Advancing Team-Based Care in Private Practices: A Case Study of a Public–Private Hybrid Model

Advancing Team-Based Care in Private Practices: A Case Study of a Public–Private Hybrid Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Advancing Team-Based Care in Private Practices: A Case Study of a Public–Private Hybrid Model Coralie Darcis, Emmett Harrison, Haizhen Mou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8743811/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background : Despite widespread enthusiasm for team-based care models, adoption remains a challenge across Canadian jurisdictions. The transformation of primary care demands innovative approaches that reconcile physician autonomy with the systemic need for collaborative, team-based care. This article examines an innovative public–private hybrid model in which publicly funded allied health professionals are integrated into a private clinic. It offers insights into how such reconciliation might be achieved. Methods : This research draws on the case study of a pilot project of a primary care private practice transitioning to team-based care in Canada. Three qualitative data collection methods were employed: document analysis, semi-structured interviews ( n =27), and non-participatory observations (six days). A manual thematic analysis of the data was conducted, results were triangulated, and the coding system was refined through research team discussions. Results : Findings highlight both the benefits and challenges of hybrid models as a pathway for primary care reform. Benefits include enabling transition to team-based care by addressing resources constraints, preserving core aspects of family physicians’ professional autonomy, and incorporating patient-centered thinking within organizations typically oriented toward efficiency and sustainability. Challenges include physician distrust of public authorities, incompatibility with the fee-for-service payment model, and structural and operational barriers. Conclusions : This research offers insights into how incremental reforms can leverage existing private infrastructure while advancing collaborative care. These findings may inform strategies in jurisdictions where primary care remains heavily reliant on independent practitioners. Future research should examine the conditions under which such models thrive, with particular attention to governance, accountability, and evolving professional identities. primary care team-based care hybrid care models healthcare policy healthcare system transformation 1. Introduction The primary care system in Canada is facing a crisis, marked by poor patient access, provider burnout, and fewer graduates choosing family medicine (1–4). The prevailing physicians’ “soloist” private-practice model is under increasing pressure (5) with escalating workloads and costs. In the early 2000s, the federal government launched major investments to support primary care reform, including an $800-million Primary Health Care Transition Fund to help provinces and territories implement transformation initiatives (6–8) . A key goal was to promote interdisciplinary teams, a shift strongly endorsed by professional organizations (9) and increasingly accepted by physicians, particularly younger ones (10,11) . Progress has been uneven. Provinces have adopted diverse models, ranging from Alberta’s physician-led networks to Ontario’s community health teams and Quebec’s family medicine groups, each with distinct structures, funding mechanisms, and team compositions (6,12,13). As a result, each jurisdiction’s primary care system looks different, with its own strengths and weaknesses (14) . This fragmented rollout, combined with limited documentation of lessons learned (8,12), underscores the need to examine local innovations to better understand pathways to team-based care. Despite widespread enthusiasm for these models, their adoption remains a challenge in numerous Canadian jurisdictions (14) due to structural and cultural barriers, funding constraints, and physician resistance (15,16). These challenges are even more pronounced in private practices, which face additional obstacles. Most still operate under the fee-for-service (FFS) payment model, which is poorly aligned with team-based care (7,17) and constrains the financing of interdisciplinary teams. In addition, the private practice model is closely tied to professional autonomy and entrepreneurship, values central to physicians’ professional identity (6,18,19). While many family physicians express interest in team-based care, efforts to maintain their autonomy complicate the transition (19). In Saskatchewan, these conditions have contributed to the development of an innovative public–private hybrid organizational model. With funding support from the provincial health authority, private practices are gradually integrating publicly funded allied health professionals into their workplaces. Their initial goal is to improve service capacity by decreasing family physicians’ workload. Initially established as pilot initiatives, these models now have permanent funding and have inspired similar efforts elsewhere in the province. While this public–private hybrid model has the potential to support the transformation of traditional private practices into team-based settings, the challenges associated with this transition are under-documented. Understanding the advantages and limitations of this model is therefore essential to inform future policy. This paper addresses this gap through a case study of a primary care clinic in Saskatchewan. It examines how public–private hybrid models can facilitate the transition of private practices to team-based care, as well as the benefits and challenges associated with this approach. The article first provides background on this clinic’s pilot initiative, followed by the study’s methodology and results. These findings inform a broader discussion of organizational and cultural change, professional dynamics, and accountability in team-based primary care. Although this study focuses on Saskatchewan, the challenges examined are common across Canada and other jurisdictions with FFS-based private practices. 2. Background Under Canada’s federal system, responsibility for the funding, governance, organization, and delivery of primary care rests with provincial and territorial governments. Although services are publicly funded, they are primarily delivered through physician-led private practices. Saskatchewan’s primary care system is highly reliant on these practices, an issue that is compounded by a shortage of family physicians and ongoing recruitment and retention challenges (20) especially in rural areas. Responding to these pressures, the Associate Family Physician Clinic (hereafter “Associate Clinic”) in southern Saskatchewan implemented a pilot project in 2023 to transition from a traditional private practice model to a team-based one. Located in a semi-rural, agricultural region, the Associate Clinic serves about 10,000 patients. Prior to the pilot project, the clinic operated as a traditional private practice, with family physicians supported by receptionists and medical office assistants (MOAs). In 2022, the clinic began its transition toward team-based care. The first change was the co-location of a mental health counselor funded by the Saskatchewan Health Authority (SHA) and focused on addressing mental health and addiction needs of patients. Over time, that role evolved into a Behavioral Health Consultant (BHC) position with a broader clinical scope. Building on the success of this initial step, the team-based care initiative expanded into a formal pilot project in October 2023. The pilot was funded by the SHA, with the goal of developing a Patient Medical Home (PMH) care model. The PMH is a physician-led, team-based model developed by the College of Family Physicians of Canada (9), in which patients are attached to family physicians who work collaboratively with an interprofessional team to deliver coordinated, and patient-centered care. As part of the pilot, the SHA funded the integration of additional allied health professionals, including nurses, with the expectation that this would reduce family physician workload, expand service offerings, and improve patient access. At the time of data collection in early 2025, the clinic consisted of one clinic manager, eight family physicians, one licensed practical nurse, two registered nurses, one BHC, four MOAs, and three receptionists. In April 2025, the pilot was formally transitioned into a permanent initiative, with sustained funding provided by the provincial Ministry of Health. Under this arrangement, the clinic operated as a public–private hybrid organizational model in which family physicians continued to be remunerated through FFS payments, while allied health professionals were publicly funded and integrated into the clinic team. While early indications suggested improvements in patient access and physician satisfaction, the hybrid arrangement also introduced organizational, operational, and governance challenges. As this model begins to inspire additional initiatives in the province and beyond, a systematic examination of its implementation, benefits, and limitations is needed. Accordingly, this study addresses the following research questions: (i) How do public–private hybrid organizational arrangements facilitate the implementation of team-based care in private primary care practices? (ii) What benefits and challenges emerge from this approach? 3. Methods To address the research questions, we used a qualitative case study design focused on the Associate Clinic’s public–private hybrid model of care. A case study design was well suited to capturing the organizational, professional, and governance dynamics of this model within its real-world context. 3.1 Data collection We used three complementary data collection methods: document analysis, semi-structured interviews, and non-participatory observations. First, document analysis allowed us to clearly understand the pilot’s background and implementation context. Documents included materials formally describing the pilot, such as role descriptions, work standards, routine measures, and reports on initial outcomes. This analysis informed the development of interview guides and observation protocols. Second, we conducted semi-structured interviews to capture stakeholder experiences. A total of 27 interviews were completed, with seven family physicians, three nurses, three family medicine residents, one clinic manager, one BHC, one MOA, 10 patients, and one SHA representative. Informed consent was obtained from all participants prior to data collection. Interviews were audio-recorded and transcribed verbatim. Participants were selected based on their exposure to both pre- and post-pilot care models, enabling them to reflect on the transition. Clinic staff and physicians were recruited via email or letters where email was unavailable. Patient recruitment involved several strategies, including posters displayed in the clinic and an announcement posted on the clinic’s Facebook page. To ensure diverse patient perspectives, patients were selected using a pre-screening questionnaire that captured age, length of registration with the clinic, and the approximate number of visits in the past 12 months. Interview guides were developed specifically for this study and adapted to participant roles and research stage. One example can be found in supplementary files. Patients were primarily asked to describe their experience with the clinic since the pilot, including perceptions of access, satisfaction, additional services, and quality of care. Clinic staff and physicians were invited to reflect on changes in care delivery model, teamwork dynamics, role distribution, and work processes, as well as factors that supported or hindered implementation. Finally, we conducted non-participatory observations of clinic workflows, completing two separate three-day observation periods. We observed daily clinic operations, morning huddles, informal interactions among team members, and a meeting involving clinic leaders and SHA representatives. We also shadowed each of the three nurses for extended periods during routine activities, including patient encounters, triage, and documentation. Observational data were recorded as detailed field notes. Data collection continued until thematic saturation was reached, defined as the point at which no new codes, themes, or dimensions emerged during subsequent interviews and observations. 3.2 Data analysis Data collection and analysis proceeded iteratively, with preliminary analysis conducted between data collection periods to refine interview guides and observational focus. We conducted multiple rounds of manual thematic analysis using an abductive approach. Initial themes were informed by the research objectives and literature, while additional themes emerged inductively during the data analysis. Regular discussions among the research team helped refine the coding system, clarify emerging categories, and improve the analysis. Findings from the interview analysis were compared with those from observations and document analysis to identify convergence and discrepancies across data sources. This triangulation strengthened analytic credibility. Following analysis, results were shared with the Associate Clinic team to confirm that findings accurately reflected their experience and to validate interpretive accuracy. Although interview excerpts are used to illustrate key findings in the Results section, interpretations are grounded in the full body of data. 4. Results The pilot project was widely regarded as a success by interviewees, particularly with respect to care delivery, patient outcomes, and provider satisfaction. Nonetheless, the data also revealed differences in perspectives and concerns among providers and highlighted both the advantages and challenges of the public–private hybrid model. The findings are organized around the key benefits and challenges of the model as identified by interviewees. 