A Review and Synthesis of TBPCC Evaluation in Canada: Looking Beyond the Quadruple Aim

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Fletcher, Paule Bellwood, Tiffany T. Hill, Susan Martin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-18173/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The objectives of this article are: 1. To synthesize peer-reviewed evidence on the outcomes of team-based primary and community care (TBPCC) in Canada on Patient and Provider Experience, Population Health, and Health Care Costs (Quadruple Aim); 2. To introduce the TBPCC Evaluation Framework; and 3. To extend the critical interpretive synthesis to include the additional four domains from the TBPCC Evaluation Framework (i.e., Relationship Centred Care, Care Process and Quality, Team Function and TBC Foundations). Methods We conducted a review of the following databases: Medline (OVID and PubMed), CINAHL, Embase, SportDiscus, and PsycINFO as well as an advanced search with Google Scholar (Title only) with the words “Canada AND primary AND team”. Review concepts included: population (patients), intervention (team-based primary health care), comparator (usual care, single practitioner delivery mode), outcome (patient and provider experience, population health, and health care costs), time (2000-present), and type (randomized controlled trials, controlled trials, quasi-experimental designs, and implementation studies/evaluations). We excluded reviews, opinion papers, laboratory-based studies, and studies based outside of Canada. Results Forty-five publications met our inclusion criteria with the majority of these (34) from Central Canada. Results were initially mapped to the domains of the Quadruple Aim, with 51% (23/45) aligning. The additional domains from the TBPCC Evaluation Framework (Team Function, Relationship Centred Care, Care Process and Quality and Team-Based Care Foundations) and the Team-Based Care (TBC) Adoption Model were integrated into the synthesis. 100% of the included articles reported outcomes that aligned with the TBPCC Evaluation Framework. Conclusion Across Canada, the value of relationships, shared understanding, communication, and coordination across teams are highlighted as is the potential of TBC to result in improvements in patient and provider experience, team function, and the quality of care. By encouraging a focus on formative as well as summative evaluation, the TBPCC Evaluation Framework provides a comprehensive approach to assessing the evidence needed to support actionable improvements for TBPCC in Canada. Trial Registration To identify peer-reviewed literature, we followed standard review methodology and reporting guidelines as established by PRISMA. We registered our review on PROSPERO (2018 CRD42018091086). General Practice Team-Based Primary and Community Care Team-Based Care Evaluation Team-Based Care Outcomes Quadruple Aim Team-Based Care Adoption Model Evaluation Framework Formative and Summative Evaluation Figures Figure 1 Figure 2 Background In Canada there is a push and a need for primary care transformation to address increasing costs, shortage of primary care providers (PCPs), and changing population needs (1). Calls for transformation are motivated by a desire to achieve the Quadruple Aim as an approach to optimizing health system performance in four areas of focus: improving the health of populations, enhancing patient and provider experience of care, and reducing per capita costs of healthcare (2,3). There is recognition of the value of team-based primary and community care (TBPCC) (4–8). Evidence suggests that TBPCC practices are able to provide more appropriate care to their patients (8–10) with improved comprehensiveness, coordination, and efficiency of care (10,11), and lower burnout rates for providers (12). Research focused on an assessment of progress in the transition to team-based practice emphasizes key change concepts for practice transformation: empanelment (attachment of patients to primary care providers), continuous and team-based healing relationships, patient-centred interactions, engaged leadership, quality improvement strategy, enhanced access, care coordination, and evidence-based care (13). The Patient Medical Home (PMH) model is dominant across North America and is a building block of TBPCC in Canada. The College of Family Physicians of Canada defines the PMH as a medical office or clinic where each patient has: her or his own family doctor; other health professionals working as a team with the patient’s doctor; timely appointments for all visits; arrangement and coordination of all other medical services; an electronic medical record; and ongoing evaluation and quality improvement programs (6). Ontario’s Family Health Team (FHT) model, implemented in 2005, may be Canada’s, if not North America’s, largest example of a jurisdictional model for a PMH. The model is based on multidisciplinary teams and an innovative incentive-based funding system. Nearly 2 million Ontarians are served by 170 FHTs (14). However, health systems transformation is complex (15) and its progress in Canada is varied province by province (16–18). There are several review articles focused on attributes of TBC in the US and internationally (1,4,8,19–22); however, there is a gap in synthesizing evaluations of TBPCC in Canada. While the Quadruple Aim provides a framework for the assessment of many of the more longitudinal outcomes of TBPCC, the transformation of primary care is a process that occurs over time and requires a focus on formative as well as summative evaluation. The TBPCC Evaluation Framework Langton et al., (2016) emphasizes the importance of congruence between “a primary care performance measurement system and accepted conceptual frameworks that articulate important features of high-quality primary care systems” (p. 37). In anticipation of the need for a coordinated approach to evaluation, we developed the TBPCC Evaluation Framework (Fig. 1 ). It is derived from the literature on TBC and was developed through an iterative process including the synthesis of literature and a review process with stakeholders: policymakers, TBC project leaders in communities, and researchers with relevant expertise. The literature was synthesised into a draft framework with a number of dimensions. The TBPCC Evaluation Framework is situated in the healthcare system, as illustrated by the World Health Organization’s partnership pentagon, which includes key stakeholder groups (23).The framework includes eight dimensions: Relationship Centred Care, Patient Experience, Provider Experience, Team Function, Care Process and Quality, Team Based Care Foundations, Population Health, and Health Care Costs. These incorporate the Quadruple Aim. Under each dimension, specific aspects have been defined, which were assigned specific measures. Validated and published evaluation tools were collected from the literature for consideration and were mapped to the framework. Table 1 Eight TBPCC Evaluation Framework Dimensions Relationship Centred Care The focus, in TBC, on supporting caring relationships between the patient, family and their providers Patient Experience Patient and family’s subjective experience of care Provider Experience Experience of individual providers in doing their work Team Function How team members interact to contribute to comprehensive, coordinated care Care Process and Quality Measuring appropriateness, efficiency, and effectiveness of care services provided to patients TBC Foundations Features of the community, policy, funding, etc. that enable an effective TBC practice Population Health Assessment of health systems utilization and health outcomes for the population served Health Care Costs Measurement of the costs of care both within the TBC practice and overall for the population served Relationship Centered Care (RCC) assesses the quality and continuity of a therapeutic relationship between the patient and the patient’s providers. RCC includes patient perceptions of provider-patient connection, cultural sensitivity/safety, and relationship continuity. Patient Experience is the patient and family’s subjective experience of the care they receive. Systematic reviews have shown strong correlation between patient experience of care and clinical safety/ effectiveness (24). This dimension is a component of the Quadruple Aim and includes patient experience of care, team, and clinic-facilities. It includes patient perception of access to care and patient empowerment. Provider Experience is the subjective experiences of individual providers in the team about their work. This includes the delivery of care to patients, their interactions with their work environment, the impact of policy on TBC and role-definition, and work/life balance. It is also one component of the Quadruple Aim. Team Function is focused on the structure and operation of a team, the interactions of team members, and the additional supports that contribute to comprehensive, coordinated care. Aspects of team function include team leadership, team composition, team capacity, team communication/coordination, team trust/relationships, and the use of enabling tools (education, IT). Care Process and Quality assesses services actively provided to patients in contrast to overall care outcomes for the population served (see health of the population dimension). Care Process and Quality includes access, health promotion, preventive care, chronic disease management, and urgent episodic illness. TBC Foundations are features of the community, TBPCC policies, jurisdictional systems, and the supporting organization(s) that enable an effective TBC practice. In particular, this includes the development of a shared vision of TBC and facilitates the alignment of policy planning to support the implementation of TBC. Aspects of TBC foundations include office space and resources, education and training, policy, scopes of practice, funding models and incentives, community supports, and regional supports. Health of the Population is the assessment of broader health systems utilization