Catherine Donnelly , B.Sc.(OT), MSc, PhD (Host): Hello everyone, welcome. I'm Catherine Donnelly and I'm the host of today's podcast and I'm thrilled to be here. I'm coming from Kingston, Ontario, Canada. I'm an Occupational Therapist by training and Associate Professor at the School of Rehabilitation Therapy at Queen's University. I'm also the Director of the Health Services and Policy Research Institute and I am one of the co-authors of the paper we're here to talk you about today.

I'm thrilled to introduce Dr. Rachelle Ashcroft, our main guest of honor today. Rachelle, over to you to do a brief introduction.

Rachelle Ashcroft, PhD: Hi, thanks very much, Catherine. I'm Rachelle Ashcroft, and I'm joining you today from Toronto, Canada, Toronto, Ontario. And I'm an Associate Professor of Social Work in the Factor-Inwentosh Faculty of Social Work at the University of Toronto, and have been a social worker for all of my career, so really pleased to be here today and talk with you today, Catherine.

Host: Wonderful. And we're here today because of Team Primary Care. And I know we're both, principal investigators of different projects through this grant. Can you Talk a little bit and start us off sharing about that project.

Rachelle Ashcroft, PhD: Sure. Team Primary Care, it's been an exciting year with Team Primary Care, where this initiative, it's been one of those fast and furious types of projects. Team Primary Care is a transformation Canadian initiative that really aimed to accelerate transformative change in the way that primary care practitioners; Family Physicians, Nurse Practitioners, as well as the other types of professionals who work in primary care including social workers, occupational therapists and so forth really aim to train all of us to work together in teams to build capacity for teams and to do so Team Primary Care was this initiative that brought together an extensive network of different types of providers and partners, to plan together, to devise what is needed by each of the different professions, specifically to improve training, supports, tools, and so on and so forth, with the aim to bolster primary care teams.

 So for us and why we're here today is we received funding as one of a number of projects funded through Team Primary Care, and Team Primary Care itself, so just to kind of give a little bit more of background, it was an initiative of the Foundation for Advancing Family Medicine funded by the Government of Canada's Employment and Social Development Canada program and was co led also by the College of Family Physicians of Canada and the Canadian Health Workforce Network.

And this has been actually quite a robust project in partnership with over a hundred health professional and educational organizations across Canada. And why that's really important is because so many of us across disciplines have been talking about how to bolster each of our professions in primary care.

I've been talking with you know, a range of different social workers and social work organizations, social work practitioners and social work leaders for a number of different years about building capacity in primary care teams. But this was the first time where we've had such organization that has brought the different disciplines together, where social work and OT and, and Family Medicine and Nurse Practitioners and, so many others who work in teams have really come together to talk about what we need collectively and, and to plan collectively.

So that's, it's been quite, an amazing initiative from that vantage point. And then just maybe lastly, I'll say more specifically. So my role has been kind of twofold. First, I've been one of the main leads of the team social work group. So myself, Dr. Keith Adamson, also, who's one of my colleagues at the University of Toronto, and we've worked together in partnership with the Canadian Association of Social Workers. So, heading Team Social Work, one of our aims has been what we've done over the last year has been to create first, the National Strategy and Vision of Social Work and Primary Care, which is going to be launched actually in September 2024.

So that's just on the cusp of being publicly shared. And why that's been important is even though we've been starting to talk in our profession of social work, of what's needed for bolstering the capacity of social work and primary care, we haven't had a really great national vision. So we've seen kind of like dispersed initiatives across the country, across provinces, even within provinces.

So that's one thing that we articulated really early on that was needed was some kind of comprehensive strategy and vision. And then, in addition, our team social work group created six online educational models that are open access, available to the public, and really focusing on the role of social work in primary care.

 The reason why that has been important is because we don't have really good comprehensive educational content that focuses on, social work practice specifically in primary care, and it has been a bit of a gap. We know that primary care is quite robust in the range of different types of health and social issues that patients and clients seek care for. And so for social work, we needed to like create some content to fill that gap. And then one of the main reasons why you and I are here today is that through this initiative, the leads across six different disciplines came together to create some foundational curricula as part of team primary care.