4.1 Benefits of the hybrid model According to participants, the primary benefits of the hybrid model were (i) the removal of resource constraints, (ii) the preservation of family physicians’ autonomy, and (iii) the promotion of patient-centered care. 4.1.1 Removal of resource constraints Associate Clinic physicians had long expressed interest in moving away from “solo” practice towards a more collaborative care model, but as a private practice they faced substantial barriers in doing so. Chief among these was a lack of financial resources to hire allied health professionals, whose salaries and benefits would have to be covered by physicians, without generating corresponding billable revenue. Recruiting experienced nurses was described as particularly costly, making such investments difficult to justify in the short term. By reallocating existing employees to the clinic and covering their compensation, the SHA removed this financial barrier. Nevertheless, the integration of publicly funded staff generated indirect costs for the clinic, including the use of space, equipment, and administrative infrastructure. One physician described this concern in the following way: “As a business you're allowing another person to come into your business, you're taking up space. It costs us money to put her in our building, to get a computer, to get the fax line, to do all the things to have a person in our building without getting any compensation.” (Associate Clinic Family Physician). As the pilot implementation progressed, the health authorities and the clinic negotiated an agreement to offset the additional costs incurred. Integrating allied health professionals also required substantial changes to workflows, coordination mechanisms, and clinical routines, demanding time and effort from the family physicians. To facilitate the transition, the health authorities provided partial funding for one of the physicians to assume a leadership role in implementing the pilot. This support allowed for dedicated time to manage change processes, liaise with stakeholders, and ensure the new roles were integrated in ways aligned with the clinic’s operational realities and care objectives. As one physician noted: “One of the most important components that maybe isn't front and center and people don't always see, is that physician leadership. Our physician leader […] has been very important, helped us stay on track, develop those work standards and keep our new staff on track with their learning and with integrating into the clinic. So, if this is going to be duplicated at other places, having that funding available for physician leadership, it's going to be very important. And someone who's like a champion at it, right?” (Associate Clinic Family Physician). This funding for physician leadership also fostered sustained engagement across the family physician group, which proved pivotal to the successful rollout of the pilot. A SHA representative described this engagement: “They take the bull by the horns, they create the workflows, and they integrate them [the allied health professionals] into the team. Physicians are really engaged, they take turns being ‘doctor of the day,’ all of that stuff. That engagement level is there. […] That physician leadership I think just creates buy-in in itself.” (SHA representative). Under these conditions, the hybrid model mitigated resource constraints and enabled the clinic to pursue organizational change at a moment when physicians were motivated to innovate but lacked the capacity to do so independently. 4.1.2 Preservation of family physicians’ autonomy Although clinic physicians expressed strong support for team-based care, many initially feared that greater involvement from the SHA could threaten their professional autonomy. One physician explained this concern in relation to the FFS model: “We as fee-for-service physicians prioritize our autonomy and freedom. That’s one of the reasons that we work in this model. So, kind of being reluctant to do something that would kind of tie our hands with that.” (Associate Clinic Family Physician). The concern about losing professional autonomy was a recurring theme in physician interviews, with several of them mentioning that it could be a barrier to adopting the hybrid public–private organizational model in other clinics. As the pilot progressed, however, most physicians reported that these fears proved largely unfounded. As one physician reflected, apprehensions about external interference were more perceived than real: “I think it’s a false barrier. I don't think it's real, but I think that that could be something that people see as a reluctance to allow SHA into their practice.” (Associate Clinic Family Physician). Overall, family physicians retained complete autonomy over clinical (e.g., how they deliver care and manage their patient panels) and organizational (e.g., how the clinic operates in terms of scheduling, workflows, and internal policies) aspects. In terms of governance, they also retained substantial autonomy: while the hybrid model required certain compromises, the clinic continues to operate as a physician-led entity, with family physicians maintaining full decision-making authority. While the implementation of the pilot was shaped by ongoing negotiations with health authorities, interviewees explained that they have adopted a cooperative and flexible approach, accommodating clinic needs. Family physicians thus maintained significant control over how the pilot was designed and implemented in their clinic. As a result, the hybrid model functioned as a compromise that enabled collaboration while preserving core elements of physician autonomy, an outcome widely viewed as essential to sustaining physician engagement. 4.1.3 Promotion of patient-centered care Private clinics operate under financial constraints that prioritize efficiency and sustainability. Physicians frequently cited financial considerations as key to decision-making. As one family physician explained, this left little room for patient-centered thinking: “There was a [SHA] manager, he’s gone now, he would say to me, ‘well, you're helping your patients.’ And I would say ‘yes, but this is a private business. If we can't pay bills, the door is closed. This isn't SHA business where you can run at deficit and still open your doors.’ […] We can't do that in a private clinic. We have to pay the bills.” (Associate Clinic Family Physician). The introduction of public funding created space for greater attention to patient needs in decision-making. Interviewees described expanded services, improved access to care, and new team-based practices, such as morning huddles, all contributing to higher quality, more continuous care. Physicians reported increased capacity to follow patients over time and to adopt a more patient-centered approach. As reflected in this comment, patients also reported greater personalized attention and continuity of care: “I felt like they were actually looking out for [me]. It wasn’t ‘Here, take these meds, we’ll see you in a couple months’, you know? […] There’s a ton of follow-up where I believe that wasn’t happening before.” (Associate Clinic patient). Several of the interviewed patients echoed this sense of personalized attention and continuity of care. Family physicians also reported feeling more able to follow their patients over time and to adopt a more patient-centered approach. In addition, involving the SHA in decision-making also facilitated stronger population-health approaches. The clinic and the health authority jointly monitored key performance indicators such as “third next available appointment”, wait times for and use of specific services, and patient satisfaction. These data guided decision-making. Furthermore, by collecting its own data on the healthcare facilities and services, the SHA gained knowledge about the healthcare needs of the patient population and the challenges facing the healthcare system. Such first-hand information helped both the SHA and the Associate Clinic obtain a deeper understanding of the local healthcare landscape and adjust the services offered at the clinic according to the patients’ needs. As one SHA representative noted, routine monitoring of service-use data enabled the health authority and clinic to adjust staffing in response to patient demand: “The BHC at Associate Clinic had 98 referrals last month. […] At this other clinic, the BHC has had 12 referrals in the same period. So, we’re going to pull her over to Associate Clinic one day or two more a week.” (SHA representative). This illustrates how SHA’s involvement in privately delivered primary care enables a level of system‑wide coordination and responsiveness that individual clinics would not be able to achieve on their own, ensuring that resources can be directed to where they are most needed. Finally, the involvement of the SHA seemed to better connect the Associate Clinic with other healthcare services such as home care, public health, and mental health services, which tended to work in silos. For example, having the BHC co-located at the Associate Clinic helped develop personal relationships and improve data and system integration between the clinic and public mental health agencies. As a result, the participants described the clinic as being better integrated into the larger healthcare system, supporting continuity of care for patients. 4.2 Challenges of the hybrid model Despite these benefits, participants identified three key challenges associated with the hybrid model: (i) physician distrust of public authorities as an impediment to uptake; (ii) incompatibility with FFS payment under some conditions; and (iii) structural and operational barriers. 4.2.1 Physician distrust of public authorities While the clinic’s medical group acknowledged the need to shift the care model to benefit both patients and physicians, they expressed concerns about the health authorities becoming involved in their business operations. Beyond fears about loss of autonomy, interview data revealed deep tensions between the professional culture of private practice and the institutional culture of the SHA. Physicians pointed to differences in visions for care delivery and, more importantly, in operational approaches. They described SHA’s management of its own facilities as inefficient, slow, and overly bureaucratic. At first, the prospect of integrating SHA personnel accustomed to different management practices raised concerns about a potential loss of efficiency within the clinic: “We did not want the SHA and the way that they tend to run clinics and their businesses in our clinic because we don't feel that’s efficient and how we want our healthcare system and our clinic to run. So that was like an overarching theme that we knew as physicians: ‘OK, when SHA is going to come into our clinic, we did not want that culture to be brought in with that.’” (Associate Clinic Family Physician). This comment suggests that cultural and operational misalignment between private clinics and public health authorities may represent a significant barrier to further implement public–private hybrid arrangements. These concerns reflect longstanding distrust of the health authority, rooted in physician perceptions that centralized institutions lack understanding of local realities: “I honestly feel like we don't have much trust in that, that the bigger institutions don't necessarily know what we need, even in our own province.” (Associate Clinic Family Physician). While trust developed over time in the Associate Clinic through close working relationships between physicians and SHA representatives, participants noted that such distrust could discourage uptake of hybrid models elsewhere. 4.2.2 Incompatibility with fee-for-service payment model Several physicians viewed the FFS payment model as incompatible with the public–private hybrid arrangement because of its influence over task delegation. It was explained that expanding nurses’ roles may require physicians to relinquish certain quick and financially advantageous procedures, creating an economic disincentive when these tasks constitute a significant proportion of their income. The Associate Clinic’s physician group accepted this short-term financial risk, viewing it as an opportunity to benefit their practice over the longer term. These physicians judged that gains in professional satisfaction and patient outcomes would outweigh the loss of billable activities. When asked how the new team-based care model affected billing under a FFS payment model, one family physician explained: “For chronic disease management appointments, it doesn’t affect [billing]. It adds some efficiency if they [the nurses] go in, and as we still go in, we’re still having our visit that we bill the government for it. For other things like removal of sutures and PAPS, we just let that go. There’s no billing that comes because we’re not seeing the patient and we just kind of take it as like that point of serving the practice.” (Associate Clinic Family Physician). This quotation illustrates that financial considerations remain a central criterion in physicians’ decisions on what tasks to delegate. Such concerns may become even more pronounced in contexts where patient demand is lower and where delegation could directly affect income. One physician put it this way: “If you go out to a scenario where my wait time was very short and I was servicing my practice really well, I might not want to delegate more because then I might have open spots in my day that then would affect my billings.” (Associate Clinic Family Physician). These dynamics indicate that FFS payment structures influenced clinical decision-making during the pilot and could constrain the expansion of task-sharing under certain conditions. As explained by interviewees, this could potentially override other important factors such as the clinical appropriateness, the potential to improve care quality and access, and the optimization of each provider’s scope of practice. 