measures and health outcomes for the population that is being supported by the team. In contrast to Care Process and Quality dimension, this includes whether individuals access care or not. The Population Health dimension includes aspects such as attachment, health promotion and preventive care, CDM, episodic illness management, and health system utilization. Healthcare Costs includes the tracking and analysis of total costs associated with individual patients within a TBPCC practice. This includes consideration of the broader, systems level costs that are influenced by the transition to TBPCC. This dimension includes facility/operational costs, direct service costs, total healthcare spending per person, hospital and ED utilization rates and costs, and medication costs. Assessing the long-term benefits of systems change requires 5–10 years (25,26); however, shorter-term evaluation is needed to support decision makers, continuous quality improvement, adaptation, and flexibility to ensure process is relevant to specific contexts and communities. To complement the dimensions, the TBPCC framework includes an adoption model (Fig. 2 ), adapted from the Clinical Adoption Meta Model (27). This encourages thinking on the evolution of indicators over time from measuring baseline and early intention to change through to observable behaviour changes to long-term outcomes. Purpose The purpose of this paper is threefold: 1. To synthesize peer-reviewed evidence on the outcomes of team-based primary and community care (TBPCC) in Canada on Patient and Provider Experience, Population Health, and Health Care Costs (Quadruple Aim) (3); 2. To introduce the TBPCC Evaluation Framework to address gaps identified in the synthesis; and 3. To extend the critical interpretive synthesis to include the additional four domains from the TBPCC Evaluation Framework (i.e., Relationship Centred Care, Care Process and Quality, Team Function and TBC Foundations). Methods Search Strategy and Selection Criteria To identify peer-reviewed literature, we followed standard review methodology and reporting guidelines as established by PRISMA (28). We registered our review on PROSPERO (2018 CRD42018091086), and our synthesis concepts were: population (patients), intervention (team-based primary health care), comparator (usual care, single practitioner delivery mode), outcome (patient and provider experience, population health, and health care costs), time (2000 to present), and type (randomized controlled trials, controlled trials, quasi-experimental designs, and implementation studies/evaluations). We searched the following databases using Medical Subject Headings (MeSH) and keywords: Cochrane Database of Systematic Reviews, Medline (OVID and PubMed), CINAHL, Embase, SportDiscus, and PsycINFO. We also conducted an advanced search with Google Scholar (Title only) with the words “Canada AND primary AND team”. We conducted the last search on April 7, 2019. One author screened for year of publication, type of study, and duplicates. 1,137 studies were imported for screening into Covidence, a review production system (Covidence.org, Melbourne Aus.). After duplicate removal, 994 studies were screened. We included studies based in Canada, and a priori chose to only include studies published in 2000 and later (29). We excluded reviews, opinion papers, laboratory-based studies, and studies based outside of Canada. Two authors screened citations at the title and abstract level (Level 1). 747 studies were identified as irrelevant, and 242 studies were included for full-text screening. Two authors then reviewed 242 citations at the full-text level (Level 2); and a third author reviewed conflicts. 71 studies were then included for data extraction. We further conducted a backward (reference lists) and forward citation search for articles included at Level 2. The last search was conducted on April 25, 2019. Data Extraction Once the final list was generated, one author extracted data based on a pre-developed data extraction sheet and another author reviewed it. We extracted the following information: authors; province; location (urban/small urban/rural); year; study design; funding model; organizational structure; team composition, traits, and communication; patient population; health care costs; identified enablers, facilitators, and challenges; and funding sources for research. We categorized included studies by region. We reviewed each study to extract data related to the Quadruple Aim outcomes, summarized findings and assessed studies for risk of bias. The extraction spreadsheet was reviewed and confirmed by a second author. Critical Interpretive Synthesis Recognizing the limitations of the aggregative focus of the data typically generated by a systematic review process (30) and the complexity of primary care transformation (26,31), this review was approached as a critical interpretive synthesis (30,32). Initially, findings were synthesized to assess outcomes in the context of the Quadruple Aim. As our synthesis progressed and it became apparent there were very few Canadian studies focused on the evaluation of TBC that aligned with these four outcomes. After data from the 71 studies were extracted, we further excluded studies that focused on evaluating addition of only single medical role into clinical practices, evaluating administrative changes in how practices are managed (e.g. new access scheduling methodology), or assessing a specific evaluation method, resulting in additional 26 exclusions. The additional dimensions of the TBPCC Evaluation Framework were then drawn into the synthesis along with the perspective provided by the Adoption Model, enabling a review of formative as well as summative outcomes. Results There were 45 peer-reviewed publications that met our final inclusion criteria. Regional representation for studies included: none from the West Coast (British Columbia); seven Prairie Provinces (Alberta, Saskatchewan, Manitoba); 34 Central Canada (Ontario, Quebec); one Atlantic Canada (New Brunswick, Nova Scotia, PEI, Newfoundland); none from the Territories (Yukon, Northwest Territories, Nunavut); and three pan-Canadian. Mapping of Studies to Quadruple Aim and the TBPCC Evaluation Framework There were 23 of the 45 included studies (51%) that assessed at least one element of the Quadruple Aim. Patient experience was the most commonly assessed, followed by provider experience. The majority of studies were from Central Canada, with 32 studies from Ontario. 100% of the included studies reported on outcomes reflected in the TBPCC Evaluation Framework. The top dimensions in the synthesis were Team Function (24 studies), and Care Process and Quality (21 studies) (see Table 2 ), neither of which are explicitly reflected in the Quadruple Aim. West Coast There were no included studies identified from this region. Prairie Provinces Four of the seven studies from the Prairie Provinces (Alberta = 6, Manitoba = 1) mapped to the Quadruple Aim. Two studies reported on patient experience (33,34), one on population health (35), and one on provider experience (36). Three of seven studies reported on team collaboration and function as important components of transitioning to TBC (36–38). Emerging themes from the studies were patient needs regarding respect, support, and advocacy, and improved knowledge, independence, care received, ability to make decisions, and overall health. Other related themes included: provider and patient experience with overall delivery and quality of care (33–35,39), provider remuneration, and support for information technology, leadership, and education (38). There was discordance for the two studies that focused on perceptions of access to care. One study emphasized that while the respect, support, and community advocacy provided to patients as a result of a TBC model was appreciated, accessibility continued to be a barrier for patients (33). Another study reported a perceived benefit improvement in access to care (34). One study noted increased job satisfaction for providers (36). Central Canada 18 of the 34 studies from Central Canada (Quebec = 2, Ontario = 32) mapped to the Quadruple Aim. Ten studies reported on patient experience (40–49), two on costs (50,51), three on population health (52–54), and three on provider experience (55–57). Emerging themes from these studies included: need for improved access to care; increased satisfaction with care; increased patient-centeredness; increased costs but improved quality of care; decreased cost of prevention over time with more appropriate provider; positive influence on care quality for health promotion and substance use outcomes; improved provider satisfaction; and need for improved care coordination. 