So, and the group that you and I worked in, that we came together with yourself, myself, and four other disciplinary heads came together to talk about and create foundational content of what's needed to prepare teams. So creating content for teams and creating content by teams.

Host: Thank you for that. That's a great overview. We talked a lot about how this really was, even though we've been talking about teams, we've been talking about interprofessional education for, I'm going to say almost decades now. And, bring us together, in that cohesive large group for a very fast one year set of projects.

And we're going to talk a lot about after in a second, about, you know, how our six professions came together and really became an exemplar and in the article; it sort of is a reflection of how we worked through that year together, even though we've all been working in teams and working in primary care, it was still a lot for us to learn in that phase, but before we talk about that component, I'm just going to step back and dig into a little bit more about the role of social workers on primary care because, social work is like a vast profession and, you know, really working in primary care for social work is quite unique, even though they're a key part of the teams from a primary care lens; from your discipline, it still represents a focused area of practice.

Can you share like a little bit of your thoughts and sort of what you see the role of social work, particularly, we're talking about increasing access for primary care through teams and just your thoughts on that.

Rachelle Ashcroft, PhD: Yeah, and this is an area that I'm quite passionate about, and maybe I'll just start by saying currently as an Associate Professor at University of Toronto, my main scholarship, my main research focus is on interprofessional primary care teams with the integration of social work and mental health care is one of those key areas that I'm very passionate about.

And my interest in this area actually started a long time ago, in my early days, working as a social worker, starting out my career back in Winnipeg, Winnipeg, Manitoba, Canada. So I've been a social worker my entire career, working across multiple different types of health settings. And I started out actually working in primary care at a place in Winnipeg called Village Clinic.

 And it was a primary care clinic that was really aimed at providing good comprehensive primary care for people who were HIV positive, living with AIDS and, required like a range of different sexual health type of good comprehensive care. So I started out my career at Village Clinic and then over the course of my clinical practice in Winnipeg as a social worker, I've, I worked in mental health residential type of care. And then eventually I moved into, I worked in child welfare for a bit, and then eventually moved into a tertiary care setting and I worked at Winnipeg's Health Science Center for about 10 years across multiple different programs from trauma, psychiatry, bone marrow transplant, nephrology, so like the whole gamut, and then spent about six years or so working in neurosurgery, in inpatient, outpatient.

And so why would I even be talking about this when we're talking about primary care, is one of the reasons why I became very passionate about primary care, particularly for social work, and the potential of social work, is that even in my short career in clinical practice, over the course of those 15 years, there was such a range of different patterns that I saw.

 The need for good mental health care, which has only increased over the years. The need for attention to social terms of health and the range of different challenges that patients experience in relation to all their health and mental health types of conditions that they experience.

Housing, the financial implications of living with illness and living with health concerns. So I saw that there's this great potential, but I also saw that in acute care, some of those issues were not being attended to really well, or it was very short term, or not as comprehensive.

And it was during my later years working in tertiary care where I'd often reflect back on just how great that type of wraparound team based care was at Village Clinic. And, simultaneously what was happening in the world was at that time when I was starting to think about this and really like think about community based solutions for attending to mental health and attending to, you know, the range of more holistic concerns that people had. At this time, it was kind of like the early phases of primary care reform in Ontario and I became really interested in what was going on in Ontario. So that's just kind of coincided with my academic pursuits. And I see now, these same teams grow, primary care teams grow.

We've definitely seen the integration of social work in primary care grow in some areas. In Ontario, we've seen like, that kind of flourish and the opportunities there flourish. And have seen like for provinces and for other locations where we've seen teams kind of expand.

For social work, it's been a really nice opportunity to add to the comprehensiveness, add to the holistic aspect of primary care. And social work and primary care really align in their aims of comprehensiveness, holistic care, person centered care, and bringing in that biopsychosocial lens. Social workers, it's a really great match for social workers because you know, we kind of use this term sometimes that in primary care, social workers are highly trained generalists, but come with such expertise that align with the communities and the people with who they work. So within primary care, it is a little bit of an exciting area for practice for social workers, because really you are working with all ages of patients. You're working with all different types of issues and concerns, and it's quite a robust role and, you know, across the life stages, across all genders and so on and so forth. And it does provide for a really kind of unique location for social work and really helps add to the aims of primary care and equity and social justice and comprehensiveness and holistic types of care.