4.2.3 Structural and operational barriers The implementation of the pilot project at the Associate Clinic unfolded in a pragmatic and largely improvisational manner. Operational and logistical aspects such as workflow organization, data sharing arrangements, and allocation of workspace were mostly established in practice, while formal contractual questions were addressed along the way. This meant that administrative constraints did not impede the early stages of implementation. However, at later stages, interviewees noted that operationalizing the hybrid model required navigating regulatory, contractual, and technical barriers associated with two systems that traditionally operated in silos and followed distinct organizational logics. They encountered barriers linked to the absence of formal agreements and the rigidity of existing contractual frameworks. One interviewee contrasted this experience with that of another, more top-down pilot project, where these issues became major obstacles to the first stages of implementation: “They're running into issues trying to do some of this co-location and EMR sharing, because contracts are stating: ‘Don't’.” (SHA representative) Financial arrangements with the hybrid model were also complex. Although publicly funded staff enhanced care delivery and physicians’ work satisfaction, their integration generated ongoing costs for space, equipment, and administrative support, requiring continuous evaluation and negotiation. Finally, managing staff funded by public and private sources introduced ambiguity around supervision, performance, and decision-making authority. Nurses reported confusion about authority, particularly given the absence of on-site SHA leadership. Participants emphasized the importance of monitoring these dynamics to prevent tension and support team cohesion as hybrid models evolve. 5. Discussion This study examined a public–private hybrid pilot model of primary care implemented within a physician-led private practice operating under a FFS payment model. The findings highlight both the potential and limitations of hybrid arrangements as pathways for advancing team-based care in settings where private practice is dominant. In this section, we consider the broader implications of these findings for primary care reform, focusing on hybrid models as catalysts for change, power and professional participation, and emerging questions of accountability. 5.1 Public–private hybrid models as a catalyst for change Implementing team-based care in private practices is challenging, particularly when physicians bear the financial and organizational risks associated with hiring additional staff. Resources are often limited, and without external support, the costs of hiring, coordinating and sustaining interprofessional teams can outweigh the perceived benefits, making change difficult to initiate (16). In this context, the hybrid model examined here functioned as a catalyst for organizational change. Public funding enabled the Associate Clinic to overcome long-standing obstacles to adopting team-based care by alleviating financial and organizational constraints and supporting dedicated physician leadership. The model allowed physicians to adopt collaborative practices while retaining the autonomy associated with private practice. Rather than requiring a fundamental restructuring of ownership, payment arrangements, and professional identities, the hybrid approach enabled incremental reform within existing institutional frameworks. These findings suggest that hybrid models may offer a pragmatic solution to physician shortages and unmet patient needs, particularly in rural or semi-rural areas. By leveraging existing private infrastructure and supplementing it with publicly funded professionals, hybrid arrangements can expand service capacity and improve access to care. While these arrangements supported service expansion, they also allowed family physicians to remain in private practice while working within teams, which has the potential to reduce pressure on family physicians, enhance their job satisfaction, and ultimately improve retention. However, the long-term success of hybrid models hinges on their scalability and sustainability. First, our findings show that misaligned institutional logics (namely, the autonomy driven, entrepreneurial orientation of private practices versus the emphasis on standardization and bureaucratic accountability within government health authorities) can fuel distrust and complicate collaboration. As Kreindler et al. (21) cautioned, partnership reforms can pose an identity threat for family physicians by compelling them to participate in bureaucratic enterprises. Addressing these tensions requires trust-building strategies that respect the professional identity of family physicians (21) and acknowledge the central role of medical practice and professional autonomy in primary care delivery. Indeed, healthcare reforms frequently falter when health authorities underestimate the financial and clinical autonomy of physicians, which is core to their professional identity (6,7,21) . Second, the success of transforming private practices into team-based settings depends on strong physician leaders acting as champions for change. Beyond providing logistical support, these champions help secure physician buy-in and sustain engagement over time. Attention to the champion’s role, including how such leaders are identified and supported, is therefore essential to effective implementation (22). Third, a one-size-fits-all approach is unlikely to address the needs of both patients and providers across different local contexts. Flexibility in implementation is therefore required to adapt team-based care models to the specific characteristics of individual communities. Furthermore, private practices vary in their capacity to accommodate change, and some may require targeted investments in infrastructure (such as physical space, digital tools, and administrative systems) to support the implementation of team-based care. 5.2 Power dynamics and professional participation in hybrid models Shared power and leadership are foundational attributes of interprofessional teamwork within primary care settings (23,24) , and the principle of shared decision-making is a cornerstone of effective team-based care models (25). While the hybrid model facilitates the integration of team-based care into private practices, it remains a physician-led model of care. In this public–private hybrid model, physician leadership was both expected and central to practice operations. The Associate Clinic was owned by a family physician and governed by the family physicians’ group, who were also the primary income earners. Power imbalances between providers from different training backgrounds represent a challenge to implementing well-functioning team-based care (23,26) , especially when allied health professionals are viewed as support staff rather than equal partners in care delivery. Cultural and professional hierarchies among healthcare providers can limit participation and influence of non-physician team members in decision-making (27) . Without mechanisms to support shared governance, hybrid models risk undermining the principles of collaborative practice. Ongoing attention will be needed to assess which of these mechanisms most effectively foster participation by allied health professionals. 5.3 A path toward more accountability in primary care Accountability, broadly defined, is the expectation that individuals or organizations will explain and justify their actions to others. In sociological terms, accountability extends beyond formal reporting requirements to include how actors recognize their responsibilities, reflect on their behavior, and respond to expectations shaped by social norms, institutions, and relationships (28). The emergence of public–private hybrid models in primary care raises questions about accountability at multiple levels. At the local level, a central concern is under what conditions these initiatives enable local health authorities to fulfill their mandates, including improving access, enhancing service integration, and responding to community’ needs. Tailoring care to local contexts requires adopting a population health approach, which in turn calls for some degree of system steering and the establishment of accountability mechanisms. Questions therefore arise about how accountability will evolve in these new hybrid arrangements. One challenge is that outcomes monitoring in primary care is difficult to implement (12), particularly when measuring patient engagement and assessing the impacts of coordinated care. Another key challenge concerns private practice physicians’ core values of autonomy and entrepreneurship. To sustain physician engagement, or in other words to ensure the “acceptability” (29) of reform efforts, these arrangements must balance respect for professional independence and autonomy with expectations of accountability and quality improvement (12) . These challenges highlight the importance of examining how governance and reporting mechanisms are negotiated in hybrid models. Beyond the local level, accountability to citizens for the performance of the healthcare system is a significant gap in Canada’s primary care landscape (7,29). One contributing factor is that primary care is publicly funded but largely delivered through private practices, a structural arrangement that has long allowed providers to operate with limited formal obligations to ensure they are meeting the needs of the populations they serve: “ Most family physicians in Canada are private contractors who carry no obligations or accountability for the breadth of services they provide, the location of their practices, their hours of operation, their staffing mix, the patients they accept or their ability to meet local population needs. ” (30) Despite decades of recommendations from expert commissions and policy initiatives aimed at strengthening accountability in healthcare (6,31,32) , Canadian provincial and territorial governments have struggled to implement mandatory requirements for primary care physicians (7) . This accountability gap has serious implications, particularly during crises when public authorities are expected to respond and community-responsive care is most needed. We argue that public–private hybrid models have the potential to introduce new accountability dynamics within the healthcare system, warranting close examination. On one hand, these arrangements may create opportunities to embed accountability if public funding is tied to explicit expectations (for example in terms of service volume, patient profiles) supported by measurement and monitoring mechanisms that inform decision-making and quality improvement. The Results section showed how new funding arrangements incrementally integrated population-health considerations into decision-making while being attentive to private practice logics. On the other hand, hybrid arrangements also carry risks. Private organizations’ priorities may come to exert greater, albeit indirect, influence over local service delivery. Governance mechanisms (such as funding agreements, performance metrics, and reporting requirements) thus play a central role in shaping how accountability is enacted in practice. In addition, hybrid models risk further blurring lines of responsibilities. Public and private actors operate under distinct accountability frameworks, agendas, mechanisms, and expectations. Public accountability is typically rooted in external expectations (i.e., democratic governance, transparency, and responsiveness to societal needs), whereas private accountability is often grounded in internal expectations such as efficiency, profitability, and professionals’ ethics. How these differing models of accountability will coexist remains an open question. The form that accountability takes in hybrid primary care arrangements, and the conditions under which it is strengthened or eroded in these models, is a pressing area for research. Future work should examine how accountability is operationalized in these settings, including whether more public sector involvement leads to new forms of reporting or answerability and how governance mechanisms influence professional behavior without undermining physician engagement. Understanding how accountability is negotiated and enforced is critical to assessing the legitimacy and effectiveness of hybrid healthcare governance. 