19 studies reported on aspects related to team function. This included determining team members’ scope of practice, boundaries, and role responsibilities (56,58–60). Other related themes included: changes in screening and prevention care (61); provider and patient experience with quality of care (50); funding related impacts on team function (52,62); support for information technology, leadership, and education (52,63–65); and physical space or co-location (59,66). One study explored patient and provider satisfaction and relationship building (40). Atlantic Canada There was one study from Atlantic Canada (Nova Scotia = 1), which did not map to the Quadruple Aim but reported on team function and ongoing interprofessional education to address issues of respect for health professions (67). Territories and Nunavut There were no included studies from this region. Pan-Canadian Studies There were three Pan-Canadian studies, with one study mapping to patient experience (24). All studies reported on access to care and included process and outcome indicators that were perceived positively in TBC setting such as: patient centeredness, comprehensiveness, and continuity of care (67,68,69). Table 2 Number of publications by region reporting elements of the Quadruple Aim categories Patient Experience Costs Population Health Provider Experience West Coast 0 0 0 0 Prairies 2 0 1 1 Central Canada 10 2 3 3 Atlantic Canada 0 0 0 0 Territories & Nunavut 0 0 0 0 Pan-Canadian 1 0 0 0 Total 14 2 4 4 Table 3 Number of publications by region reporting elements of the TBPCC Evaluation Framework dimensions Care Process and Quality Team Function Patient Experience Provider Experience RCC Population Health Health Care Costs TBC Foundations West Coast 0 0 0 0 0 0 0 0 Prairies 4 4 2 3 1 2 1 2 Central Canada 14 19 11 3 1 3 2 11 Atlantic Canada 0 1 0 0 0 0 0 0 Territories and Nunavut 0 0 0 0 0 0 0 0 Pan-Canadian 3 0 1 0 0 0 0 0 Total 21 24 14 6 2 5 3 13 Discussion Our integrative synthesis found many Canadian examples of TBPCC evaluation. Ontario has the largest population and the longest TBPCC adoption timeframe in Canada and has the majority of included studies. Other smaller provinces and those who are later in the transition to TBPCC had fewer evaluation studies; this was expected. The lack of studies that met our criteria from the West Coast was also expected. Although community health centres have been operating in BC for several decades, and there have been a number of shorter-lived initiatives focused on TBPCC, our search strategy found very little focused on the outcomes of these efforts. BC is now in the early stages of a new push to TBPCC backed by a number of provincially funded initiatives to support the development and implementation of an integrated system of Primary Care Networks and PMHs (16). This is in line with similar efforts in other provinces. As such, we anticipate that the literature focused on aspects of formative evaluation of TBPCC in Canada will grow dramatically in the near future. The gap in literature from Nunavut and the territories was more surprising. A targeted search resulted in a number of articles that describe team-based practices in the North, the use of telehealth and paraprofessionals to support team-based practice, and the challenges facing teams where positions are filled with temporary rotating staff and turnover is high (70,71). This suggests a more targeted exploration of the evaluation of TBPCC in Northern and in rural and remote communities as an area for future research. All articles included in the integrative synthesis are aligned with at least one dimension of the TBPCC Evaluation Framework. System transformation in primary care is complex and is a process that occurs over time. Because many provinces are early in this transition, the longitudinal assessment required to assess most elements of the Quadruple Aim are not yet possible or published, which is likely part of the reason why only 51% of studies mapped to the Quadruple Aim. The TBPCC Evaluation Framework intentionally has a broader scope supporting formative and summative evaluation. Next, we provide further contextualization of the eight dimensions of the framework and why these are important to measure. Canadian TBPCC Evaluation – Across the TBPCC Framework Dimensions Relationship Centred Care (RCC): In our review, studies demonstrated associations between RCC and improved patient outcomes with emphasis on the importance of communication and collaboration (37,40). There is evidence that skills and behaviours related to collaboration are most likely to show significant effects on patient outcomes (37). Evaluation of RCC is important as relationships can be disrupted in poorly functioning teams. Patient Experience: From our review, there is considerable evidence that TBPCC can enhance patient experience of care through strategies related to accessibility, respectful supportive relationships, enhanced opportunities for knowledge sharing, self-management, and community advocacy (24,33,34,40). The availability of enhanced case management or specialized support roles also positively influences patient experience (44,45,72). These benefits are particularly salient for more vulnerable populations (47,65), who feel they are given the chance to ‘tell their story and be heard’ in team-based settings (48). Provider Experience: The review suggests that providers can find working in a team very useful, particularly for complex patients (36,57). Providers perceive there is improved access, continuity of care, and patient-centered-ness in TBC (5,44). Communication and shared understanding of roles contributes to enhanced provider experience (35,36,44,57) as does the availability of providers with specific expertise (e.g. mental health/counselling or CDM) (39,55). Team Function: Team Function was the most evaluated dimension in the included articles (24/45; 53%). The review underscored the value of proactively supporting effective communication and trusting relationships among team members (36–38,73). Common barriers to collaboration and team function include the time it takes to build relationships, the lack of opportunities for co-location, and challenges with role definition (59,64,66). Despite some studies that suggest only moderate success in the context of interdisciplinary collaboration (63,74), there is ample evidence of the importance of working to develop shared values in primary care teams and the value of efforts to improve group dynamics to support higher levels of interdisciplinary collaboration (5,44,74–76). Working to build understanding of roles and shared leadership is also widely attributed to enhancing collaboration (58,60,61,65). There is also evidence of the value of interprofessional education (67,77). Intentional, team-focused activities, including formal meetings, professional development programs, social activities, and retreats, are essential to sustaining and building relationships needed for highly functioning teams (75,78). Care Process and Quality: A number of studies included in our review suggest that TBC leads to improvements in patients’ perceptions of quality of care, accessibility of care, knowledge of medical conditions, and their ability to self-manage (24,34,40,44,50,53,72,79). Providers’ perceptions of capacity can be enhanced through shared care models and opportunities for interprofessional collaboration (39,48,52,61). However, other studies suggest the accessibility of care is still an issue, even in highly-functioning team-based practices (33,43,46). A pan-Canadian study found that the likelihood of reporting access issues or unmet needs was not significantly different in TBC vs. non-TBC settings (68). However, there is evidence that quality of care, particularly for CDM, is better in team-based practices and particularly in community health centres or practices with blended capitation models (62,69,80). TBC Foundations: The most salient issues for teams that emerged from our synthesis are physician remuneration, co-location, interoperable electronic health records, visionary leadership, and educational support (38,39,52,56,62). Larger numbers of physicians on teams and the distribution of teams across sites has been negatively associated with team performance (42,56,59); there is evidence that smaller, co-located teams are more likely to collaborate effectively (66).The physical layout of a space, the presence of coordinator or team management roles, and the use of alternative funding models have been highlighted as foundational to success (56,62,80). Health of the Population: TBPCC can improve outcomes in population health (e.g. fewer Emergency Room visits for low acuity) (81,82). Some studies highlight early indicators of improvement in population health through TBPCC (35). For example, one study found that increased accessibility to dietitians resulted in increased likelihood of PCPs discussing nutrition for weight management (52). Another study discovered improved CDM and preventive care in TBPCC (53). An addiction shared care program also showed early success (54). Health Care Costs: Physician remuneration is an important issue for interprofessional teams across Canada and is a frequent stumbling block (38). Due to the longitudinal nature of cost savings related to longer-term, expected outcomes, there is a paucity of evidence in this dimension. A study focused on the cost effectiveness of a team-based prevention program for complex patients found that it was both more expensive and more effective than other programs (50). There is also evidence that the integration of new team members becomes more cost effective over time (51). Limitations The systematic search strategy limited our initial searches to academic literature only, missing publications in the grey literature. There were no results for Western Canada or Nunavut and the Territories, and only limited results in Atlantic Canada. However, we are aware that at the practice level TBC innovations in primary care are being implemented in these regions. A more extensive search that includes a focus on grey literature and government publications could address some of the regional gaps highlighted in this synthesis. Conclusions There were 23 studies (51%) that mapped to the outcomes of the Quadruple Aim. The broader TBPCC Evaluation Framework was able to map all 45 included articles as it was developed specifically for TBPCC. It considers early and late evaluation needs, and includes dimensions on Relationship Centred Care, Team Function, Care Process and Quality, and TBC Foundations. By encouraging a focus on formative as well as summative evaluation, the TBPCC Evaluation Framework provides a comprehensive approach to assessing the evidence needed to support actionable improvements for TBPCC in Canada. This review highlights a range of positive outcomes associated with the various dimensions of TBPCC. Across the board the evidence underscores the value of relationships, visionary leadership, efforts to support enhanced collaboration and shared understanding and clear communication in the transition to team-based practice. List of Abbreviations BC British Columbia CDM Chronic Disease Management FHT Family Health Team RCC Relationship Centred Care TBC Team-Based Care TBPCC Team-Based Primary and Community Care PCN Primary Care Network PCP Primary Care Provider PMH Patient Medical Home WHO World Health Organization Declarations