And then lastly, maybe one of the things I'll say is that the commitment and the foundation of primary care of having that the longitudinal relationship and having a foundation of relationship and trusting relationships with patients is also really aligned with what is important in social work, on what we train social workers and what we learn as social workers is like really key to doing the work is having those strong trusting relationships and primary care provides that location in the community to do some really meaningful work that is aligned with what clients and patients need and what communities need.

Host: Those are all excellent points, Rachelle. It's funny as you're speaking, I was just reflecting. And we've known each other for over a decade now. And I've never heard your full story of how you got into primary care. And it's funny because mine's almost the exact flip side, but we came to it at the intersection of this in the 2000s of primary care reform and transformation.

But I had a flip experience. So rather than starting out in primary care, I actually started out in rehabilitation, had some time in community, did a little bit of private practice, 10 years into my career, moved to Kingston and started to work with what would be now my mentor, Dr. Mirian McCall, who was doing what I realize now groundbreaking work looking at rehab and primary care in the early 2000s.

And all at the time when, you know, health reform and these primary care transformation funds came about. And what's interesting, I started to, as I was learning about primary care, I look back and thought to myself, wow, if I had only sort of had this bigger lens and hadn't really thought about primary care before as an occupational therapist.

Because in occupational therapy, you know, we often say we're rehabilitation professionals. And, you know, it's really taken me a lot of time and sort of those early experiences to realize that, as occupational therapists, we provide, like social workers, services from a social work lens, an occupational therapy lens, and sometimes we work in rehabilitation, like post injury, and that's a lot of what we do.

But as occupational therapists, we can also work upstream, looking at prevention and how do we think about having people maintain function sort of before an injury happens. So again, I started working from like a research perspective in the mid early 2000s. And then was so inspired, actually, I did a little bit of contract work at a community health center and actually spent almost eight years working a day a week at the Queen's family health team, as an occupational therapist and really saw firsthand, but the flip side of you, I saw firsthand later on in my career, really, I truly do believe that primary care is where so many of the disciplines, the interprofessional health disciplines can make such a difference. If there was access, to a range of providers in primary care, I believe that the system would be much better off and we could support transitions from these tertiary centres back into the community, but also help monitor and do much more preventative care.

Like, there's two pieces that I'm going to pull up that I often think about, and I'm going to link them back to this paper in a sec. This idea of comprehensiveness, like, for us, in occupational therapy and the rehab professionals, I'm going to bring in my speech and language, audiology and, and physio colleagues, like we often are episodic, like someone gets injured.

We provide care at a certain time. We rarely would see someone again, whereas in primary care, it was like a light bulb went off that I am seeing this person today, but a year from now, and I did see people and aging over the eight years and, as an occupational therapist, we're really interested in helping people participate in the everyday activities and look at mental health, physical health, cognitive, spiritual, and that holistic, and which so many of the interprofessional providers do bring that comprehensive lens to it.

So, and the other thing is just that long term, so that long term relationship, being able to see people over time and seeing anything. So I remember when as OTs will come to me and say like, what should I do? And I'm like, you know, you should focus on the needs of the population of the clinic and whatever someone's having problems, if they're having challenges participating in everyday activities, that is your lens.

And it's not about their diagnosis. It's not about their age. It's like, how can you help them? And I love that all the team members really bring that, like, we're comprehensive, we're generalists, and we're working with people over in that relational sort of lens, so.

Rachelle Ashcroft, PhD: And maybe I'll just add there, Catherine, you know, kind of emphasizing the need for comprehensive mental health care.

We know that there are long wait lists everywhere. We know that there is so hard to get really access to good mental health resources. Primary care is one of those places where it is potentially one of those optimal settings if we bolster teams to help respond to that growing need for mental health care and kind of for what you had just mentioned. We know it's highly prevalent. We know mental health, like depression, anxiety, highly prevalent and is seen quite frequently in primary care. For a good community based mental health care, we know there's a need for early identification, early treatment. And kind of aligned with what you're talking about with comprehensiveness; the case management, the ongoing coordination, the ability to follow up, the ability to like have intimate conversations about something that you're struggling with, with somebody that you trust, that has developed, through that long term relationship is really, really important and quite powerful for mental health care.

