but many flowed in. In Quebec, a high proportion stayed after residency training (81.6%). In British Columbia, only 23.7% stayed, but many flowed in., Conclusion: This study provides information about the relationship between where family physicians did their residency programs and where they subsequently practised. Our results add important information to the health human resource literature.