Ethics Approval and Consent to Participate : Not Applicable Consent for Publication : Not Applicable Availability of data and materials : The dataset generated and analysed during the current study are available from the corresponding author on reasonable request Competing interests : The Authors declare that they have no competing interests Funding : This research was funded by a grant from the Strategic Innovation Fund from the Department of Family Practice at UBC. The funder has no role in the design of the study or in the collection, analysis or interpretation of the data. Authors’ contributions: SF Completed level 1 reviews and level 2 reviews (with MA); reviewed data extraction and conducted 2 nd round of analysis (after PB); developed outline (with MP and MA) and drafted full paper. PB : Completed level 1 reviews, conducted initial data extraction (into spreadsheet) and completed first round of analysis; developed tables and drafted results section, reviewed and edited all drafts. TH : Reviewed data extraction tables and full text articles to confirm analysis, formatted, reviewed and edited all drafts. SM : Assisted in level 1 review, located copies of all the included papers, and initiated the data extraction. MA : Registered review and set search parameters, completed level 1 and 2 reviews of the included articles, developed outline with SF and MP, reviewed and edited all drafts. MP : Completed level 1 reviews and resolved conflicts for levels 1, 2, and 3; developed outline with SF and MA, drafted evaluation framework sections of paper and reviewed/edited all drafts. All authors reviewed and approved the final manuscript. Acknowledgements : Not Applicable Authors Information: Sarah Fletcher, PhD is a Medical Anthropologist and the research manager for the Innovation Support Unit, Department of Family Practice (UBC). Paule Bellwood, PhD(c) is a research analyst with the Innovation Support Unit, Department of Family Practice (UBC). Tiffany T. Hill, MA is a research analyst with the Innovation Support Unit, Department of Family Practice (UBC). Susan Martin, MA is a research assistant with the Innovation Support Unit, Department of Family Practice (UBC). Maureen Ashe, Ph.D. is an Associate Professor in the DFP at UBC, a Research Scientist at the Centre for Hip Health and Mobility, and the Canada Research Chair in Community Mobility. 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The cost of integrating a physical activity counselor in the primary health care team. J Am Board Fam Med. 2012;25(2):250–2. Aboueid S, Bourgeault I, Giroux I. Nutrition and obesity care in multidisciplinary primary care settings in Ontario, Canada: Short duration of visits and complex health problems perceived as barriers. Prev Med Rep. 2018 Jun 1;10:242–7. Hogg W, Lemelin J, Dahrouge S, Liddy C, Armstrong CD, Legault F, Dalziel B, Zhang W. Randomized controlled trial of anticipatory and preventive multidisciplinary team care: for complex patients in a community-based primary care setting. Canadian family physician. 2009 Dec 1;55(12):e76-85. Kahan M, Wilson L, Midmer D, Ordean A, Lim H. Short-term outcomes in patients attending a primary care–based addiction shared care program. Canadian Family Physician. 2009 Nov 1;55(11):1108-9. Farrar S, Kates N, Crustolo AM, Nikolaou L. Integrated model for mental health care. Are health care providers satisfied with it?. Canadian Family Physician. 2001 Dec 1;47(12):2483-8. Goldman J, Meuser J, Rogers J, Lawrie L, Reeves S. Interprofessional collaboration in family health teams: an Ontario-based study. Canadian Family Physician. 2010 Oct 1;56(10):e368-74. Moore AE, Nair K, Patterson C, White J, House S, Kadhim-Saleh A, et al. Physician and Nurse Perspectives of an Interprofessional and Integrated Primary Care-Based Program for Seniors. J Res Interprofessional Pract Educ [Internet]. 2013 Mar 27 [cited 2018 Oct 12];3(1). Available from: https://www.jripe.org/jripe/index.php/journal/article/view/95 Kotecha J, Brown JB, Han H, Harris SB, Green M, Russell G, et al. Influence of a quality improvement learning collaborative program on team functioning in primary healthcare. Fam Syst Health. 2015 Sep;33(3):222–30. Legault F, Humbert J, Amos S, Hogg W, Ward N, Dahrouge S, et al. Difficulties Encountered in Collaborative Care: Logistics Trumps Desire. J Am Board Fam Med. 2012 Mar 1;25(2):168–76. MacNaughton K, Chreim S, Bourgeault IL. Role construction and boundaries in interprofessional primary health care teams: a qualitative study. BMC Health Serv Res. 2013 Nov 24;13(1):486. Harris SB, Green ME, Brown JB, Roberts S, Russell G, Fournie M, et al. Impact of a quality improvement program on primary healthcare in Canada: A mixed-method evaluation. Health Policy. 2015 Apr 1;119(4):405–16. Kiran T, Kopp A, Moineddin R, Glazier RH. Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention. Can Med Assoc J. 2015 Nov 17;187(17):E494–502. Sibbald SL, McPherson C, Kothari A. Ontario primary care reform and quality improvement activities: an environmental scan. BMC Health Serv Res. 2013 Jun 10;13:209. Smith-Carrier T, Neysmith S. Analyzing the Interprofessional Working of a Home-Based Primary Care Team*. Can J Aging Rev Can Vieil. 2014 Sep;33(3):271–84. Smith-Carrier T, Pham T-N, Akhtar S, Nowaczynski M, Seddon G, Sinha S. “A More Rounded Full Care Model”: Interprofessional Team Members’ Perceptions of Home-Based Primary Care in Ontario, Canada. Home Health Care Serv Q. 2015 Oct 2;34(3–4):232–51. Oandasan IF, Conn LG, Lingard L, Karim A, Jakubovicz D, Whitehead C, et al. The impact of space and time on interprofessional teamwork in Canadian primary health care settings: implications for health care reform. Prim Health Care Res Dev. 2009 Apr;10(2):151–62. Sargeant J, Loney E, Murphy G. Effective interprofessional teams: “Contact is not enough” to build a team. J Contin Educ Health Prof. 2008 Sep 1;28(4):228–34. Zygmunt A, Asada Y, Burge F. Is team-based primary care associated with less access problems and self-reported unmet need in Canada? Int J Health Serv. 2017;47(4):725–51. Zygmunt A, Berge F. Inter-provincial variation and determinants of access to team-based primary care in Canada. Dalhous Med J. 2014;41(1). McCarthy K. Understanding the challenges, witnessing primary health care in action. The Canadian nurse. 2006 Apr 1;102(4):9. Minore B, Boone M. Realizing potential: improving interdisciplinary professional/paraprofessional health care teams in Canada’s northern aboriginal communities through education. J Interprof Care. 2002;16(2):139–47. Hudon C, Chouinard M-C, Dubois M-F, Roberge P, Loignon C, Tchouaket É, et al. Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study. Ann Fam Med. 2018 May;16(3):232–9. Brown JB, Lewis L, Ellis K, Stewart M, Freeman TR, Kasperski MJ. Mechanisms for communicating within primary health care teams. Canadian Family Physician. 2009 Dec 1;55(12):1216-22. Sicotte C, D’Amour D, Moreault M-P. Interdisciplinary collaboration within Quebec community health care centres. Soc Sci Med. 2002 Sep 1;55(6):991–1003. Brown JB, Lewis L, Ellis K, Beckhoff C, Stewart M, Freeman T, et al. Sustaining primary health care teams: What is needed? J Interprof Care. 2010 Jul;24(4):463–5. Brown SR, Irwin G. Measuring and Improving Continuity in Residency Primary Care Practice. Ann Fam Med. 2018 May 1;16(3):273–4. Manca DP, Greiver M, Carroll JC, Salvalaggio G, Cave A, Rogers J, et al. Finding a BETTER way: A qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice. BMC Fam Pract. 2014 Apr 11;15(1):66. Brown JB, Ryan BL, Thorpe C, Markle EKR, Hutchison B, Glazier RH. Measuring teamwork in primary care: Triangulation of qualitative and quantitative data. Fam Syst Health. 2015 Sep;33(3):193–202. Vingilis E, Paquette-Warren J, Kates N, Crustolo A-M, Greenslade J, Psych B, et al. Descriptive and Process Evaluation of a Shared Primary Care Program. 2007;10. Liddy C, Singh J, Hogg W, Dahrouge S, Taljaard M. Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study. BMC Fam Pract. 2011 Oct 18;12(1):114. Cross-Barnet C, Ruiz S, Skillman M, Dhopeshwarkar R, Singer R, Carpenter R, Campanella S, Freij M, Snyder L, Colligan E. Higher quality at lower cost: Community health worker interventions in the health care innovation awards. Journal of Health Disparities Research and Practice. 2018;11(2):10. Reddy A, Wong E, Canamucio A, Nelson K, Fihn SD, Yoon J, et al. Association between Continuity and Team-Based Care and Health Care Utilization: An Observational Study of Medicare-Eligible Veterans in VA Patient Aligned Care Team. Health Serv Res [Internet]. 2018 Sep 11 [cited 2018 Oct 1];0(0). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13042 Supplementary Files PRISMA2009checklist.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-18173","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":428664,"identity":"6a5463c7-1921-4fc1-ad08-7ed462360c6a","order_by":1,"name":"Sarah C. 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Calls for transformation are motivated by a desire to achieve the Quadruple Aim as an approach to optimizing health system performance in four areas of focus: improving the health of populations, enhancing patient and provider experience of care, and reducing per capita costs of healthcare (2,3).\u003c/p\u003e \u003cp\u003eThere is recognition of the value of team-based primary and community care (TBPCC) (4\u0026ndash;8). Evidence suggests that TBPCC practices are able to provide more appropriate care to their patients (8\u0026ndash;10) with improved comprehensiveness, coordination, and efficiency of care (10,11), and lower burnout rates for providers (12). Research focused on an assessment of progress in the transition to team-based practice emphasizes key change concepts for practice transformation: empanelment (attachment of patients to primary care providers), continuous and team-based healing relationships, patient-centred interactions, engaged leadership, quality improvement strategy, enhanced access, care coordination, and evidence-based care (13).