Background and Purpose

NPs across Canada have struggled not only to expand their legislated scope of practice, but to also carve out a niche in the health care system. Plagued by legislative and system barriers, NPs have lobbied continuously for policy changes that better support NP practice and improve patient care (DiCenso, Bryant-Lukosius, Bourgeault & Treloar, 2010). Fifty years of history demonstrates the leverages and barriers to NP practice in Canada (Edwards, Rowan & Grinspun, 2011).

The NPLC model in Ontario was born from these struggles. The term Nurse Practitioner-Led Clinic was coined by the MOHLTC in Ontario, specific to this model of primary health care in Ontario. The first was established in 2007, primarily to alleviate a gap in access to primary health care services. This was followed by the establishment of an additional 25 NPLCs developed across Ontario (MOHLTC, 2015). Key features of the NPLCs are that the clinics are independently incorporated and include patient registration to the clinic and not to an individual provider (Heale, 2012). The NPLC model is unique in that NPs are the primary care providers and have overall accountability for their patients. However the NPs work within an interprofessional team which includes RNs and/or RPNs, social workers, dieticians and physicians (Heale, 2012). This

organizational structure promoted the reduction of NP practice barriers by allowing the NP to work to the full scope of practice. Within the NPLCs, there was an expectation for the same comprehensive, evidence-based family health care services that other models provide (Virani, 2012).

NPLCs have other organizational characteristics. Located in underserviced areas, many of the patients that are registered at NPLCs have not had access to primary health care for long periods of time, up to years (Heale, 2012; Virani, 2012). NPLCs have EMR rather than paper charts (Association of Family Health Teams of Ontario, 2016). EMRs include features such as the ability to highlight areas to follow up with patient issues and communicate among health care providers through electronic tracking features. In addition, EMRs often include specific sections with templates for care, such as a diabetes care template (Stellefson, Dipnarine & Stopka, 2013).

Despite advancements in primary health care such as the introduction of electronic communication tools, there are many barriers to the successful implementation of a model of primary health care. Studies of other primary health care models in Ontario have confirmed that organizational structural components such as governance, human resources, office infrastructure, access, patient-provider relationship and continuity of care all have an impact on the quality of care (Dahrouge et al., 2009; Russell, Dahrouge, Tuna, Hogg, Geneau & Gebremichael, 2010). In addition, there are also implementation factors that promote successful outcomes of the model of care, such as the effectiveness of the interprofessional team (Russell et al., 2010). Successful implementation of high quality care within the primary health care organization includes the “use of evidence-based practices in providing programs and services” (Virani, 2012, p. 17). Collaboration and partnerships within and external to the organization, as well as with the patient, are also important features of successful implementation (Virani, 2012).

One measure of the success of a model of primary health care is the extent to which health care providers within an organization are able to address complex health issues. Organizational structures can impact the quality of care for patients with high clinical complexity. Many chronic diseases, such as diabetes, that are managed routinely in primary health care settings are very complex (Agarwal, Kaczorowski & Hanna, 2012; CDA, 2013; Harris et al., 2006) and health care providers often have difficulty in implementing CPGs, or best practice, especially when patients have multiple chronic diseases, or multimorbidity (CDA, 2013; Fortin, Soubhi, Hudon, Bayliss & Akker, 2007; Harris et al., 2006). Along with barriers such as time constraints, patient self-care that conflicts with guidelines and issues in the coordination of care, clinical guidelines that only consider one condition and give limited consideration of multiple concurrent conditions and the interactions between them are a barrier to the implementation of clinical guidelines (Bower et al., 2011; Fortin et al., 2007; Smith, O’Kelly & O’Dowd, 2010).

Research shows the value of NP care in specific settings, such as in hospital (Hurlock-Chorostecki, Forchuck, Orchard, Reeves & van Soeren, 2013). NPs also have proven value in primary health care. For example, a case analysis was of the effectiveness of shared medical appointments three in NP-led, multidisciplinary chronic disease management programs for diabetes, hypertension and heart failure, in US clinics was conducted. Cases were evaluated using the elements of the Chronic Care Model and results indicate that (Watts et al., 2009). The NPLCs are different in that they are a model of comprehensive primary health care, much like a community health centre, but with NPs as primary care providers and interprofessional team leaders (Heale, 2012). There has been no research into the model itself, in particular an exploration of organizational factors and the quality of care of complex clinical presentations. To that end a study was undertaken of the NPLC model.

A chart audit was conducted in five NPLCs utilizing a tool that reflected internal organizational processes along with external links. The purpose was to determine the comprehensiveness of care for patients with diabetes and multimorbidity in NPLCs through evaluation of the completeness of the care items identified in the clinical practice guideline for diabetes (CDA, 2013). This included a review of the extent to which care items from the diabetes CPGs were met and the influence of organizational factors on that care.

6.2.2.1 Framework

The Donabedian (2003) quality framework (Structure-Process-Outcome) is useful in studying quality in health care. The components of structure and process help to define the characteristics of, and interactions between, organizational features and health care system and provide a guide to the study of NPLCs. Structure is the way that health care is set up including material and human resources as well as organizational characteristics. There is often a disconnect between these components in the delivery of health care, such as between primary health care organizations and community programs directed to patient support for self-care (Zhang, Van Leuven & Neidlinger, 2012). Process refers to the activities that constitute health care such as diagnosis, treatment, patient education and patient involvement (Donabedian, 2003). Processes within primary health care clinic environments impact the quality of care of patients with complex medical histories. Patients with multimorbidities are more difficult to treat than patients with only one chronic condition (Fortin et al., 2007), so a review of processes in the care of these patients is helpful in providing insight on organizational effectiveness. The implication is that appropriate and effective structure and processes will result in higher quality of care and better patient health outcomes.

6.2.3 Methods and Procedures