So, that long term relationship is essential for mental health care, and so thinking about how teams can respond and, and why the importance that is one of the core areas that I'm very passionate about is because we know that there is this gap with mental health care, and we see that people who have early access to identification, treatment, coordination, trusting relationships, and team based care, do better.

Host: And I'm just going to pick up a few things too, because we both talked about that really primary care is not the main area of practice for many of, like myself as an occupational therapist, the rehabilitation, sort of the typical profession, social work. And I know that we've talked about this lots back and forth, and this was what brought us together, that all of the disciplines that we worked with, so speech and language on in these modules, audiology, social work, physical therapy, dieticians.

What we realized is as these teams, these professions enter into primary care, many people don't understand the sector. This is really was the foundation of, of the article is like we came together to co design a module that would give people an understanding of primary care. I don't know what your thoughts are that in the need from a social work perspective.

Rachelle Ashcroft, PhD: Yeah, maybe I'll just mention, it's really interesting because we did come together as six disciplines. And came together to create these foundational kind of educational modules with the aim of upskilling and thinking about upskilling and bolstering the capacity for teams and came from that mindset of IPE, which is the short that we sometimes use for interprofessional education and IPE refers to a pedagogical type of approach that brings kind of different perspectives and students together for training and education together. So, one of our aims was to create content for teams by teams. And it's interesting when you say that not everybody understands or knows what primary care refers to. We even conceptually, you know, we sometimes debate about primary care, primary health care.

But what was fascinating within our group, and that we talk a little bit about in the article, is just the process of how we collaborated together. Even though across our six disciplines, each of us representing the six disciplines have worked in primary care, are doing research in primary care, and that we all know primary care really well, but yet, even early on, that part of our process was realizing the differences in how each of our professions first, the terms that we use, so we had to even have some discussion about what's the terminology that we're using, does it align with each of the professions, and even carving out that time for us to discuss as a team of six different disciplines; that was something that we didn't really anticipate that we'd have to go and do a deep dive in, of just kind of understanding each discipline's way of interfacing and working in teams. So for example, there were of us where our provider, profession or whatever the term that we use working in primary care are embedded directly in teams, physically present in teams. Where there other disciplines on our group of six where it was more like the term for, what is the term, Catherine? It was more distant. Distant, like there's

Host: We're almost like a virtual team member.

Rachelle Ashcroft, PhD: Like a virtual team, or like refer, referrals, or it's somebody who's not necessarily embedded directly in the team, but is working either, intermittently, and called in like intermittently or working part time intermittently.

So there's a range of different ways that different disciplines are embedded in teams. Team compositions are so varied. And so, for us, what we talk about in the article is just that process of collaboration had to start with us not only understanding each other's roles. We talk about roles a lot, but we actually had to have a better understanding of just the contextual context, like the contextual elements and the contextual features of how our disciplines are working in primary care and what that means.

So it's, we had to start almost like a level higher before even talking about specific roles, which was quite fascinating.

Host: Yeah. And I just, as you're talking, it's making me reflect that because we're the leads for all of our different projects, that we were kind of using each other as a sounding board too. So, it wasn't an intentional coming together process when we first did it. It was very much initially about how do we make this module on understanding primary care, and then it really unfolded to how do we connect, really, at some points every week to really tease out some of these challenges of how we situate our disciplines in primary care.

What language are we consistently using? Because I love the fact that the module eventually and, is being used across multiple disciplines. So we had to be conscious that this made sense to everybody. But then people were bringing our conversations that we were kind of confirming back out to their own disciplines, too.

So, it was kind of like this hub and spoke, I was thinking were just talking. And I'm just going to end because there is so much focus here in Canada right now. And really, I'm going to say in the States and across the world, after the pandemic, primary care has taken a huge hit. And I think it's because it's so relational and the foundation of systems and it's been so hard for people.

We know that sometimes, I think up to 15 percent of Ontarians don't have access to a primary care provider and teams are touted as the solution. And I just thought we could reflect now, we've got the module and the grant has really provided opportunities to bring people together to think of upskilling.