\u003c/p\u003e \u003cp\u003eThe Patient Medical Home (PMH) model is dominant across North America and is a building block of TBPCC in Canada. The College of Family Physicians of Canada defines the PMH as a medical office or clinic where each patient has: her or his own family doctor; other health professionals working as a team with the patient\u0026rsquo;s doctor; timely appointments for all visits; arrangement and coordination of all other medical services; an electronic medical record; and ongoing evaluation and quality improvement programs (6).\u003c/p\u003e \u003cp\u003eOntario\u0026rsquo;s Family Health Team (FHT) model, implemented in 2005, may be Canada\u0026rsquo;s, if not North America\u0026rsquo;s, largest example of a jurisdictional model for a PMH. The model is based on multidisciplinary teams and an innovative incentive-based funding system. Nearly 2\u0026nbsp;million Ontarians are served by 170 FHTs (14). However, health systems transformation is complex (15) and its progress in Canada is varied province by province (16\u0026ndash;18).\u003c/p\u003e \u003cp\u003eThere are several review articles focused on attributes of TBC in the US and internationally (1,4,8,19\u0026ndash;22); however, there is a gap in synthesizing evaluations of TBPCC in Canada. While the Quadruple Aim provides a framework for the assessment of many of the more longitudinal outcomes of TBPCC, the transformation of primary care is a process that occurs over time and requires a focus on formative as well as summative evaluation.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eThe TBPCC Evaluation Framework\u003c/h2\u003e \u003cp\u003eLangton et al., (2016) emphasizes the importance of congruence between \u0026ldquo;a primary care performance measurement system and accepted conceptual frameworks that articulate important features of high-quality primary care systems\u0026rdquo; (p.\u0026nbsp;37). In anticipation of the need for a coordinated approach to evaluation, we developed the TBPCC Evaluation Framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). It is derived from the literature on TBC and was developed through an iterative process including the synthesis of literature and a review process with stakeholders: policymakers, TBC project leaders in communities, and researchers with relevant expertise. The literature was synthesised into a draft framework with a number of dimensions.\u003c/p\u003e \u003cp\u003eThe TBPCC Evaluation Framework is situated in the healthcare system, as illustrated by the World Health Organization\u0026rsquo;s partnership pentagon, which includes key stakeholder groups (23).The framework includes eight dimensions: Relationship Centred Care, Patient Experience, Provider Experience, Team Function, Care Process and Quality, Team Based Care Foundations, Population Health, and Health Care Costs. These incorporate the Quadruple Aim.\u003c/p\u003e \u003cp\u003eUnder each dimension, specific aspects have been defined, which were assigned specific measures. Validated and published evaluation tools were collected from the literature for consideration and were mapped to the framework.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eEight TBPCC Evaluation Framework Dimensions\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRelationship Centred Care\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eThe focus, in TBC, on supporting caring relationships between the patient, family and their providers\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003ePatient Experience\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient and family\u0026rsquo;s subjective experience of care\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eProvider Experience\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eExperience of individual providers in doing their work\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTeam Function\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eHow team members interact to contribute to comprehensive, coordinated care\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eCare Process and Quality\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMeasuring appropriateness, efficiency, and effectiveness of care services provided to patients\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTBC Foundations\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eFeatures of the community, policy, funding, etc. that enable an effective TBC practice\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003ePopulation Health\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAssessment of health systems utilization and health outcomes for the population served\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHealth Care Costs\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMeasurement of the costs of care both within the TBC practice and overall for the population served\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eRelationship Centered Care (RCC)\u003c/span\u003e assesses the quality and continuity of a therapeutic relationship between the patient and the patient\u0026rsquo;s providers. RCC includes patient perceptions of provider-patient connection, cultural sensitivity/safety, and relationship continuity.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003ePatient Experience\u003c/span\u003e is the patient and family\u0026rsquo;s subjective experience of the care they receive. Systematic reviews have shown strong correlation between patient experience of care and clinical safety/ effectiveness (24). This dimension is a component of the Quadruple Aim and includes patient experience of care, team, and clinic-facilities. It includes patient perception of access to care and patient empowerment.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eProvider Experience\u003c/span\u003e is the subjective experiences of individual providers in the team about their work. This includes the delivery of care to patients, their interactions with their work environment, the impact of policy on TBC and role-definition, and work/life balance. It is also one component of the Quadruple Aim.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eTeam Function\u003c/span\u003e is focused on the structure and operation of a team, the interactions of team members, and the additional supports that contribute to comprehensive, coordinated care. Aspects of team function include team leadership, team composition, team capacity, team communication/coordination, team trust/relationships, and the use of enabling tools (education, IT).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eCare Process and Quality\u003c/span\u003e assesses services actively provided to patients in contrast to overall care outcomes for the population served (see health of the population dimension). Care Process and Quality includes access, health promotion, preventive care, chronic disease management, and urgent episodic illness.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eTBC Foundations\u003c/span\u003e are features of the community, TBPCC policies, jurisdictional systems, and the supporting organization(s) that enable an effective TBC practice. In particular, this includes the development of a shared vision of TBC and facilitates the alignment of policy planning to support the implementation of TBC. Aspects of TBC foundations include office space and resources, education and training, policy, scopes of practice, funding models and incentives, community supports, and regional supports.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eHealth of the Population\u003c/span\u003e is the assessment of broader health systems utilization measures and health outcomes for the population that is being supported by the team. In contrast to Care Process and Quality dimension, this includes whether individuals access care or not. The Population Health dimension includes aspects such as attachment, health promotion and preventive care, CDM, episodic illness management, and health system utilization.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eHealthcare Costs\u003c/span\u003e includes the tracking and analysis of total costs associated with individual patients within a TBPCC practice. This includes consideration of the broader, systems level costs that are influenced by the transition to TBPCC. This dimension includes facility/operational costs, direct service costs, total healthcare spending per person, hospital and ED utilization rates and costs, and medication costs.\u003c/p\u003e \u003cp\u003eAssessing the long-term benefits of systems change requires 5\u0026ndash;10\u0026nbsp;years (25,26); however, shorter-term evaluation is needed to support decision makers, continuous quality improvement, adaptation, and flexibility to ensure process is relevant to specific contexts and communities. To complement the dimensions, the TBPCC framework includes an adoption model (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), adapted from the Clinical Adoption Meta Model (27). This encourages thinking on the evolution of indicators over time from measuring baseline and early intention to change through to observable behaviour changes to long-term outcomes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThe purpose of this paper is threefold: 1. To synthesize peer-reviewed evidence on the outcomes of team-based primary and community care (TBPCC) in Canada on Patient and Provider Experience, Population Health, and Health Care Costs (Quadruple Aim) (3); 2. To introduce the TBPCC Evaluation Framework to address gaps identified in the synthesis; and 3. To extend the critical interpretive synthesis to include the additional four domains from the TBPCC Evaluation Framework (i.e., Relationship Centred Care, Care Process and Quality, Team Function and TBC Foundations).