6. Conclusion The transformation of primary care in Canada, as in many other countries, requires approaches that reconcile physician autonomy with the growing need for collaborative, team-based care. The public–private hybrid model piloted at the Associate Clinic offers valuable insights into how this balance might be achieved within healthcare systems where the private practice model is dominant. This qualitative case study highlights both the promise and limits of hybrid arrangements. On one hand, the integration of publicly funded allied health professionals can act as a catalyst for organizational change that is widely recognized as necessary but difficult to implement in private practice settings. By alleviating financial and organizational constraints, the hybrid model provides a pragmatic pathway for advancing team-based care. On the other hand, the model faces challenges related to payment structures, distrust between private and public sectors, and operational constraints. As healthcare systems seek to expand team-based care, hybrid models may serve as transitional frameworks that foster the culture and norms of interdisciplinary collaboration. Future research should examine the conditions under which these models can be sustained and scaled, with particular attention to governance, accountability, and evolving professional identities. The implications of these findings extend beyond Saskatchewan. As populations age and healthcare costs increase, primary care systems in both Canada and elsewhere face tensions between physician autonomy and the need for integrated care delivery. Public–private hybrid models, as illustrated in this case, offer a potential pathway for incremental reform by leveraging private infrastructure while advancing collaborative care. These insights may be particularly relevant in jurisdictions where primary care remains heavily reliant on independent practitioners. Declarations Author Contributions Statement HM supervised the research. All authors contributed to the conception and design of the work. CD collected and analyzed the data. All authors participated in the interpretation of data and the writing of the manuscript. All authors read and approved the final manuscript. Ethics declaration Ethical approval was obtained from the Behavioral Research Ethics Board (BREB) of the University of Saskatchewan. All procedures involving human participants were conducted in accordance with the Tri‑Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2, 2022), the national standard governing research ethics in Canada, and with the 2024 revision of the Declaration of Helsinki. All participants provided informed consent prior to taking part in the study. Funding declaration This study was funded by the Saskatchewan Health Research Foundation (SHRF) through an Align research grant. The funder had no role in the design of the study; in the collection, analysis, and interpretation of data; or in writing the manuscript. Acknowledgements We acknowledge the support from the Saskatchewan Health Research Foundation (SHRF) Align Grant. We also acknowledge Heather McWhinney for helping edit and proofread the manuscript. Author(s) Conflicts of Interest Dr. Harrison provides family medicine services in private practice at the Associate Family Physicians clinic, the clinical site studied in this research. To mitigate potential bias, the study design was finalized before data collection; data extraction and analysis were conducted by coauthors who do not have any relationship to the clinic; and interpretations were reviewed collaboratively by all authors. The authors report no other conflicts of interest. Data availability Data generated and analyzed during the current study are not publicly available due to privacy and anonymity considerations. Sharing the data could compromise the confidentiality of participants and violate ethical guidelines. References Bell R, Chow M. Canada has a primary-care crisis. Here are three steps we must take to solve this problem. The Globe and Mail (Online) [Internet]. 2022 Jul 16 [cited 2023 Nov 21]; Available from: https://www.theglobeandmail.com/opinion/article-canada-has-a-primary-care-crisis-here-are-three-steps-we-must-take-to/ Duong D. Primary care is facing a capacity crisis - Can pandemic lessons help chart a path forward? CMAJ. 2022;194(43):E1488. Flood CM, Thomas B, McGibbon E. Canada’s primary care crisis: Federal government response. Healthc Manage Forum. 2023 Sep 1;36(5):327–32. Brown-Shrevens D, Wright V, Kiran T. Team-based care key to alleviating primary-care crisis. Healthy Debate (Online) [Internet]. 2023 Apr 4; Available from: https://healthydebate.ca/2023/04/topic/team-based-care-primary-care-crisis/ Oglivie M. “Beyond crisis levels”: Why Ontario doctors are fleeing family medicine. Toronto Star (Online). 2016 Feb 16; Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: Systems in motion. Milbank Quarterly. 2011;89(2):256–88. Aggarwal M, Hutchison B, Abdelhalim R, Baker GR. Building high-performing primary care systems: After a decade of policy change, is Canada “walking the talk?” Milbank Quarterly. 2023;00(0):1–52. Naylor D, Girard F, Mintz J, Fraser N, Jenkins T, Power C. Unleashing Innovation: Excellent Healthcare for Canada [Internet]. Ottawa; 2015. Available from: https://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf College of Family Physicians of Canada. A new vision for Canada: Family Practice—The Patient’s Medical Home [Internet]. Mississauga, ON; 2019. Available from: https://patientsmedicalhome.ca Hedden L, Banihosseini S, Strydom N, McCracken R. Family physician perspectives on primary care reform priorities: A cross-sectional survey. CMAJ Open. 2021;9(2):E466–73. Mitra G, Grudniewicz A, Lavergne MR, Fernandez R, Scott I. Alternative payment models: A path forward. Canadian Family Physician. 2021;67(11):805–7. Leslie M, Khayatzadeh-Mahani A, Birdsell J, Forest PG, Henderson R, Gray RP, et al. An implementation history of primary health care transformation: Alberta’s primary care networks and the people, time and culture of change. BMC Fam Pract. 2020;21(1):1–20. Strumpf E, Ammi M, Diop M, Fiset-Laniel J, Tousignant P. The impact of team-based primary care on health care services utilization and costs: Quebec’s family medicine groups. J Health Econ [Internet]. 2017;55:76–94. Available from: http://dx.doi.org/10.1016/j.jhealeco.2017.06.009 Peckham A, Kreindler S, Church J, Chatwood S, Marchildon G. Primary Care Reforms in Ontario, Manitoba, Alberta, and the Northwest Territories. Vol. 2. Toronto; 2018. Suter E, Mallinson S, Misfeldt R, Boakye O, Nasmith L, Wong ST. Advancing team-based primary health care: A comparative analysis of policies in western Canada. BMC Health Serv Res. 2017;17(1):1–9. Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, et al. Core principles and values of effective team-based health care. Washington; 2012. p. 79–80. Levesque JF, Haggerty JL, Hogg W, Burge F, Wong ST, Katz A, et al. Barriers and facilitators for primary care reform in Canada: Results from a deliberative synthesis across five provinces. Healthcare policy. 2015;11(2):44–57. Willis E. Introduction: taking stock of medical dominance. Health Sociology Review. 2006;15(5):421–31. McDonald J, Jayasuriya R, Harris MF. The influence of power dynamics and trust on multidisciplinary collaboration: A qualitative case study of type 2 diabetes mellitus. BMC Health Serv Res. 2012;12(1):1–10. Okpalauwaekwe U, MacPhee BK, Balezantis L, Mahani A, Zarzeczny A, Ramsden VR, et al. Facilitators, barriers, and priorities for enhancing primary care recruitment and retention in Saskatchewan, Canada. BMC primary care. 2025;26(1):373. Kreindler SA, Struthers A, Metge CJ, Charette C, Harlos K, Beaudin P, et al. Pushing for partnership: physician engagement and resistance in primary care renewal. J Health Organ Manag. 2019;33(2):126–40. Shaw EK, Howard J, West DR, Crabtree BF, Nease DE, Tutt B, et al. The Role of the Champion in Primary Care Change Efforts. The Journal of the American Board of Family Medicine [Internet]. 2012 Sep 1;25(5):676–85. Available from: file:///C:/Users/Ivone/AppData/Local/Mendeley Ltd./Mendeley Desktop/Downloaded/Honrado et al. - 2002 - Classification and Mapping of Terrestrial and Inter-Tidal Vegetation in the Atlantic Coast of Northern Portugal.pdf Khan AI, Barnsley J, Harris JK, Wodchis WP, Irfan A, Barnsley J, et al. Examining the extent and factors associated with interprofessional teamwork in primary care settings. J Interprof Care. 2022;36(1):52–63. D’Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. J Interprof Care. 2005;19(SUPPL. 1):8–20. Xyrichis A, Ream E. Teamwork: A concept analysis. J Adv Nurs. 2008;61(2):232–41. Baker L, Egan-Lee E, Martimianakis MA, Reeves S. Relationships of power: Implications for interprofessional education. J Interprof Care. 2011;25(2):98–104. MacNaughton K, Chreim S, Bourgeault IL. Role construction and boundaries in interprofessional primary health care teams: A qualitative study. BMC Health Serv Res. 2013;13(1). Giddens A. The constitution of society: Outline of the theory of structuration. Berkeley, CA: University of California Press.; 1984. Kreindler SA, Metge C, Struthers A, Harlos K, Charette C, Bapuji S, et al. Primary care reform in Manitoba, Canada, 2011–15: Balancing accountability and acceptability. Health Policy (New York) [Internet]. 2019;123(6):532–7. Available from: https://doi.org/10.1016/j.healthpol.2019.03.014 Shahaed H, Glazier RH, Anderson M, Barbazza E, Bos VLLC, Saunes IS, et al. Primary care for all: lessons for Canada from peer countries with high primary care attachment. CMAJ Canadian Medical Association Journal. 2023;195(47):E1628–36. Peckham A, Ho J, Marchildon G, Marani H, Farr M, Farrell P, et al. Policy Innovations in Primary Care Across Canada A Rapid Review Prepared for the Canadian Foundation for Healthcare Improvement Acknowledgements We would like to gratefully acknowledge the support of. Toronto; 2018. Usher S, Denis JL, Préval J, Baker R, Chreim S, Kreindler S, et al. Learning from health system reform trajectories in seven Canadian provinces. Health Econ Policy Law. 2021;16(4):383–99. Additional Declarations Competing interest reported. Dr. Harrison provides family medicine services in private practice at the Associate Family Physicians clinic, the clinical site studied in this research. To mitigate potential bias, the study design was finalized before data collection; data extraction and analysis were conducted by coauthors who do not have any relationship to the clinic; and interpretations were reviewed collaboratively by all authors. The authors report no other conflicts of interest. Supplementary Files SuppfileInterviewguideexample.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers invited by journal 19 Feb, 2026 Editor assigned by journal 19 Feb, 2026 Editor invited by journal 10 Feb, 2026 Submission checks completed at journal 09 Feb, 2026 First submitted to journal 09 Feb, 2026 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. 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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-8743811","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":590549735,"identity":"76abcd07-6f28-4c3f-94d8-90705e5120c9","order_by":0,"name":"Coralie Darcis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIie3PsWrDMBCA4TMCTSFZlaF5hgMtHYKf5YRBWTJkb6Ce4qnkEfwKeQSBwV7cehV0STAkSwZ3y2BoVWgpHWR37KAfJLjh4ySAUOi/dkR3GXcIlp8zGyf0Q/RfCXwRgGKczLKnU0ebJUyr51N37BuVZ1WLsI29RNSVFIQa5vVKCrV7VYd6LQnKxEtQaHCkADSag0odgTUzUep/nCPsRvgO2Jw5UP+i8v2ldeRxiHC3xQBat4W4UaklSVFaDPyl5PeEyWRuz8z9JZEHe5VIZeUls2zHbNfHi2mjo7dbH9/l+1Uruu2Dl3w3+T3SKAiFQqHQUB98slSzyQ1RuAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":true,"prefix":"","firstName":"Coralie","middleName":"","lastName":"Darcis","suffix":""},{"id":590549736,"identity":"4dae97d2-0f7a-4723-a8fa-6ff671264038","order_by":1,"name":"Emmett Harrison","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Emmett","middleName":"","lastName":"Harrison","suffix":""},{"id":590549737,"identity":"55d30171-8e0e-4bce-91b2-873a020aa7b7","order_by":2,"name":"Haizhen Mou","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"Haizhen","middleName":"","lastName":"Mou","suffix":""}],"badges":[],"createdAt":"2026-01-30 17:38:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8743811/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8743811/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102742257,"identity":"1ca3d2d8-0072-433a-b9a4-334c4dda475c","added_by":"auto","created_at":"2026-02-16 08:06:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":712479,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8743811/v1/95eade8c-a768-4621-acd6-395930a2732f.pdf"},{"id":102742256,"identity":"61b10a6f-3bb9-4f57-bbf2-5cdb2295aebb","added_by":"auto","created_at":"2026-02-16 08:06:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":153062,"visible":true,"origin":"","legend":"","description":"","filename":"SuppfileInterviewguideexample.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8743811/v1/67e08dfe15808bb68be9290d.pdf"}],"financialInterests":"Competing interest reported. Dr. Harrison provides family medicine services in private practice at the Associate Family Physicians clinic, the clinical site studied in this research. To mitigate potential bias, the study design was finalized before data collection; data extraction and analysis were conducted by coauthors who do not have any relationship to the clinic; and interpretations were reviewed collaboratively by all authors. The authors report no other conflicts of interest.","formattedTitle":"Advancing Team-Based Care in Private Practices: A Case Study of a Public–Private Hybrid Model","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe primary care system in Canada is facing a crisis, marked by poor patient access, provider burnout, and fewer graduates choosing family medicine (1\u0026ndash;4). The prevailing physicians\u0026rsquo; \u0026ldquo;soloist\u0026rdquo; private-practice model is under increasing pressure (5) with escalating workloads and costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the early 2000s, the federal government launched major investments to support primary care reform, including an $800-million Primary Health Care Transition Fund to help provinces and territories implement transformation initiatives \u003cem\u003e(6\u0026ndash;8)\u003c/em\u003e. A key goal was to promote interdisciplinary teams, a shift strongly endorsed by professional organizations \u003cem\u003e(9)\u003c/em\u003e and increasingly accepted by physicians, particularly younger ones\u003cem\u003e\u0026nbsp;(10,11)\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProgress has been uneven. Provinces have adopted diverse models, ranging from Alberta\u0026rsquo;s physician-led networks to Ontario\u0026rsquo;s community health teams and Quebec\u0026rsquo;s family medicine groups, each with distinct structures, funding mechanisms, and team compositions (6,12,13). As a result, each jurisdiction\u0026rsquo;s primary care system looks different, with its own strengths and weaknesses\u0026nbsp;\u003cspan lang=\"EN-CA\"\u003e(14)\u003c/span\u003e. This fragmented rollout, combined with limited documentation of lessons learned (8,12), underscores the need to examine local innovations to better understand pathways to team-based care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite widespread enthusiasm for these models, their adoption remains a challenge in numerous Canadian jurisdictions (14) due to structural and cultural barriers, funding constraints, and physician resistance (15,16). These challenges are even more pronounced in private practices, which face additional obstacles. Most still operate under the fee-for-service (FFS) payment model, which is poorly aligned with team-based care (7,17) and constrains the financing of interdisciplinary teams. In addition, the private practice model is closely tied to professional autonomy and entrepreneurship, values central to physicians\u0026rsquo; professional identity (6,18,19). While many family physicians express interest in team-based care, efforts to maintain their autonomy complicate the transition (19).