基于团队的初级保健的背景杠杆：来自三个国家五个司法管辖区改革干预措施的经验教训。
Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries.
作者信息
Russell Grant M, Miller William L, Gunn Jane M, Levesque Jean-Frederic, Harris Mark F, Hogg William E, Scott Cathie M, Advocat Jenny R, Halma Lisa, Chase Sabrina M, Crabtree Benjamin F
机构信息
Southern Academic Primary Care Research Unit, School of Primary and Allied Health Care, Monash University, Clayton, Australia.
Department of Family Medicine, Lehigh Valley Health Network, Allentown, USA.
出版信息
Fam Pract. 2018 May 23;35(3):276-284. doi: 10.1093/fampra/cmx095.
BACKGROUND
Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.
OBJECTIVE
To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.
METHODS
An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.
RESULTS
Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.
CONCLUSION
The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.
背景
由于医疗保健成本上升以及管理长期健康状况的需求，大多数西方国家都在寻求初级保健（PC）改革。一项常见的改革——将跨专业团队引入传统的初级保健环境——尽管有资金投入和积极性，但实施起来却很困难。
目的
综合三个国家五个司法管辖区的研究结果，以确定影响初级保健实践中团队合作成功实施的常见背景因素。
方法
一个国际研究团队通过电话会议和定期面对面会议，采用协作反思审议方法，重新分析和综合他们已发表和未发表的数据以及他们自己的工作经验。通过反思和促进讨论对研究进行评估，以确定与团队合作成功实施相关的因素。使用矩阵来总结研究中的解释。
结果
七个常见因素影响一个司法管辖区实施初级保健团队的能力。当资金来源超出按服务收费、护理提供不需要医生直接参与且治理包括非医生学科时，基于团队的初级保健得到促进。其他外部驱动因素包括：卫生专业组织对以团队为导向的初级保健的态度、实践所需的外部问责程度以及它们与社区和医疗邻里的联系程度。涉及外展促进、领导力培训和团队活动资金支持的项目有一定效果。
结论
医生主导和与医生挂钩的按服务收费支付结构的结合，为实施以团队为导向的初级保健提供了巨大障碍。政策制定者在实施以团队为导向的初级保健时，应仔细考虑这些因素以及我们确定的其他驱动因素的影响。
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