Summary of the included studies (n = 32)
After searching MEDLINE, EMBASE and EBSCOhost databases, 11,731 identified peer-reviewed records were collated and uploaded into Covidence (Covidence, Melbourne, Australia), a web-based screening and data extraction tool for authors conducting systematic and scoping reviews. Covidence identified and removed 3,645 duplicates, leaving 8,086 records for title and abstract screening. Grey literature search identified 100 records, in which 9 duplicates were identified and removed, leaving 91 records for title screen and full text review. Thirty-two (32) studies and documents are included in this scoping review: 22 peer-reviewed studies and 10 grey literature documents. The PRISMA-ScR flow diagram illustrates the numbers of records and the reasons of exclusion in title/abstract screening and full text assessment (see Fig. 1).
Over half of the studies and documents (18) were from Canada (56%), 8 (25%) were from Europe, 3 (9.5%) were from the UK, and 3 (9.5%) were from Australia.
Twenty-two (69%) of the included documents were empirical using qualitative research methodology, including qualitative study, case study, ethnographic method, grounded theory, and qualitative study in mixed-method design (see Fig. 2). Data were mostly collected through in-depth semi-structured interviews, focus groups, observations, fieldnotes, document analysis, and survey content analysis.
Grey literature documents (n = 10, 31%) were non-empirical studies and include practice guides and toolkits for interprofessional, inter-sectoral collaboration by primary care professional associations (n = 3, 10%), webinar presentations on family health teams collaborating with other health organizations in OHTs (n = 5, 15%), environmental scan about healthcare inter-organizational collaboration (n = 1, 3%), and frameworks for such collaboration (n = 1, 3%). Additional file 1: Appendix 3 illustrates details of the characteristics of the included studies and documents.
Factors deemed most important to any structure and processes for collaboration to enable family physicians’ participation in integrated care
This scoping review identifies three main factors related to a structure or model, as well as three main themes related to the processes that are critical to enable collaboration among and with FPs in integrated care (see Fig. 3).
Structural factors for integrated care between FPs and other health sectors
Structural factors that enable collaboration among and with FPs in integrated care include: (1) shared vision, values, and goals, (2) collaborative leadership, and (3) collaborative governance for decision-making process.
Shared vision, values, and goals
A shared vision, and defined values and goals were critical for FPs and other healthcare sectors to collaborate (Table 2). Developing a Memorandum of Understanding (MOU) to clarify common values and vision and identifying goals for change was identified as a key factor to success [22,23,24,25]. In addition to clarifying common vision and goals, parties involved also felt it critical to define their shared identity and values [22,23,24,25,26,27,28,29,30]. One study conducted in Holland [34] reported using data collected from local health and municipal organizations (public health, health centres, primary care, municipality) to develop a district health profile, which guided stakeholders in developing their common vision and goals for collaboration. Common goals clarified the mutual benefits from collaboration, such as sharing resources and working together to apply for funding support [25, 29, 31]. Common goals also included a common understanding of the problems and a joint approach to problem-solving through agreed-upon actions [25, 26, 28, 30, 32, 33].
Collaborative leadership
Effective collaborative leadership included broad representation from all partners and stakeholders. The leadership structure often took the form of steering committees or boards that included representatives from primary care, hospital, community and municipal, so that the voice of each sector could be heard [25, 27, 28, 30, 35, 36, 39]. Key to the collaborative leadership was strong primary care physician leadership, such as a physician group or professional committee that would develop communication channels within the group and support quality of care [28, 35,36,37].
The collaborative leadership facilitated joint planning, relationship building, systems thinking, and coordinating collaborative processes [25, 27, 28, 30, 35, 36, 39]. Additionally, leadership was found to play an important role in clarifying shared vision, goals, and values, fostering trust between partners, and promoting personal and organizational growth through collaboration [26, 28].
Collaborative decision-making
Inter-organizational collaboration requires a framework to guide decision-making, which increases partner accountability. Governance should be fair, formalized, and anchored in primary care. An appropriate management structure could help to execute the leadership team’s vision of the integrated care team, and plan and structure collaboration between primary care physicians and specialists [40]. Additionally, this management structure identified appropriate change management tools and resources to facilitate collaboration across partner organizations [27, 29, 35, 37, 39,40,41, 45]. Collaboration teams formalized communication methods (i.e., regular meetings, structured types of communication, use of common language) [25, 27, 32, 36,37,38,39, 42,43,44,45], freed up resources across partners (i.e., use of shared EMR and appointment system, transparency about cost) [29, 39, 42], managed organizational coherence and stability [23, 25, 42], and developed shared decision-making agreements to accommodate diverse viewpoints including conflict resolution for all partners [27, 30, 46].
Processes of collaboration for integrated care between FPs and other health sectors
Three main themes emerged related to activities that encouraged FPs’ successful collaboration with other healthcare sectors: (1) effective communication, (2) building relationships, and (3) motivation for change. Table 3 illustrates the main and specific processes of FPs in collaboration with other healthcare sectors in integrated care.
Effective communication
Developing effective communication was reported in most of the studies and documents. The studies included in this review identified specific processes that made communication effective. Partners engaged in reciprocal communication [23, 24, 47, 49], during which primary care physicians and collaboration partners delivered feedback to each other. They chose appropriate communication tools (e.g., telephone, email, EMR message) and styles (e.g., face-to-face, virtual) to fit both individual and group needs [26, 27, 32, 33, 38, 42]. In-person and face-to-face meetings proved effective for interpersonal and inter-organizational communication [40, 43, 47, 48]. Additionally, partners worked towards continuous, consistent, and open communication to achieve effective patient care, address problems, and find solutions [24, 27, 29, 30, 33, 36, 38].
Building relationships
Professional and interpersonal relationships between partners were developed from initial face-to-face meetings as well as prior mutual acquaintanceship. Taking time to learn about one another facilitated and supported relationships [32, 33, 36, 42, 49,50,51]. Developing a culture of mutual trust and respect among partners was key to relationship building between team members [29, 30, 33, 36, 38, 40, 45, 49, 52]. To facilitate trust and respect, partners learned about each other’s roles from various sectors and worked to clarify roles, responsibilities and expectations from all team members [23, 38, 40, 49, 53]. Partners often used MOU to design tasks and ensure agreed-upon roles and principles [36, 40, 52, 53]. Shared power enabled the elimination of a hierarchy creating a safe space for exploring questions [24, 28, 32, 40, 52].
Motivation for change
Making change in order to improve patient care was a key motivation for FPs to collaborate among themselves and with others. Identifying and highlighting the motivation for change allowed FPs and partners to explore and experiment on new models of care [42]. Being open to new ideas requires a growth mindset [24, 37]. Change management and tools required to support collaboration are needed with an ability to remain motivated to push boundaries to the envisioned change [23, 27, 45].
Theoretical frameworks/approaches used to understand collaboration between FPs and other health sectors
Three frameworks were identified in the literature that provide insight into collaborative initiatives which included FPs (see Table 4). A Social Identity Approach (SIA) provides a valuable lens that emphasizes the importance of shared identity, especially for FPs/GPs that function autonomously, in achieving change [22] in the UK. Analysis of collaborative initiatives in Belgium using a framework of interprofessional collaboration considers the interactive elements within organizations which can support, or derail, change efforts [32]. Similarly, a study in Australia using a competing values framework (CVF) to support the analysis of collaboration by and with FPs explores dimensions that are seen to be in direct opposition and can create challenges to change efforts if all values must be satisfied [31].