\u003c/p\u003e\n\u003cp\u003eIn Saskatchewan, these conditions have contributed to the development of an innovative public\u0026ndash;private hybrid organizational model. With funding support from the provincial health authority, private practices are gradually integrating publicly funded allied health professionals into their workplaces. Their initial goal is to improve service capacity by decreasing family physicians\u0026rsquo; workload. Initially established as pilot initiatives, these models now have permanent funding and have inspired similar efforts elsewhere in the province.\u003c/p\u003e\n\u003cp\u003eWhile this public\u0026ndash;private hybrid model has the potential to support the transformation of traditional private practices into team-based settings, the challenges associated with this transition are under-documented. Understanding the advantages and limitations of this model is therefore essential to inform future policy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis paper addresses this gap through a case study of a primary care clinic in Saskatchewan. It examines how public\u0026ndash;private hybrid models can facilitate the transition of private practices to team-based care, as well as the benefits and challenges associated with this approach.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003earticle first provides background on this clinic\u0026rsquo;s pilot initiative, followed by the study\u0026rsquo;s methodology and results. These findings inform a broader discussion of organizational and cultural change, professional dynamics, and accountability in team-based primary care. Although this study focuses on Saskatchewan, the challenges examined are common across Canada and other jurisdictions with FFS-based private practices.\u003c/p\u003e"},{"header":"2.\tBackground","content":"\u003cp\u003eUnder Canada\u0026rsquo;s federal system, responsibility for the funding, governance, organization, and delivery of primary care rests with provincial and territorial governments. Although services are publicly funded, they are primarily delivered through physician-led private practices. Saskatchewan\u0026rsquo;s primary care system is highly reliant on these practices, an issue that is compounded by a shortage of family physicians and ongoing recruitment and retention challenges (20)\u0026nbsp;especially in rural areas.\u003c/p\u003e\n\u003cp\u003eResponding to these pressures, the Associate Family Physician Clinic (hereafter \u0026ldquo;Associate Clinic\u0026rdquo;) in southern Saskatchewan implemented a pilot project in 2023 to transition from a traditional private practice model to a team-based one. Located in a semi-rural, agricultural region, the Associate Clinic serves about 10,000 patients. Prior to the pilot project, the clinic operated as a traditional private practice, with family physicians supported by receptionists and medical office assistants (MOAs). In 2022, the clinic began its transition toward team-based care. The first change was the co-location of a\u0026nbsp;mental health counselor\u0026nbsp;funded by the Saskatchewan Health Authority (SHA) and focused on addressing mental health and addiction needs of patients. Over time, that role evolved into a Behavioral Health Consultant (BHC) position with a broader clinical scope.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBuilding on the success of this initial step, the team-based care initiative expanded into a formal pilot project in October 2023. The pilot was funded by the SHA, with the goal of developing a Patient Medical Home (PMH) care model. The PMH is a physician-led, team-based model developed by the College of Family Physicians of Canada (9), in which patients are attached to family physicians who work collaboratively with an interprofessional team to deliver coordinated, and patient-centered care. As part of the pilot, the SHA funded the integration of additional allied health professionals, including nurses, with the expectation that this would reduce family physician workload, expand service offerings, and improve patient access.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the time of data collection in early 2025, the clinic consisted of one clinic manager, eight family physicians, one licensed practical nurse, two registered nurses, one BHC, four MOAs, and three receptionists. In April 2025, the pilot was formally transitioned into a permanent initiative, with sustained funding provided by the provincial Ministry of Health. Under this arrangement, the clinic operated as a public\u0026ndash;private hybrid organizational model in which family physicians continued to be remunerated through FFS payments, while allied health professionals were publicly funded and integrated into the clinic team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile early indications suggested improvements in patient access and physician satisfaction, the hybrid arrangement also introduced organizational, operational, and governance challenges. As this model begins to inspire additional initiatives in the province and beyond, a systematic examination of its implementation, benefits, and limitations is needed. Accordingly, this study addresses the following research questions: (i) How do public\u0026ndash;private hybrid organizational arrangements facilitate the implementation of team-based care in private primary care practices? (ii) What benefits and challenges emerge from this approach?\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003eTo address the research questions, we used a qualitative case study design focused on the Associate Clinic\u0026rsquo;s public\u0026ndash;private hybrid model of care. A case study design was well suited to capturing the organizational, professional, and governance dynamics of this model within its real-world context.\u003c/p\u003e\n\u003ch2\u003e3.1 Data collection\u003c/h2\u003e\n\u003cp\u003eWe used three complementary data collection methods: document analysis, semi-structured interviews, and non-participatory observations. First, document analysis allowed us to clearly understand the pilot\u0026rsquo;s background and implementation context. Documents included materials formally describing the pilot, such as role descriptions, work standards, routine measures, and reports on initial outcomes. This analysis informed the development of interview guides and observation protocols.\u003c/p\u003e\n\u003cp\u003eSecond, we conducted semi-structured interviews\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eto capture\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003estakeholder experiences. A total of 27 interviews were completed, with seven family physicians, three nurses, three family medicine residents, one clinic manager, one BHC, one MOA, 10 patients, and one SHA representative. Informed consent was obtained from all participants prior to data collection. Interviews were audio-recorded and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003eParticipants were selected based on their exposure to both pre- and post-pilot care models, enabling them to reflect on the transition. Clinic staff and physicians were recruited via email or letters where email was unavailable. Patient recruitment involved several strategies, including posters displayed in the clinic and an announcement posted on the clinic\u0026rsquo;s Facebook page. To ensure diverse patient perspectives, patients were selected using a pre-screening questionnaire that captured age, length of registration with the clinic, and the approximate number of visits in the past 12 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterview guides were developed specifically for this study and adapted to participant roles and research stage. One example can be found in supplementary files. Patients were primarily asked to describe their experience with the clinic since the pilot, including perceptions of access, satisfaction, additional services, and quality of care. Clinic staff and physicians were invited to reflect on changes in care delivery model, teamwork dynamics, role distribution, and work processes, as well as factors that supported or hindered implementation.\u003c/p\u003e\n\u003cp\u003eFinally, we conducted non-participatory observations\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eof clinic workflows, completing two separate three-day observation periods. We observed daily clinic operations, morning huddles, informal interactions among team members, and a meeting involving clinic leaders and SHA representatives. We also shadowed each of the three nurses for extended periods during routine activities, including patient encounters, triage, and documentation. Observational data were recorded as detailed field notes.\u003c/p\u003e\n\u003cp\u003eData collection continued until thematic saturation was reached, defined as the point at which no new codes, themes, or dimensions emerged during subsequent interviews and observations.\u003c/p\u003e\n\u003ch2\u003e3.2 Data analysis\u003c/h2\u003e\n\u003cp\u003eData collection and analysis proceeded iteratively, with preliminary analysis conducted between data collection periods to refine interview guides and observational focus. We conducted multiple rounds of manual thematic analysis using an abductive approach. Initial themes were informed by the research objectives and literature, while additional themes emerged inductively during the data analysis. Regular discussions among the research team helped refine the coding system, clarify emerging categories, and improve the analysis.\u003c/p\u003e\n\u003cp\u003eFindings from the interview analysis were compared with those from observations and document analysis to identify convergence and discrepancies across data sources. This triangulation strengthened analytic credibility. Following analysis, results were shared with the Associate Clinic team to confirm that findings accurately reflected their experience and to validate interpretive accuracy. Although interview excerpts are used to illustrate key findings in the Results section, interpretations are grounded in the full body of data.\u003c/p\u003e"},{"header":"4.\tResults","content":"\u003cp\u003eThe pilot project was widely regarded as a success by interviewees, particularly with respect to care delivery, patient outcomes, and provider satisfaction. Nonetheless, the data also revealed differences in perspectives and concerns among providers and highlighted both the advantages and challenges of the public\u0026ndash;private hybrid model. The findings are organized around the key benefits and challenges of the model as identified by interviewees.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e4.1 Benefits of the hybrid model\u003c/h2\u003e\n\u003cp\u003eAccording to participants, the primary benefits of the hybrid model were (i) the removal of resource constraints, (ii) the preservation of family physicians\u0026rsquo; autonomy, and (iii) the promotion of patient-centered care.\u003c/p\u003e\n\u003ch3\u003e4.1.1 Removal of resource constraints\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eAssociate Clinic physicians had long expressed interest in moving away from \u0026ldquo;solo\u0026rdquo; practice towards a more collaborative care model, but as a private practice they faced substantial barriers in doing so. Chief among these was a lack of financial resources to hire allied health professionals, whose salaries and benefits would have to be covered by physicians, without generating corresponding billable revenue. Recruiting experienced nurses was described as particularly costly, making such investments difficult to justify in the short term. By reallocating existing employees to the clinic and covering their compensation, the SHA removed this financial barrier.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNevertheless, the integration of publicly funded staff generated indirect costs for the clinic, including the use of space, equipment, and administrative infrastructure. One physician described this concern in the following way:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;As a business you\u0026apos;re allowing another person to come into your business, you\u0026apos;re taking up space. It costs us money to put her in our building, to get a computer, to get the fax line, to do all the things to have a person in our building without getting any compensation.\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eAs the pilot implementation progressed, the health authorities and the clinic negotiated an agreement to offset the additional costs incurred.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIntegrating allied health professionals also required substantial changes to workflows, coordination mechanisms, and clinical routines, demanding time and effort from the family physicians. To facilitate the transition, the health authorities provided partial funding for one of the physicians to assume a leadership role in implementing the pilot. This support allowed for dedicated time to manage change processes, liaise with stakeholders, and ensure the new roles were integrated in ways aligned with the clinic\u0026rsquo;s operational realities and care objectives. As one physician noted:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;One of the most important components that maybe isn\u0026apos;t front and center and people don\u0026apos;t always see, is that physician leadership. Our physician leader [\u0026hellip;] has been very important, helped us stay on track, develop those work standards and keep our new staff on track with their learning and with integrating into the clinic. So, if this is going to be duplicated at other places, having that funding available for physician leadership, it\u0026apos;s going to be very important. And someone who\u0026apos;s like a champion at it, right?