Just wanted to end on your reflection about teams and their ability to support access to primary care because that's ultimately the end point of this work and what we want to help achieve.

Rachelle Ashcroft, PhD: Yeah. And, I mean, that's a big question for us to end on but maybe just a few, a couple, a couple of things. First, just, you know, in the spirit of the work that we did for Team Primary Care, we really do need to advance our understanding of and create scopes of practice across the different disciplines together with one another to think about how we're organizing teams. Because our practice still in education and our practice in thinking about organizations is we still have that siloed thinking that permeates.

 So thinking about scopes of practice across the disciplines together before we even establish teams, I think is one thing. Thinking about those competencies and creating a more robust set of, for example, like a common set of competencies across the disciplines that help articulate the range of different skills, knowledge, you know, values, attitudes, you know, the range that span teams, for teams, and help prepare teams. But there's also additional types of structural features that we should be thinking about. And so coming back to the social work. So this is what we've been working on for the last year in our national, the Canadian Association of Social Workers, national strategy and vision document that's going out.

We do highlight some of those, not only like the strengths and the robust role of social work in teams, but we do articulate some of those core challenges that we've experienced as a discipline and that we know that other disciplines in teams have also experienced. And so, for example, one of the things that we know is that there's, other opportunities and other ways to kind of like maximize scopes of practice and maximize education.

So, thinking more robustly, how can we use the range of different team members and comprise teams in a way that, that does so, maximizes, you know, different provider's education and what they're bringing to teams. Second, in Canada and elsewhere, we know that even across provinces, that there's some differences in scopes of practice.

So having, you more continuity across our provinces. So for social work, for example, we know in some provinces that there are social workers have the legal ability to diagnose certain common mental disorders. Whereas other provinces, that's not the case. So having more continuity in terms of scopes of practice, would help us have more continuity in the ability to formulate teams to the maximum education of individuals. And it's not to say, I'm not, I'm not suggesting that all teams should be the exact same, because it really should be based on what the patient population needs are, what the community's needs are, but, having just more tools to be able to respond in a more greater continuity. In addition to that, there are still gaps in data and evidence around the range of different team members. So having a better understanding of what teams are doing and, you know, kind of like a better, kind of more robust understanding of that and having more robust data that helps demonstrate kind of team's input, team's contribution, and that will also help us as an interprofessional team to better plan for the future, better plan and do more comprehensive quality improvement type of initiatives that are inclusive of the range of different disciplines.

Host: You know, I know that was big question to end, and, you know, I think those are key, key points, too. I know there's lots of other sort of features, and that could be a whole other conversation that I'd love to have with you, too. You know, as you were talking, I was also thinking, for the much about that we need to know about each other, even awareness by Canadians, because I think some people are even part of a team who don't even know they're a team, and they don't know how to access team members directly.

And, you know, that direct access to a team member to offload and provide physicians and nurse practitioners with time in their schedule to deal with some of those acute medical issues, because we know that so many of the issues that are coming into primary care could be well managed by some of the other team members thinking about mental health issues, MSK issues, issues with everyday function, and, I think we've lots to do, and I think these modules and this work that was funded by Team Primary Care is like a wonderful push to get us, you know, working as providers, and now I see how can we get this information out to Canadians so they can start to really be self advocates for how they can access the services they need in primary care, and I'm actually wondering if we should even end it with that sort of thought as sort of almost our next steps of how we might even use the modules.

Thank you for that, Rachelle. Thank you for having the conversation. I know there's lots that we could dig into about this huge topic, but it's really nice just to sit down and do a little bit of reflection about the work that we had done together over the past year. So, thank you so much.

Rachelle Ashcroft, PhD: Thanks, Katherine. Maybe I'll just add that I really encourage people to take a look at the range of different team primary care projects, the range of different really interesting output that happen as a result of Team Primary Care, because there's such a range of diverse types of projects that occurred across Canada, across different disciplines, across different key partnership groups. And so would encourage people to take a look and then hope that this is, you know, a catalyst that will to grow and continue to make that snowball rolling down a hill and kind of just continue to grow and grow and grow.

Host: That's great. Thanks so much, Rachelle.

Rachelle Ashcroft, PhD: Okay. Thanks, Catherine.

Host: Thank you.