The following is a summary of “Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study,” published in the June 2023 issue of Primary Care by Brooks, et al.

The establishment of Family Health Teams in Ontario aimed to reshape primary care services to meet the evolving needs of an aging population, particularly those affected by frailty and multimorbidity. However, the evaluations of family health teams have produced varied outcomes, highlighting the need for a better understanding of their development and implementation.

To gain insights into the approach taken by a well-established family health team in Southwest Ontario in developing interprofessional chronic disease management programs, researchers conducted interviews with 22 health professionals affiliated or working with the team—the interviews aimed to identify successful strategies and areas requiring improvement.

Through qualitative analysis of the interview transcripts, two primary themes emerged. The first theme, “Interprofessional team building,” encompassed establishing relationships and collaboration among team members. Two subthemes were identified within this theme: (a) collegial learning, which emphasized shared knowledge and expertise, and (b) informal and electronic communication, which facilitated effective information exchange and coordination.

The emphasis on collegiality among professionals within the family health team, promoting a collaborative approach rather than hierarchical relationships, created opportunities for informal communication and shared learning. This led to improved care for patients. However, it was also observed that the team’s approach unintentionally created silos, leading to fragmented care for more complex patients with multiple chronic conditions. 

Formal communication and process structures are needed to optimize clinical resources’ deployment, engagement, and professional development and better support chronic disease management. The measures could help avoid internal care fragmentation and ensure coordinated care for patients with clustered chronic conditions.

Source: bmcprimcare.biomedcentral.com/articles/10.1186/s12875-023-02073-x