\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eThis funding for physician leadership also fostered sustained engagement across the family physician group, which proved pivotal to the successful rollout of the pilot. A SHA representative described this engagement:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They take the bull by the horns, they create the workflows, and they integrate them [the allied health professionals] into the team. Physicians are really engaged, they take turns being \u0026lsquo;doctor of the day,\u0026rsquo; all of that stuff. That engagement level is there. [\u0026hellip;] That physician leadership I think just creates buy-in in itself.\u0026rdquo; (SHA representative).\u003c/p\u003e\n\u003cp\u003eUnder these conditions, the hybrid model mitigated resource constraints and enabled the clinic to pursue organizational change at a moment when physicians were motivated to innovate but lacked the capacity to do so independently.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e4.1.2 Preservation of family physicians\u0026rsquo; autonomy\u003c/h3\u003e\n\u003cp\u003eAlthough clinic physicians expressed strong support for team-based care, many initially feared that greater involvement from the SHA could threaten their professional autonomy. One physician explained this concern in relation to the FFS model:\u0026nbsp;\u0026ldquo;We as fee-for-service physicians prioritize our autonomy and freedom. That\u0026rsquo;s one of the reasons that we work in this model. So, kind of being reluctant to do something that would kind of tie our hands with that.\u0026rdquo; (Associate Clinic Family Physician). The concern about losing professional autonomy was a recurring theme in physician interviews, with several of them mentioning that it could be a barrier to adopting the hybrid public\u0026ndash;private organizational model in other clinics. As the pilot progressed, however, most physicians reported that these fears proved largely unfounded. As one physician reflected, apprehensions about external interference were more perceived than real:\u0026nbsp;\u0026ldquo;I think it\u0026rsquo;s a false barrier. I don\u0026apos;t think it\u0026apos;s real, but I think that that could be something that people see as a reluctance to allow SHA into their practice.\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eOverall, family physicians retained complete autonomy over clinical (e.g., how they deliver care and manage their patient panels) and organizational (e.g., how the clinic operates in terms of scheduling, workflows, and internal policies) aspects. In terms of governance, they also retained substantial autonomy: while the hybrid model required certain compromises, the clinic continues to operate as a physician-led entity, with family physicians maintaining full decision-making authority. While the implementation of the pilot was shaped by ongoing negotiations with health authorities, interviewees explained that they have adopted a cooperative and flexible approach, accommodating clinic needs. \u003cstrong\u003eFamily physicians thus maintained significant control over how the pilot was designed and implemented in their clinic.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAs a result,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe hybrid model functioned as a compromise that enabled collaboration while preserving core elements of physician autonomy, an outcome widely viewed as essential to sustaining physician engagement.\u003c/p\u003e\n\u003ch3\u003e4.1.3 Promotion of patient-centered care\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003ePrivate clinics operate under financial constraints that prioritize efficiency and sustainability. Physicians frequently cited financial considerations as key to decision-making. As one family physician explained, this left little room for patient-centered thinking:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There was a [SHA] manager, he\u0026rsquo;s gone now, he would say to me, \u0026lsquo;well, you\u0026apos;re helping your patients.\u0026rsquo; And I would say \u0026lsquo;yes, but this is a private business. If we can\u0026apos;t pay bills, the door is closed. This isn\u0026apos;t SHA business where you can run at deficit and still open your doors.\u0026rsquo; [\u0026hellip;] We can\u0026apos;t do that in a private clinic. We have to pay the bills.\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eThe introduction of public funding created space for greater attention to patient needs in decision-making. Interviewees described expanded services, improved access to care, and new team-based practices, such as morning huddles, all contributing to higher quality, more continuous care. Physicians reported increased capacity to follow patients over time and to adopt a more patient-centered approach. As reflected in this comment, patients also reported greater personalized attention and continuity of care:\u0026nbsp;\u0026ldquo;I felt like they were actually looking out for [me]. It wasn\u0026rsquo;t \u0026lsquo;Here, take these meds, we\u0026rsquo;ll see you in a couple months\u0026rsquo;, you know? [\u0026hellip;] There\u0026rsquo;s a ton of follow-up where I believe that wasn\u0026rsquo;t happening before.\u0026rdquo; (Associate Clinic patient). Several of the interviewed patients echoed this sense of personalized attention and continuity of care. Family physicians also reported feeling more able to follow their patients over time and to adopt a more patient-centered approach.\u003c/p\u003e\n\u003cp\u003eIn addition, involving the SHA in decision-making also facilitated stronger population-health approaches. The clinic and the health authority jointly monitored key performance indicators such as \u0026ldquo;third next available appointment\u0026rdquo;, wait times for and use of specific services, and patient satisfaction. These data guided decision-making. Furthermore, by collecting its own data on the healthcare facilities and services, the SHA gained knowledge about the healthcare needs of the patient population and the challenges facing the healthcare system. Such first-hand information helped both the SHA and the Associate Clinic obtain a deeper understanding of the local healthcare landscape and adjust the services offered at the clinic according to the patients\u0026rsquo; needs. As one SHA representative noted, routine monitoring of service-use data enabled the health authority and clinic to adjust staffing in response to patient demand:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The BHC at Associate Clinic had 98 referrals last month. [\u0026hellip;] At this other clinic, the BHC has had 12 referrals in the same period. So, we\u0026rsquo;re going to pull her over to Associate Clinic one day or two more a week.\u0026rdquo; (SHA representative).\u003c/p\u003e\n\u003cp\u003eThis illustrates how SHA\u0026rsquo;s involvement in privately delivered primary care enables a level of system‑wide coordination and responsiveness that individual clinics would not be able to achieve on their own, ensuring that resources can be directed to where they are most needed.\u003c/p\u003e\n\u003cp\u003eFinally, the involvement of the SHA seemed to better connect the Associate Clinic with other healthcare services such as home care, public health, and mental health services, which tended to work in silos. For example, having the BHC co-located at the Associate Clinic helped develop personal relationships and improve data and system integration between the clinic and public mental health agencies. As a result, the participants described the clinic as being better integrated into the larger healthcare system, supporting continuity of care for patients.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e4.2 Challenges of the hybrid model\u003c/h2\u003e\n\u003cp\u003eDespite these benefits, participants identified three key challenges associated with the hybrid model: (i) physician distrust of public authorities as an impediment to uptake; (ii) incompatibility with FFS payment under some conditions; and (iii) structural and operational barriers.\u003c/p\u003e\n\u003ch3\u003e4.2.1 Physician distrust of public authorities\u003c/h3\u003e\n\u003cp\u003eWhile the clinic\u0026rsquo;s medical group acknowledged the need to shift the care model to benefit both patients and physicians, they expressed concerns about the health authorities becoming involved in their business operations. Beyond fears about loss of autonomy, interview data revealed deep tensions between the professional culture of private practice and the institutional culture of the SHA. Physicians pointed to differences in visions for care delivery and, more importantly, in operational approaches. They described SHA\u0026rsquo;s management of its own facilities as inefficient, slow, and overly bureaucratic. At first, the prospect of integrating SHA personnel accustomed to different management practices raised concerns about a potential loss of efficiency within the clinic:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We did not want the SHA and the way that they tend to run clinics and their businesses in our clinic because we don\u0026apos;t feel that\u0026rsquo;s efficient and how we want our healthcare system and our clinic to run. So that was like an overarching theme that we knew as physicians: \u0026lsquo;OK, when SHA is going to come into our clinic, we did not want that culture to be brought in with that.\u0026rsquo;\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eThis comment suggests that cultural and operational misalignment between private clinics and public health authorities may represent a significant barrier to further implement public\u0026ndash;private hybrid arrangements.\u003c/p\u003e\n\u003cp\u003eThese concerns reflect longstanding distrust of the health authority, rooted in physician perceptions that centralized institutions lack understanding of local realities:\u0026nbsp;\u0026ldquo;I honestly feel like we don\u0026apos;t have much trust in that, that the bigger institutions don\u0026apos;t necessarily know what we need, even in our own province.\u0026rdquo; (Associate Clinic Family Physician). While trust developed over time in the Associate Clinic through close working relationships between physicians and SHA representatives, participants noted that such distrust could discourage uptake of hybrid models elsewhere.\u003c/p\u003e\n\u003ch3\u003e4.2.2 Incompatibility with fee-for-service payment model\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eSeveral physicians viewed the FFS payment model as incompatible with the public\u0026ndash;private hybrid arrangement because of its influence over task delegation. It was explained that expanding nurses\u0026rsquo; roles may require physicians to relinquish certain quick and financially advantageous procedures, creating an economic disincentive when these tasks constitute a significant proportion of their income.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Associate Clinic\u0026rsquo;s physician group accepted this short-term financial risk, viewing it as an opportunity to benefit their practice over the longer term. These physicians judged that gains in professional satisfaction and patient outcomes would outweigh the loss of billable activities. When asked how the new team-based care model affected billing under a FFS payment model, one family physician explained:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;For chronic disease management appointments, it doesn\u0026rsquo;t affect [billing]. It adds some efficiency if they [the nurses] go in, and as we still go in, we\u0026rsquo;re still having our visit that we bill the government for it. For other things like removal of sutures and PAPS, we just let that go. There\u0026rsquo;s no billing that comes because we\u0026rsquo;re not seeing the patient and we just kind of take it as like that point of serving the practice.\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eThis quotation illustrates that financial considerations remain a central criterion in physicians\u0026rsquo; decisions on what tasks to delegate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSuch concerns may become even more pronounced in contexts where patient demand is lower and where delegation could directly affect income. One physician put it this way:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If you go out to a scenario where my wait time was very short and I was servicing my practice really well, I might not want to delegate more because then I might have open spots in my day that then would affect my billings.\u0026rdquo; (Associate Clinic Family Physician).\u003c/p\u003e\n\u003cp\u003eThese dynamics indicate that FFS payment structures influenced clinical decision-making during the pilot and could constrain the expansion of task-sharing under certain conditions. As explained by interviewees, this could potentially override other important factors such as the clinical appropriateness, the potential to improve care quality and access, and the optimization of each provider\u0026rsquo;s scope of practice.\u003c/p\u003e\n\u003ch3\u003e4.2.3 Structural and operational barriers\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe implementation of the pilot project at the Associate Clinic unfolded in a pragmatic and largely improvisational manner. Operational and logistical aspects such as workflow organization, data sharing arrangements, and allocation of workspace were mostly established in practice, while formal contractual questions were addressed along the way. This meant that administrative constraints did not impede the early stages of implementation.\u003c/p\u003e\n\u003cp\u003eHowever, at later stages, interviewees noted that operationalizing the hybrid model required navigating regulatory, contractual, and technical barriers associated with two systems that traditionally operated in silos and followed distinct organizational logics. They encountered barriers linked to the absence of formal agreements and the rigidity of existing contractual frameworks. One interviewee contrasted this experience with that of another, more top-down pilot project, where these issues became major obstacles to the first stages of implementation:\u0026nbsp;\u0026ldquo;They\u0026apos;re running into issues trying to do some of this co-location and EMR sharing, because contracts are stating: \u0026lsquo;Don\u0026apos;t\u0026rsquo;.