\u003c/p\u003e \u003c/div\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy and Selection Criteria\u003c/h2\u003e \u003cp\u003eTo identify peer-reviewed literature, we followed standard review methodology and reporting guidelines as established by PRISMA (28). We registered our review on PROSPERO (2018 CRD42018091086), and our synthesis concepts were: population (patients), intervention (team-based primary health care), comparator (usual care, single practitioner delivery mode), outcome (patient and provider experience, population health, and health care costs), time (2000 to present), and type (randomized controlled trials, controlled trials, quasi-experimental designs, and implementation studies/evaluations).\u003c/p\u003e \u003cp\u003eWe searched the following databases using Medical Subject Headings (MeSH) and keywords: Cochrane Database of Systematic Reviews, Medline (OVID and PubMed), CINAHL, Embase, SportDiscus, and PsycINFO. We also conducted an advanced search with Google Scholar (Title only) with the words \u0026ldquo;Canada AND primary AND team\u0026rdquo;. We conducted the last search on April 7, 2019. One author screened for year of publication, type of study, and duplicates. 1,137 studies were imported for screening into Covidence, a review production system (Covidence.org, Melbourne Aus.). After duplicate removal, 994 studies were screened. We included studies based in Canada, and a priori chose to only include studies published in 2000 and later (29). We excluded reviews, opinion papers, laboratory-based studies, and studies based outside of Canada. Two authors screened citations at the title and abstract level (Level 1). 747 studies were identified as irrelevant, and 242 studies were included for full-text screening. Two authors then reviewed 242 citations at the full-text level (Level 2); and a third author reviewed conflicts. 71 studies were then included for data extraction. We further conducted a backward (reference lists) and forward citation search for articles included at Level 2. The last search was conducted on April 25, 2019.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction\u003c/h2\u003e \u003cp\u003eOnce the final list was generated, one author extracted data based on a pre-developed data extraction sheet and another author reviewed it. We extracted the following information: authors; province; location (urban/small urban/rural); year; study design; funding model; organizational structure; team composition, traits, and communication; patient population; health care costs; identified enablers, facilitators, and challenges; and funding sources for research. We categorized included studies by region. We reviewed each study to extract data related to the Quadruple Aim outcomes, summarized findings and assessed studies for risk of bias. The extraction spreadsheet was reviewed and confirmed by a second author.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCritical Interpretive Synthesis\u003c/h2\u003e \u003cp\u003eRecognizing the limitations of the aggregative focus of the data typically generated by a systematic review process (30) and the complexity of primary care transformation (26,31), this review was approached as a critical interpretive synthesis (30,32). Initially, findings were synthesized to assess outcomes in the context of the Quadruple Aim. As our synthesis progressed and it became apparent there were very few Canadian studies focused on the evaluation of TBC that aligned with these four outcomes. After data from the 71 studies were extracted, we further excluded studies that focused on evaluating addition of only single medical role into clinical practices, evaluating administrative changes in how practices are managed (e.g. new access scheduling methodology), or assessing a specific evaluation method, resulting in additional 26 exclusions. The additional dimensions of the TBPCC Evaluation Framework were then drawn into the synthesis along with the perspective provided by the Adoption Model, enabling a review of formative as well as summative outcomes.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eThere were 45 peer-reviewed publications that met our final inclusion criteria. Regional representation for studies included: none from the West Coast (British Columbia); seven Prairie Provinces (Alberta, Saskatchewan, Manitoba); 34 Central Canada (Ontario, Quebec); one Atlantic Canada (New Brunswick, Nova Scotia, PEI, Newfoundland); none from the Territories (Yukon, Northwest Territories, Nunavut); and three pan-Canadian.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eMapping of Studies to Quadruple Aim and the TBPCC Evaluation Framework\u003c/h2\u003e \u003cp\u003eThere were 23 of the 45 included studies (51%) that assessed at least one element of the Quadruple Aim. Patient experience was the most commonly assessed, followed by provider experience. The majority of studies were from Central Canada, with 32 studies from Ontario. 100% of the included studies reported on outcomes reflected in the TBPCC Evaluation Framework. The top dimensions in the synthesis were Team Function (24 studies), and Care Process and Quality (21 studies) (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), neither of which are explicitly reflected in the Quadruple Aim.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eWest Coast\u003c/h2\u003e \u003cp\u003eThere were no included studies identified from this region.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003ePrairie Provinces\u003c/h2\u003e \u003cp\u003eFour of the seven studies from the Prairie Provinces (Alberta\u0026thinsp;=\u0026thinsp;6, Manitoba\u0026thinsp;=\u0026thinsp;1) mapped to the Quadruple Aim. Two studies reported on patient experience (33,34), one on population health (35), and one on provider experience (36). Three of seven studies reported on team collaboration and function as important components of transitioning to TBC (36\u0026ndash;38). Emerging themes from the studies were patient needs regarding respect, support, and advocacy, and improved knowledge, independence, care received, ability to make decisions, and overall health. Other related themes included: provider and patient experience with overall delivery and quality of care (33\u0026ndash;35,39), provider remuneration, and support for information technology, leadership, and education (38).\u003c/p\u003e \u003cp\u003eThere was discordance for the two studies that focused on perceptions of access to care. One study emphasized that while the respect, support, and community advocacy provided to patients as a result of a TBC model was appreciated, accessibility continued to be a barrier for patients (33). Another study reported a perceived benefit improvement in access to care (34). One study noted increased job satisfaction for providers (36).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eCentral Canada\u003c/h2\u003e \u003cp\u003e18 of the 34 studies from Central Canada (Quebec\u0026thinsp;=\u0026thinsp;2, Ontario\u0026thinsp;=\u0026thinsp;32) mapped to the Quadruple Aim. Ten studies reported on patient experience (40\u0026ndash;49), two on costs (50,51), three on population health (52\u0026ndash;54), and three on provider experience (55\u0026ndash;57). Emerging themes from these studies included: need for improved access to care; increased satisfaction with care; increased patient-centeredness; increased costs but improved quality of care; decreased cost of prevention over time with more appropriate provider; positive influence on care quality for health promotion and substance use outcomes; improved provider satisfaction; and need for improved care coordination. 19 studies reported on aspects related to team function. This included determining team members\u0026rsquo; scope of practice, boundaries, and role responsibilities (56,58\u0026ndash;60). Other related themes included: changes in screening and prevention care (61); provider and patient experience with quality of care (50); funding related impacts on team function (52,62); support for information technology, leadership, and education (52,63\u0026ndash;65); and physical space or co-location (59,66). One study explored patient and provider satisfaction and relationship building (40).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eAtlantic Canada\u003c/h2\u003e \u003cp\u003eThere was one study from Atlantic Canada (Nova Scotia\u0026thinsp;=\u0026thinsp;1), which did not map to the Quadruple Aim but reported on team function and ongoing interprofessional education to address issues of respect for health professions (67).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eTerritories and Nunavut\u003c/h2\u003e \u003cp\u003eThere were no included studies from this region.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003ePan-Canadian Studies\u003c/h2\u003e \u003cp\u003eThere were three Pan-Canadian studies, with one study mapping to patient experience (24). All studies reported on access to care and included process and outcome indicators that were perceived positively in TBC setting such as: patient centeredness, comprehensiveness, and continuity of care (67,68,69).