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Abstract Background Canada has been referred to as the land of ‘perpetual pilot projects’. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times – one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients’ medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. Methods We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). Discussion This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Introduction: Community based primary health care (CBPHC) organizations are critical providers of integrated care for complex patients. Exemplar cases exist, but efforts to scale up and spread successful models continue to face major challenges. While scale and spread has become a popular topic, there are still significant gaps in our understanding of what components or activities of integrated care models should and can be spread from one locale or jurisdiction to the next, and to what degree we allow for local adaptation of those activities. Theory/Methods: To address this identified gap we developed a survey for managers and providers in CBPHC organizations that allows respondents to specify which activities require local adaptation for their scale up and spread and which need to be more standardized. The survey builds on learning from the iCOACH project, a study analyzing 9 integrated models of community-based primary health care (CBPHC) in Ontario, Quebec and New Zealand. To develop the survey we carried out 1) a targeted literature review identifying existing reviews of key activities of integrated CBPHC; 2) a workshop session with CBPHC managers and providers to validate the approach and aim of the survey; 3) mapping the findings of the literature review to coded qualitative data from the iCOACH study to validate identified activities; and 4) validation and initial testing of a pilot survey. Results: The literature review yielded 32activities of integrated CBPHC, each of which were found to be present in iCOACH case studies. The workshop session was run in January 2018 with 17 participants. from 3 case study sites. Participants identified all activities as important to models of integrated care; but reported varying needs for standardization or adaptation for specific elements. Discussion from the workshop was used to refine survey wording and structure. The draft survey was tested with managers and providers in CBPHC organizations using cognitive interviewing techniques to refine the instrument. Small scale testing of the survey will be undertaken with staff in 2 CBPHC sites. Discussion: Multiple methods were used to validate the key activities of integrated care; however, the ways in which these activities are implemented in scale and spread efforts are nuanced and context dependent. Conclusions: The survey tool developed will help us to unpack these nuances and contextual influences, with the aim of clarifying core versus peripheral activities of integrated care at different stages of the scale and spread process (e.g., whether early or later stages of adoption). Lessons learned: One critical finding from the symposium was that conceptualizations of fidelity and adaptation are widely varied and needs to be clearly stated in any assessment. Ensuring clarity of these terms was central to the development of this survey. Limitations: While the survey has strong content validity due to our development methodology, additional work will be required to test reliability and other components of validity prior to wider adoption of the survey. Suggestions for future research: Following testing in Canadian settings, we plan to deploy the survey to CBPHC organizations internationally.

Abstract Background Mental illness is a substantial and rising contributor to the global burden of disease. Access to and utilization of mental health care, however, is limited by structural barriers such as specialist availability, time, out-of-pocket costs, and attitudinal barriers including stigma. Innovative solutions like virtual care are rapidly entering the health care domain. The advancement and adoption of virtual care for mental health, however, often occurs in the absence of rigorous evaluation and adequate planning for sustainability and spread. Methods A pragmatic randomized controlled trial with a nested comparative effectiveness arm, and concurrent realist process evaluation to examine acceptability, effectiveness, and cost-effectiveness of the Big White Wall (BWW) online platform for mental health self-management and peer support among individuals aged 16 and older who are accessing mental health services in Ontario, Canada. Participants will be randomized to 3 months of BWW or treatment as usual. At the end of the 3 months, participants in the intervention group will have the opportunity to opt-in to an intervention extension arm. Those who opt-in will be randomized to receive an additional 3 months of BWW or no additional intervention. The primary outcome is recovery at 3 months as measured by the Recovery Assessment Scale-revised (RAS-r). Secondary outcomes include symptoms of depression and anxiety measured with the Personal Health Questionnaire-9 item (PHQ-9) and the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7) respectively, quality of life measured with the EQ-5D-5L, and community integration assessed with the Community Integration Questionnaire. Cost-effectiveness evaluations will account for the cost of the intervention and direct health care costs. Qualitative interviews with participants and stakeholders will be conducted throughout. Discussion Understanding the impact of virtual strategies, such as BWW, on patient outcomes and experience, and health system costs is essential for informing whether and how health system decision-makers can support these strategies system-wide. This requires clear evidence of effectiveness and an understanding of how the intervention works, for whom, and under what circumstances. This study will produce such effectiveness data for BWW, while simultaneously exploring the characteristics and experiences of users for whom this and similar online interventions could be helpful. Trial registration Clinicaltrials.gov NCT02896894 . Registered on 31 August 2016 (retrospectively registered).

Canada has the lowest rate of attachment to primary care providers among OECD countries, which makes access and continuity of care problematic. To address this important issue, seven Canadian provinces have implemented centralized waiting lists (CWLs) for unattached patients in primary care. Introduced at different times, no two provinces' CWLs are exactly alike. The main goal of these CWLs is to reduce the number of unattached patients. In some provinces, CWLs also serve to monitor primary care activity or prioritize vulnerable patients. Societal pressure and broader primary care reform influenced the implementation of the CWLs in each province. Monitoring, in terms of data collected and purpose, differs between provinces. The interprovincial comparison enables identification of strengths, weaknesses, opportunities and threats during implementation and at each step of the CWLs: registration, patient assessment and attachment. Common issues with CWLs across provinces include the importance of monitoring to facilitate implementation, the need for specific measures to ensure access for vulnerable and complex patients, and the shortage of primary care providers.

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated community-based and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them.

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of the population. Across the world CBPHC is at varying stages of development and few standard models exist. In order to scale up and spread successful models of care it is important to study what works and why. The first step is to select ‘appropriate’ cases to study. In this commentary we reflect on our journey in the selection of CBPHC models for older adults, revealing the limited utility of sourcing the empirical literature; the difficulty in identifying “successful” models to study when outcomes of importance differ across stakeholders; the value of drawing on clinical and organisational networks and experts; and the association between policy context and ease of case selection. Such insights have important implications for case study methodology in health services and policy research.

The aim of this paper is to set the foundation for subsequent empirical studies of the “Implementing models of primary care for older adults with complex needs” project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on “meso level” integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of community-based primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based.