\u0026rdquo; (SHA representative)\u003c/p\u003e\n\u003cp\u003eFinancial arrangements with the hybrid model were also complex. Although publicly funded staff enhanced care delivery and physicians\u0026rsquo; work satisfaction, their integration generated ongoing costs for space, equipment, and administrative support, requiring continuous evaluation and negotiation.\u003c/p\u003e\n\u003cp\u003eFinally, managing staff funded by public and private sources introduced ambiguity around supervision, performance, and decision-making authority. Nurses reported confusion about authority, particularly given the absence of on-site SHA leadership. Participants emphasized the importance of monitoring these dynamics to prevent tension and support team cohesion as hybrid models evolve.\u003c/p\u003e"},{"header":"5.\tDiscussion","content":"\u003cp\u003eThis study examined a public\u0026ndash;private hybrid pilot model of primary care implemented within a physician-led private practice operating under a FFS payment model. The findings highlight both the potential and limitations of hybrid arrangements as pathways for advancing team-based care in settings where private practice is dominant. In this section, we consider the broader implications of these findings for primary care reform, focusing on hybrid models as catalysts for change, power and professional participation, and emerging questions of accountability.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e5.1 Public\u0026ndash;private hybrid models as a catalyst for change\u003c/h2\u003e\n\u003cp\u003eImplementing team-based care in private practices is challenging, particularly when physicians bear the financial and organizational risks associated with hiring additional staff. Resources are often limited, and without external support, the costs of hiring, coordinating and sustaining interprofessional teams can outweigh the perceived benefits, making change difficult to initiate (16).\u003c/p\u003e\n\u003cp\u003eIn this context, the hybrid model examined here functioned as a catalyst for organizational change. Public funding enabled the Associate Clinic to overcome long-standing obstacles to adopting team-based care by alleviating financial and organizational constraints and supporting dedicated physician leadership. The model allowed physicians to adopt collaborative practices while retaining the autonomy associated with private practice. Rather than requiring a fundamental restructuring of ownership, payment arrangements, and professional identities, the hybrid approach enabled incremental reform within existing institutional frameworks.\u003c/p\u003e\n\u003cp\u003eThese findings suggest that hybrid models may offer a pragmatic solution to physician shortages and unmet patient needs, particularly in rural or semi-rural areas. By leveraging existing private infrastructure and supplementing it with publicly funded professionals, hybrid arrangements can expand service capacity and improve access to care. While these arrangements supported service expansion, they also allowed family physicians to remain in private practice while working within teams, which has the potential to reduce pressure on family physicians, enhance their job satisfaction, and ultimately improve retention.\u003c/p\u003e\n\u003cp\u003eHowever, the long-term success of hybrid models hinges on their scalability and sustainability. First, our findings show that misaligned institutional logics (namely, the autonomy driven, entrepreneurial orientation of private practices \u003cem\u003eversus\u003c/em\u003e the emphasis on standardization and bureaucratic accountability within government health authorities) can fuel distrust and complicate collaboration. As Kreindler et al. \u003cem\u003e(21)\u003c/em\u003e cautioned, partnership reforms can pose an identity threat for family physicians by compelling them to participate in bureaucratic enterprises. Addressing these tensions\u0026nbsp;requires trust-building strategies that respect the professional identity of family physicians \u003cem\u003e(21)\u0026nbsp;\u003c/em\u003eand acknowledge the central role of medical practice and professional autonomy in primary care delivery. Indeed, healthcare reforms frequently falter when health authorities underestimate the financial and clinical autonomy of physicians, which is core to their professional identity \u003cem\u003e(6,7,21)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eSecond, the success of transforming private practices into team-based settings depends on strong physician leaders acting as champions for change. Beyond providing logistical support, these champions help secure physician buy-in and sustain engagement over time. Attention to the champion\u0026rsquo;s role, including how such leaders are identified and supported, is therefore essential to effective implementation \u003cem\u003e(22).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThird, a one-size-fits-all approach is unlikely to address the needs of both patients and providers across different local contexts. Flexibility in implementation is therefore required to adapt team-based care models to the specific characteristics of individual communities. Furthermore, private practices vary in their capacity to accommodate change, and some may require targeted investments in infrastructure (such as physical space, digital tools, and administrative systems) to support the implementation of team-based care.\u003c/p\u003e\n\u003ch2\u003e5.2 Power dynamics and professional participation in hybrid models\u003c/h2\u003e\n\u003cp\u003eShared power and leadership are foundational attributes of interprofessional teamwork within primary care settings \u003cem\u003e(23,24)\u003c/em\u003e,\u003cem\u003e\u0026nbsp;\u003c/em\u003eand the principle of shared decision-making is a cornerstone of effective team-based care models \u003cem\u003e(25).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile the hybrid model facilitates the integration of team-based care into private practices, it remains a physician-led model of care. In this public\u0026ndash;private hybrid model, physician leadership was both expected and central to practice operations. The Associate Clinic was owned by a family physician and governed by the family physicians\u0026rsquo; group, who were also the primary income earners.\u003c/p\u003e\n\u003cp\u003ePower imbalances between providers from different training backgrounds represent a challenge to implementing well-functioning team-based care \u003cem\u003e(23,26)\u003c/em\u003e, especially when allied health professionals are viewed as support staff rather than equal partners in care delivery. Cultural and professional hierarchies among healthcare providers can limit participation and influence of non-physician team members in decision-making\u003cem\u003e\u0026nbsp;(27)\u003c/em\u003e. Without mechanisms to support shared governance, hybrid models risk undermining the principles of collaborative practice. Ongoing attention will be needed to assess which of these mechanisms most effectively foster participation by allied health professionals.\u003c/p\u003e\n\u003ch2\u003e5.3 A path toward more accountability in primary care\u003c/h2\u003e\n\u003cp\u003eAccountability, broadly defined, is the expectation that individuals or organizations will explain and justify their actions to others. In sociological terms, accountability extends beyond formal reporting requirements to include how actors recognize their responsibilities, reflect on their behavior, and respond to expectations shaped by social norms, institutions, and relationships (28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe emergence of public\u0026ndash;private hybrid models in primary care raises questions about accountability at multiple levels. At the local level, a central concern is under what conditions these initiatives enable local health authorities to fulfill their mandates, including improving access, enhancing service integration, and responding to community\u0026rsquo; needs. Tailoring care to local contexts requires adopting a population health approach, which in turn calls for some degree of system steering and the establishment of accountability mechanisms.\u003c/p\u003e\n\u003cp\u003eQuestions therefore arise about how accountability will evolve in these new hybrid arrangements. One challenge is that outcomes monitoring in primary care is difficult to implement (12),\u0026nbsp;particularly when measuring patient engagement and assessing the impacts of coordinated care. Another key challenge concerns private practice physicians\u0026rsquo; core values of autonomy and entrepreneurship. To sustain physician engagement, or in other words to ensure the \u0026ldquo;acceptability\u0026rdquo; (29)\u003cem\u003e\u0026nbsp;\u003c/em\u003eof reform efforts, these arrangements must balance respect for professional independence and autonomy with expectations of accountability and quality improvement \u003cem\u003e(12)\u003c/em\u003e. These challenges\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ehighlight the importance of examining how governance and reporting mechanisms are negotiated in hybrid models.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond the local level, accountability to citizens for the performance of the healthcare system is a significant gap in Canada\u0026rsquo;s primary care landscape (7,29). One contributing factor is that primary care is publicly funded but largely delivered through private practices, a structural arrangement that has long allowed providers to operate with limited formal obligations to ensure they are meeting the needs of the populations they serve:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMost family physicians in Canada are private contractors who carry no obligations or accountability for the breadth of services they provide, the location of their practices, their hours of operation, their staffing mix, the patients they accept or their ability to meet local population needs.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(30)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite decades of recommendations from expert commissions and policy initiatives aimed at strengthening accountability in healthcare \u003cem\u003e(6,31,32)\u003c/em\u003e, Canadian provincial and territorial governments have struggled to implement mandatory requirements for primary care physicians \u003cem\u003e(7)\u003c/em\u003e. This accountability gap has serious implications, particularly during crises when public authorities are expected to respond and community-responsive care is most needed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe argue that public\u0026ndash;private hybrid models have the potential to introduce new accountability dynamics within the healthcare system, warranting close examination. On one hand, these arrangements may create opportunities to embed accountability if public funding is tied to explicit expectations (for example in terms of service volume, patient profiles) supported by measurement and monitoring mechanisms that inform decision-making and quality improvement. The Results section showed how new funding arrangements incrementally integrated population-health considerations into decision-making while being attentive to private practice logics.\u003c/p\u003e\n\u003cp\u003eOn the other hand, hybrid arrangements also carry risks. Private organizations\u0026rsquo; priorities may come to exert greater, albeit indirect, influence over local service delivery. Governance mechanisms (such as funding agreements, performance metrics, and reporting requirements) thus play a central role in shaping how accountability is enacted in practice. In addition, hybrid models risk further blurring lines of responsibilities. Public and private actors operate under distinct accountability frameworks, agendas, mechanisms, and expectations. Public accountability is typically rooted in external\u003cem\u003e\u0026nbsp;\u003c/em\u003eexpectations (i.e., democratic governance, transparency, and responsiveness to societal needs), whereas private accountability is often grounded in internal expectations such as efficiency, profitability, and professionals\u0026rsquo; ethics. How these differing models of accountability will coexist remains an open question.\u003c/p\u003e\n\u003cp\u003eThe form that accountability takes in hybrid primary care arrangements, and the conditions under which it is strengthened or eroded in these models, is a pressing area for research. Future work should examine how accountability is operationalized in these settings, including whether more public sector involvement leads to new forms of reporting or answerability and how governance mechanisms influence professional behavior without undermining physician engagement. Understanding how accountability is negotiated and enforced is critical to assessing the legitimacy and effectiveness of hybrid healthcare governance.\u003c/p\u003e"},{"header":"6.\tConclusion","content":"\u003cp\u003eThe transformation of primary care in Canada, as in many other countries, requires approaches that reconcile physician autonomy with the growing need for collaborative, team-based care. The public\u0026ndash;private hybrid model piloted at the Associate Clinic offers valuable insights into how this balance might be achieved within healthcare systems where the private practice model is dominant.\u003c/p\u003e\n\u003cp\u003eThis qualitative case study highlights both the promise and limits of hybrid arrangements. On one hand, the integration of publicly funded allied health professionals can act as a catalyst for organizational change that is widely recognized as necessary but difficult to implement in private practice settings. By alleviating financial and organizational constraints, the hybrid model provides a pragmatic pathway for advancing team-based care. On the other hand, the model faces challenges related to payment structures, distrust between private and public sectors, and operational constraints.