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eNumber of publications by region reporting elements of the Quadruple Aim categories\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient Experience\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eCosts\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003ePopulation Health\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eProvider Experience\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWest Coast\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePrairies\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCentral Canada\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAtlantic Canada\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTerritories \u0026amp; Nunavut\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePan-Canadian\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTotal\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eNumber of publications by region reporting elements of the TBPCC Evaluation Framework dimensions\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eCare Process and Quality\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eTeam Function\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient Experience\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eProvider Experience\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eRCC\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003ePopulation Health\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003eHealth Care Costs\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003eTBC Foundations\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWest Coast\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePrairies\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCentral Canada\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e19\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAtlantic Canada\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTerritories and Nunavut\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePan-Canadian\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTotal\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e21\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e24\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eOur integrative synthesis found many Canadian examples of TBPCC evaluation. Ontario has the largest population and the longest TBPCC adoption timeframe in Canada and has the majority of included studies. Other smaller provinces and those who are later in the transition to TBPCC had fewer evaluation studies; this was expected. The lack of studies that met our criteria from the West Coast was also expected. Although community health centres have been operating in BC for several decades, and there have been a number of shorter-lived initiatives focused on TBPCC, our search strategy found very little focused on the outcomes of these efforts. BC is now in the early stages of a new push to TBPCC backed by a number of provincially funded initiatives to support the development and implementation of an integrated system of Primary Care Networks and PMHs (16). This is in line with similar efforts in other provinces. As such, we anticipate that the literature focused on aspects of formative evaluation of TBPCC in Canada will grow dramatically in the near future.\u003c/p\u003e \u003cp\u003eThe gap in literature from Nunavut and the territories was more surprising. A targeted search resulted in a number of articles that describe team-based practices in the North, the use of telehealth and paraprofessionals to support team-based practice, and the challenges facing teams where positions are filled with temporary rotating staff and turnover is high (70,71). This suggests a more targeted exploration of the evaluation of TBPCC in Northern and in rural and remote communities as an area for future research.\u003c/p\u003e \u003cp\u003eAll articles included in the integrative synthesis are aligned with at least one dimension of the TBPCC Evaluation Framework. System transformation in primary care is complex and is a process that occurs over time. Because many provinces are early in this transition, the longitudinal assessment required to assess most elements of the Quadruple Aim are not yet possible or published, which is likely part of the reason why only 51% of studies mapped to the Quadruple Aim. The TBPCC Evaluation Framework intentionally has a broader scope supporting formative and summative evaluation. Next, we provide further contextualization of the eight dimensions of the framework and why these are important to measure.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCanadian TBPCC Evaluation \u0026ndash; Across the TBPCC Framework Dimensions\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003cp\u003eRelationship Centred Care (RCC):\u003c/p\u003e \u003cp\u003eIn our review, studies demonstrated associations between RCC and improved patient outcomes with emphasis on the importance of communication and collaboration (37,40). There is evidence that skills and behaviours related to collaboration are most likely to show significant effects on patient outcomes (37). Evaluation of RCC is important as relationships can be disrupted in poorly functioning teams.\u003c/p\u003e \u003cp\u003ePatient Experience:\u003c/p\u003e \u003cp\u003eFrom our review, there is considerable evidence that TBPCC can enhance patient experience of care through strategies related to accessibility, respectful supportive relationships, enhanced opportunities for knowledge sharing, self-management, and community advocacy (24,33,34,40). The availability of enhanced case management or specialized support roles also positively influences patient experience (44,45,72). These benefits are particularly salient for more vulnerable populations (47,65), who feel they are given the chance to \u0026lsquo;tell their story and be heard\u0026rsquo; in team-based settings (48).\u003c/p\u003e \u003cp\u003eProvider Experience:\u003c/p\u003e \u003cp\u003eThe review suggests that providers can find working in a team very useful, particularly for complex patients (36,57). Providers perceive there is improved access, continuity of care, and patient-centered-ness in TBC (5,44). Communication and shared understanding of roles contributes to enhanced provider experience (35,36,44,57) as does the availability of providers with specific expertise (e.g. mental health/counselling or CDM) (39,55).\u003c/p\u003e \u003cp\u003eTeam Function:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eTeam Function\u003c/span\u003e was the most evaluated dimension in the included articles (24/45; 53%). The review underscored the value of proactively supporting effective communication and trusting relationships among team members (36\u0026ndash;38,73). Common barriers to collaboration and team function include the time it takes to build relationships, the lack of opportunities for co-location, and challenges with role definition (59,64,66). Despite some studies that suggest only moderate success in the context of interdisciplinary collaboration (63,74), there is ample evidence of the importance of working to develop shared values in primary care teams and the value of efforts to improve group dynamics to support higher levels of interdisciplinary collaboration (5,44,74\u0026ndash;76). Working to build understanding of roles and shared leadership is also widely attributed to enhancing collaboration (58,60,61,65). There is also evidence of the value of interprofessional education (67,77). Intentional, team-focused activities, including formal meetings, professional development programs, social activities, and retreats, are essential to sustaining and building relationships needed for highly functioning teams (75,78).\u003c/p\u003e \u003cp\u003eCare Process and Quality:\u003c/p\u003e \u003cp\u003eA number of studies included in our review suggest that TBC leads to improvements in patients\u0026rsquo; perceptions of quality of care, accessibility of care, knowledge of medical conditions, and their ability to self-manage (24,34,40,44,50,53,72,79). Providers\u0026rsquo; perceptions of capacity can be enhanced through shared care models and opportunities for interprofessional collaboration (39,48,52,61). However, other studies suggest the accessibility of care is still an issue, even in highly-functioning team-based practices (33,43,46). A pan-Canadian study found that the likelihood of reporting access issues or unmet needs was not significantly different in TBC vs. non-TBC settings (68). However, there is evidence that quality of care, particularly for CDM, is better in team-based practices and particularly in community health centres or practices with blended capitation models (62,69,80).\u003c/p\u003e \u003cp\u003eTBC Foundations:\u003c/p\u003e \u003cp\u003eThe most salient issues for teams that emerged from our synthesis are physician remuneration, co-location, interoperable electronic health records, visionary leadership, and educational support (38,39,52,56,62). Larger numbers of physicians on teams and the distribution of teams across sites has been negatively associated with team performance (42,56,59); there is evidence that smaller, co-located teams are more likely to collaborate effectively (66).The physical layout of a space, the presence of coordinator or team management roles, and the use of alternative funding models have been highlighted as foundational to success (56,62,80).\u003c/p\u003e \u003cp\u003eHealth of the Population:\u003c/p\u003e \u003cp\u003eTBPCC can improve outcomes in population health (e.g. fewer Emergency Room visits for low acuity) (81,82). Some studies highlight early indicators of improvement in population health through TBPCC (35). For example, one study found that increased accessibility to dietitians resulted in increased likelihood of PCPs discussing nutrition for weight management (52). Another study discovered improved CDM and preventive care in TBPCC (53). An addiction shared care program also showed early success (54).\u003c/p\u003e \u003cp\u003eHealth Care Costs:\u003c/p\u003e \u003cp\u003ePhysician remuneration is an important issue for interprofessional teams across Canada and is a frequent stumbling block (38). Due to the longitudinal nature of cost savings related to longer-term, expected outcomes, there is a paucity of evidence in this dimension. A study focused on the cost effectiveness of a team-based prevention program for complex patients found that it was both more expensive and more effective than other programs (50). There is also evidence that the integration of new team members becomes more cost effective over time (51).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe systematic search strategy limited our initial searches to academic literature only, missing publications in the grey literature. There were no results for Western Canada or Nunavut and the Territories, and only limited results in Atlantic Canada. However, we are aware that at the practice level TBC innovations in primary care are being implemented in these regions. A more extensive search that includes a focus on grey literature and government publications could address some of the regional gaps highlighted in this synthesis.