Table 3 First steps of CMI implementation in each clinic – Case stories

A

The services of this family medicine group ^a are provided in two sites located in a medium-sized city. The first site is close to a lower-income neighbourhood and adjacent to a local community health centre ^b. The second site is smaller and further away from the downtown area than the first. The four NCMs in both sites have good team cohesion, trusting relationships, strong leadership, and significant professional experience (e.g., case management, chronic illnesses). They divide their responsibilities equally, including case management activities, thus strengthening teamwork and collaboration. They also have strong collaboration with the clinic’s family physicians who introduce them to patients who may benefit from the intervention. In this clinic, a community of practice allows NCM to reflect on their roles, solutions to common issues, and concerns regarding inclusion criteria. The community of practice provided support from two experienced nurses in case management and from a researcher patient partner on how to approach patients

B

This clinic includes seven sites, two of which are involved in the CMI. One site has experienced more nursing staff turnover than the other. The two NCM in both sites who lead the intervention have limited experience in primary care. Prior to starting the CMI, both had experience recruiting patients in a research project, and one had previous experience with ISP. This NCM also has a good working knowledge of health and social resources, which helped facilitate organizational collaboration. The NCM work collaboratively with the nurse practitioner and family physicians at the clinic. The staff showed leadership during the first steps of the CMI implementation, and the health services manager supported them. The clinic also has support from an experienced hospital NCM who has access to patient health information. There were several meetings with the hospital NCM, the clinic’s family physicians and the clinic’s manager to provide an overview of the project, plan the next steps and clarify their roles

C

This clinic is located in a town in a rural area. The NCM is an experienced family practice nurse who worked as a critical care nurse at the local hospital in the adult medical-surgical intensive care unit. This individual was chosen for this role by the health services manager for the region. The NCM works collaboratively with the nurse practitioner and family physicians at the clinic. Collaboration between the NCM and health services manager is strong, with frequent discussions about identifying and recruiting patients as well as strategies for patient meetings, including the ISP. During the implementation stage, the NCM and health services manager performed a mock recruitment and consent to develop confidence and build research skills. There were organizational meetings with clinic family physicians, the nurse practitioner and staff to plan for the CMI implementation. There was also a meeting to discuss patients who could benefit from the CMI. The NCM took ownership of their role and would be a very good mentor for others coming into a NCM role in the region or across the province

D

This clinic is adjacent to a local hospital. The NCM is an experienced family practice nurse working in the clinic since it opened (early 2018), with previous experience working in the local hospital in the ED and on the medical floor. This individual was chosen for this role by the health services manager for the region, who also acts as the clinic manager. The NCM works collaboratively with other providers, such as the nurse practitioner and family physicians at the clinic, which helps to foster and support understanding of the CMI within the clinic. Collaboration between the NCM, clinic manager and regional primary healthcare coordinator is frequent and open. In particular, the NCM and primary healthcare coordinator worked together at the implementation stage to identify participants and set up systems to keep track of potential and recruited patients. There were several meetings with clinic family physicians, the nurse practitioner and staff to discuss patients who would be a good fit for the CMI, based on intervention inclusion and exclusion criteria. A meeting was held at the clinic to discuss barriers to patient participation, which centred around a discussion on solutions for these barriers

E

The clinic is adjacent to an outpatient facility which houses medical clinics, diagnostic services, and an urgent care centre. The centre provides several services and primary health care programs, while offering additional satellite centres in priority neighbourhoods. Leading the CMI implementation, the NCM hails from the adjoining community health centre and is knowledgeable about the health system. This individual has been chosen due to a strong medical background and knowledge of the healthcare system. The NCM is highly experienced in community partnership initiatives aimed at addressing social determinants of health (e.g., food security and advocacy for affordable housing). The NCM works collaboratively with the health service manager, where a positive history of working together seems to be helping to move the project along. In the clinic the NCM was physically separated from the primary care providers. The CMI is strongly supported by management and the team of primary care providers. There is regular access and communication within the clinical team

F

This clinic is near a hospital and medical school. Many of its patients receive health and social supports through an associated clinic, but the clinic largely relies on referrals to external supports to meet patients’ complex needs. A NCM external to the clinic was hired to steer the CMI. Because the NCM was outside the patient’s existing circle of care, the family physician introduced the NCM in order to foster a relationship of trust. The NCM brings to the CMI valuable experience and skills, as well as an established network of local health providers and social supports. This helps to connect with and support patients and to engage and coordinate health providers and social supports across multiple organizations and physical locations. The NCM works collaboratively with family physicians, who may share important patient information using the clinic’s electronic medical record (EMR) system