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs healthcare systems seek to expand team-based care, hybrid models may serve as transitional frameworks that foster the culture and norms of interdisciplinary collaboration. Future research should examine the conditions under which these models can be sustained and scaled, with particular attention to governance, accountability, and evolving professional identities.\u003c/p\u003e\n\u003cp\u003eThe implications of these findings extend beyond Saskatchewan. As populations age and healthcare costs increase, primary care systems in both Canada and elsewhere face tensions between physician autonomy and the need for integrated care delivery. Public\u0026ndash;private hybrid models, as illustrated in this case, offer a potential pathway for incremental reform by leveraging private infrastructure while advancing collaborative care. These insights may be particularly relevant in jurisdictions where primary care remains heavily reliant on independent practitioners.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHM supervised the research. All authors contributed to the conception and design of the work. CD collected and analyzed the data. All authors participated in the interpretation of data and the writing of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Behavioral Research Ethics Board (BREB) of the University of Saskatchewan. All procedures involving human participants were conducted in accordance with the Tri‑Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2, 2022), the national standard governing research ethics in Canada, and with the 2024 revision of the Declaration of Helsinki. All participants provided informed consent prior to taking part in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Saskatchewan Health Research Foundation (SHRF) through an Align research grant. The funder had no role in the design of the study; in the collection, analysis, and interpretation of data; or in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the support from the Saskatchewan Health Research Foundation (SHRF) Align Grant. \u0026nbsp;We also acknowledge Heather McWhinney for helping edit and proofread the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor(s) Conflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Harrison provides family medicine services in private practice at the Associate Family Physicians clinic, the clinical site studied in this research. To mitigate potential bias, the study design was finalized before data collection; data extraction and analysis were conducted by coauthors who do not have any relationship to the clinic; and interpretations were reviewed collaboratively by all authors. The authors report no other conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData generated and analyzed during the current study are not publicly available due to privacy and anonymity considerations. Sharing the data could compromise the confidentiality of participants and violate ethical guidelines.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBell R, Chow M. Canada has a primary-care crisis. Here are three steps we must take to solve this problem. The Globe and Mail (Online) [Internet]. 2022 Jul 16 [cited 2023 Nov 21]; Available from: https://www.theglobeandmail.com/opinion/article-canada-has-a-primary-care-crisis-here-are-three-steps-we-must-take-to/\u003c/li\u003e\n\u003cli\u003eDuong D. Primary care is facing a capacity crisis - Can pandemic lessons help chart a path forward? CMAJ. 2022;194(43):E1488. \u003c/li\u003e\n\u003cli\u003eFlood CM, Thomas B, McGibbon E. Canada\u0026rsquo;s primary care crisis: Federal government response. Healthc Manage Forum. 2023 Sep 1;36(5):327\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eBrown-Shrevens D, Wright V, Kiran T. Team-based care key to alleviating primary-care crisis. Healthy Debate (Online) [Internet]. 2023 Apr 4; Available from: https://healthydebate.ca/2023/04/topic/team-based-care-primary-care-crisis/\u003c/li\u003e\n\u003cli\u003eOglivie M. \u0026ldquo;Beyond crisis levels\u0026rdquo;: Why Ontario doctors are fleeing family medicine. Toronto Star (Online). 2016 Feb 16; \u003c/li\u003e\n\u003cli\u003eHutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: Systems in motion. Milbank Quarterly. 2011;89(2):256\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eAggarwal M, Hutchison B, Abdelhalim R, Baker GR. Building high-performing primary care systems: After a decade of policy change, is Canada \u0026ldquo;walking the talk?\u0026rdquo; Milbank Quarterly. 2023;00(0):1\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eNaylor D, Girard F, Mintz J, Fraser N, Jenkins T, Power C. Unleashing Innovation: Excellent Healthcare for Canada [Internet]. Ottawa; 2015. Available from: https://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf\u003c/li\u003e\n\u003cli\u003eCollege of Family Physicians of Canada. A new vision for Canada: Family Practice\u0026mdash;The Patient\u0026rsquo;s Medical Home [Internet]. Mississauga, ON; 2019. Available from: https://patientsmedicalhome.ca\u003c/li\u003e\n\u003cli\u003eHedden L, Banihosseini S, Strydom N, McCracken R. Family physician perspectives on primary care reform priorities: A cross-sectional survey. CMAJ Open. 2021;9(2):E466\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eMitra G, Grudniewicz A, Lavergne MR, Fernandez R, Scott I. Alternative payment models: A path forward. Canadian Family Physician. 2021;67(11):805\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eLeslie M, Khayatzadeh-Mahani A, Birdsell J, Forest PG, Henderson R, Gray RP, et al. An implementation history of primary health care transformation: Alberta\u0026rsquo;s primary care networks and the people, time and culture of change. BMC Fam Pract. 2020;21(1):1\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eStrumpf E, Ammi M, Diop M, Fiset-Laniel J, Tousignant P. The impact of team-based primary care on health care services utilization and costs: Quebec\u0026rsquo;s family medicine groups. J Health Econ [Internet]. 2017;55:76\u0026ndash;94. Available from: http://dx.doi.org/10.1016/j.jhealeco.2017.06.009\u003c/li\u003e\n\u003cli\u003ePeckham A, Kreindler S, Church J, Chatwood S, Marchildon G. Primary Care Reforms in Ontario, Manitoba, Alberta, and the Northwest Territories. Vol. 2. Toronto; 2018. \u003c/li\u003e\n\u003cli\u003eSuter E, Mallinson S, Misfeldt R, Boakye O, Nasmith L, Wong ST. Advancing team-based primary health care: A comparative analysis of policies in western Canada. BMC Health Serv Res. 2017;17(1):1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, et al. Core principles and values of effective team-based health care. Washington; 2012. p. 79\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eLevesque JF, Haggerty JL, Hogg W, Burge F, Wong ST, Katz A, et al. Barriers and facilitators for primary care reform in Canada: Results from a deliberative synthesis across five provinces. Healthcare policy. 2015;11(2):44\u0026ndash;57. \u003c/li\u003e\n\u003cli\u003eWillis E. Introduction: taking stock of medical dominance. Health Sociology Review. 2006;15(5):421\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eMcDonald J, Jayasuriya R, Harris MF. The influence of power dynamics and trust on multidisciplinary collaboration: A qualitative case study of type 2 diabetes mellitus. BMC Health Serv Res. 2012;12(1):1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eOkpalauwaekwe U, MacPhee BK, Balezantis L, Mahani A, Zarzeczny A, Ramsden VR, et al. Facilitators, barriers, and priorities for enhancing primary care recruitment and retention in Saskatchewan, Canada. BMC primary care. 2025;26(1):373. \u003c/li\u003e\n\u003cli\u003eKreindler SA, Struthers A, Metge CJ, Charette C, Harlos K, Beaudin P, et al. Pushing for partnership: physician engagement and resistance in primary care renewal. J Health Organ Manag. 2019;33(2):126\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eShaw EK, Howard J, West DR, Crabtree BF, Nease DE, Tutt B, et al. The Role of the Champion in Primary Care Change Efforts. The Journal of the American Board of Family Medicine [Internet]. 2012 Sep 1;25(5):676\u0026ndash;85. Available from: file:///C:/Users/Ivone/AppData/Local/Mendeley Ltd./Mendeley Desktop/Downloaded/Honrado et al. - 2002 - Classification and Mapping of Terrestrial and Inter-Tidal Vegetation in the Atlantic Coast of Northern Portugal.pdf\u003c/li\u003e\n\u003cli\u003eKhan AI, Barnsley J, Harris JK, Wodchis WP, Irfan A, Barnsley J, et al. Examining the extent and factors associated with interprofessional teamwork in primary care settings. J Interprof Care. 2022;36(1):52\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eD\u0026rsquo;Amour D, Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. J Interprof Care. 2005;19(SUPPL. 1):8\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eXyrichis A, Ream E. Teamwork: A concept analysis. J Adv Nurs. 2008;61(2):232\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eBaker L, Egan-Lee E, Martimianakis MA, Reeves S. Relationships of power: Implications for interprofessional education. J Interprof Care. 2011;25(2):98\u0026ndash;104. \u003c/li\u003e\n\u003cli\u003eMacNaughton K, Chreim S, Bourgeault IL. Role construction and boundaries in interprofessional primary health care teams: A qualitative study. BMC Health Serv Res. 2013;13(1). \u003c/li\u003e\n\u003cli\u003eGiddens A. The constitution of society: Outline of the theory of structuration. Berkeley, CA: University of California Press.; 1984. \u003c/li\u003e\n\u003cli\u003eKreindler SA, Metge C, Struthers A, Harlos K, Charette C, Bapuji S, et al. Primary care reform in Manitoba, Canada, 2011\u0026ndash;15: Balancing accountability and acceptability. Health Policy (New York) [Internet]. 2019;123(6):532\u0026ndash;7. Available from: https://doi.org/10.1016/j.healthpol.2019.03.014\u003c/li\u003e\n\u003cli\u003eShahaed H, Glazier RH, Anderson M, Barbazza E, Bos VLLC, Saunes IS, et al. Primary care for all: lessons for Canada from peer countries with high primary care attachment. CMAJ Canadian Medical Association Journal. 2023;195(47):E1628\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003ePeckham A, Ho J, Marchildon G, Marani H, Farr M, Farrell P, et al. Policy Innovations in Primary Care Across Canada A Rapid Review Prepared for the Canadian Foundation for Healthcare Improvement Acknowledgements We would like to gratefully acknowledge the support of. Toronto; 2018. \u003c/li\u003e\n\u003cli\u003eUsher S, Denis JL, Pr\u0026eacute;val J, Baker R, Chreim S, Kreindler S, et al. Learning from health system reform trajectories in seven Canadian provinces. Health Econ Policy Law. 2021;16(4):383\u0026ndash;99. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"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":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"primary care, team-based care, hybrid care models, healthcare policy, healthcare system transformation","lastPublishedDoi":"10.21203/rs.3.rs-8743811/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8743811/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Despite widespread enthusiasm for team-based care models, adoption remains a challenge across Canadian jurisdictions. The transformation of primary care demands innovative approaches that reconcile physician autonomy with the systemic need for collaborative, team-based care. This article examines an innovative public–private hybrid model in which publicly funded allied health professionals are integrated into a private clinic. It offers insights into how such reconciliation might be achieved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This research draws on the case study of a pilot project of a primary care private practice transitioning to team-based care in Canada. Three qualitative data collection methods were employed: document analysis, semi-structured interviews (\u003cem\u003en\u003c/em\u003e=27), and non-participatory observations (six days). A manual thematic analysis of the data was conducted, results were triangulated, and the coding system was refined through research team discussions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Findings highlight both the benefits and challenges of hybrid models as a pathway for primary care reform. Benefits include enabling transition to team-based care by addressing resources constraints, preserving core aspects of family physicians’ professional autonomy, and incorporating patient-centered thinking within organizations typically oriented toward efficiency and sustainability. Challenges include physician distrust of public authorities, incompatibility with the fee-for-service payment model, and structural and operational barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: This research offers insights into how incremental reforms can leverage existing private infrastructure while advancing collaborative care. These findings may inform strategies in jurisdictions where primary care remains heavily reliant on independent practitioners. Future research should examine the conditions under which such models thrive, with particular attention to governance, accountability, and evolving professional identities.\u003c/p\u003e","manuscriptTitle":"Advancing Team-Based Care in Private Practices: A Case Study of a Public–Private Hybrid Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 08:06:31","doi":"10.21203/rs.3.rs-8743811/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-17T21:43:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149198085525334481658528808847217953740","date":"2026-03-17T15:49:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T06:00:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T05:59:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T00:03:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-09T20:59:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-02-09T20:54:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c8facbfd-c0e8-4efe-8a7e-0a6f68374b23","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-19T06:08:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 08:06:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8743811","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8743811","identity":"rs-8743811","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}