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusions","content":" \u003cp\u003eThere were 23 studies (51%) that mapped to the outcomes of the Quadruple Aim. The broader TBPCC Evaluation Framework was able to map all 45 included articles as it was developed specifically for TBPCC. It considers early and late evaluation needs, and includes dimensions on Relationship Centred Care, Team Function, Care Process and Quality, and TBC Foundations. By encouraging a focus on formative as well as summative evaluation, the TBPCC Evaluation Framework provides a comprehensive approach to assessing the evidence needed to support actionable improvements for TBPCC in Canada.\u003c/p\u003e \u003cp\u003eThis review highlights a range of positive outcomes associated with the various dimensions of TBPCC. Across the board the evidence underscores the value of relationships, visionary leadership, efforts to support enhanced collaboration and shared understanding and clear communication in the transition to team-based practice.\u003c/p\u003e "},{"header":"List of Abbreviations","content":"\u003cp\u003eBC British Columbia\u003c/p\u003e \u003cp\u003eCDM Chronic Disease Management\u003c/p\u003e \u003cp\u003eFHT Family Health Team\u003c/p\u003e \u003cp\u003eRCC Relationship Centred Care\u003c/p\u003e \u003cp\u003eTBC Team-Based Care\u003c/p\u003e \u003cp\u003eTBPCC Team-Based Primary and Community Care\u003c/p\u003e \u003cp\u003ePCN Primary Care Network\u003c/p\u003e \u003cp\u003ePCP Primary Care Provider\u003c/p\u003e \u003cp\u003ePMH Patient Medical Home\u003c/p\u003e \u003cp\u003eWHO World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The dataset generated and analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The Authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research was funded by a grant from the Strategic Innovation Fund from the Department of Family Practice at UBC. The funder has no role in the design of the study or in the collection, analysis or interpretation of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSF\u003c/strong\u003e Completed level 1 reviews and level 2 reviews (with MA); reviewed data extraction and conducted 2\u003csup\u003end\u003c/sup\u003e round of analysis (after PB); developed outline (with MP and MA) and drafted full paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePB\u003c/strong\u003e: Completed level 1 reviews, conducted initial data extraction (into spreadsheet) and completed first round of analysis; developed tables and drafted results section, reviewed and edited all drafts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTH\u003c/strong\u003e: Reviewed data extraction tables and full text articles to confirm analysis, formatted, reviewed and edited all drafts.\u003cbr /\u003e \u003cstrong\u003eSM\u003c/strong\u003e: Assisted in level 1 review, located copies of all the included papers, and initiated the data extraction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMA\u003c/strong\u003e: Registered review and set search parameters, completed level 1 and 2 reviews of the included articles, developed outline with SF and MP, reviewed and edited all drafts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMP\u003c/strong\u003e: Completed level 1 reviews and resolved conflicts for levels 1, 2, and 3; developed outline with SF and MA, drafted evaluation framework sections of paper and reviewed/edited all drafts.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Information:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSarah Fletcher, PhD is a Medical Anthropologist and the research manager for the Innovation Support Unit, Department of Family Practice (UBC).\u003c/p\u003e\n\u003cp\u003ePaule Bellwood, PhD(c) is a research analyst with the Innovation Support Unit, Department of Family Practice (UBC).\u003c/p\u003e\n\u003cp\u003eTiffany T. Hill, MA is a research analyst with the Innovation Support Unit, Department of Family Practice (UBC). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSusan Martin, MA is a research assistant with the Innovation Support Unit, Department of Family Practice (UBC).\u003c/p\u003e\n\u003cp\u003eMaureen Ashe, Ph.D. is an Associate Professor in the DFP at UBC, a Research Scientist at the Centre for Hip Health and Mobility, and the Canada Research Chair in Community Mobility.\u003c/p\u003e\n\u003cp\u003eMorgan Price, MD, PhD, CCFP, FCFP is an Associate Professor, Department of Family Practice (UBC), Director of the Innovation Support Unit and Interim Co-Head, Department of Family Practice (UBC).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBest A, Greenlagh T, Lewis S, Saul JE, Carroll S, Bitz J. Large-System Transformation in Health Care: A Realist Review. Milbank Q. 2012;90(3):421\u0026ndash;56.\u003c/li\u003e\n\u003cli\u003eBerwick DM, Nolan TW, Whittington J. 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Finding a BETTER way: A qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice. BMC Fam Pract. 2014 Apr 11;15(1):66.\u003c/li\u003e\n\u003cli\u003eBrown JB, Ryan BL, Thorpe C, Markle EKR, Hutchison B, Glazier RH. Measuring teamwork in primary care: Triangulation of qualitative and quantitative data. Fam Syst Health. 2015 Sep;33(3):193\u0026ndash;202.\u003c/li\u003e\n\u003cli\u003eVingilis E, Paquette-Warren J, Kates N, Crustolo A-M, Greenslade J, Psych B, et al. Descriptive and Process Evaluation of a Shared Primary Care Program. 2007;10.\u003c/li\u003e\n\u003cli\u003eLiddy C, Singh J, Hogg W, Dahrouge S, Taljaard M. Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study. BMC Fam Pract. 2011 Oct 18;12(1):114.\u003c/li\u003e\n\u003cli\u003eCross-Barnet C, Ruiz S, Skillman M, Dhopeshwarkar R, Singer R, Carpenter R, Campanella S, Freij M, Snyder L, Colligan E. Higher quality at lower cost: Community health worker interventions in the health care innovation awards. Journal of Health Disparities Research and Practice. 2018;11(2):10.\u003c/li\u003e\n\u003cli\u003eReddy A, Wong E, Canamucio A, Nelson K, Fihn SD, Yoon J, et al. Association between Continuity and Team-Based Care and Health Care Utilization: An Observational Study of Medicare-Eligible Veterans in VA Patient Aligned Care Team. Health Serv Res [Internet]. 2018 Sep 11 [cited 2018 Oct 1];0(0). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13042\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Team-Based Primary and Community Care, Team-Based Care Evaluation, Team-Based Care Outcomes, Quadruple Aim, Team-Based Care Adoption Model, Evaluation Framework, Formative and Summative Evaluation","lastPublishedDoi":"10.21203/rs.3.rs-18173/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-18173/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground \u003c/p\u003e\u003cp\u003eThe objectives of this article are: 1. To synthesize peer-reviewed evidence on the outcomes of team-based primary and community care (TBPCC) in Canada on Patient and Provider Experience, Population Health, and Health Care Costs (Quadruple Aim); 2. To introduce the TBPCC Evaluation Framework; and 3. To extend the critical interpretive synthesis to include the additional four domains from the TBPCC Evaluation Framework (i.e., Relationship Centred Care, Care Process and Quality, Team Function and TBC Foundations). \u003c/p\u003e\u003cp\u003eMethods \u003c/p\u003e\u003cp\u003eWe conducted a review of the following databases: Medline (OVID and PubMed), CINAHL, Embase, SportDiscus, and PsycINFO as well as an advanced search with Google Scholar (Title only) with the words “Canada AND primary AND team”. Review concepts included: population (patients), intervention (team-based primary health care), comparator (usual care, single practitioner delivery mode), outcome (patient and provider experience, population health, and health care costs), time (2000-present), and type (randomized controlled trials, controlled trials, quasi-experimental designs, and implementation studies/evaluations). We excluded reviews, opinion papers, laboratory-based studies, and studies based outside of Canada. \u003c/p\u003e\u003cp\u003eResults \u003c/p\u003e\u003cp\u003eForty-five publications met our inclusion criteria with the majority of these (34) from Central Canada. Results were initially mapped to the domains of the Quadruple Aim, with 51% (23/45) aligning. The additional domains from the TBPCC Evaluation Framework (Team Function, Relationship Centred Care, Care Process and Quality and Team-Based Care Foundations) and the Team-Based Care (TBC) Adoption Model were integrated into the synthesis. 100% of the included articles reported outcomes that aligned with the TBPCC Evaluation Framework. \u003c/p\u003e\u003cp\u003eConclusion \u003c/p\u003e\u003cp\u003eAcross Canada, the value of relationships, shared understanding, communication, and coordination across teams are highlighted as is the potential of TBC to result in improvements in patient and provider experience, team function, and the quality of care. By encouraging a focus on formative as well as summative evaluation, the TBPCC Evaluation Framework provides a comprehensive approach to assessing the evidence needed to support actionable improvements for TBPCC in Canada. \u003c/p\u003e\u003cp\u003eTrial Registration \u003c/p\u003e\u003cp\u003eTo identify peer-reviewed literature, we followed standard review methodology and reporting guidelines as established by PRISMA. We registered our review on PROSPERO (2018 CRD42018091086).\u003c/p\u003e","manuscriptTitle":"A Review and Synthesis of TBPCC Evaluation in Canada: Looking Beyond the Quadruple Aim","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-03-20 21:34:18","doi":"10.21203/rs.3.rs-18173/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b60a8d7e-7f4b-4d84-aaf8-c6881d7bc689","owner":[],"postedDate":"March 20th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":73025,"name":"General Practice"}],"tags":[],"updatedAt":"2020-05-04T17:24:43+00:00","versionOfRecord":[],"versionCreatedAt":"2020-03-20 21:34:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-18173","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-18173","identity":"rs-18173","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}