Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study

BACKGROUND: The creation of Family Health Teams in Ontario was intended to reconfigure primary care services to better meet the needs of an aging population, an increasing proportion of which is affected by frailty and multimorbidity. However, evaluations of family health teams have yielded mixed results. METHODS: We conducted interviews with 22 health professionals affiliated or working with a well-established family health team in Southwest Ontario to understand how it approached the development of interprofessional chronic disease management programs, including successes and areas for improvement. RESULTS: Qualitative analysis of the transcripts identified two primary themes: [1] Interprofessional team building and [2] Inadvertent creation of silos. Within the first theme, two subthemes were identified: (a) collegial learning and (b) informal and electronic communication. CONCLUSION: Emphasis on collegiality among professionals, rather than on more traditional hierarchical relationships and common workspaces, created opportunities for better informal communication and shared learning and hence better care for patients. However, formal communication and process structures are required to optimize the deployment, engagement, and professional development of clinical resources to better support chronic disease management and to avoid internal care fragmentation for more complex patients with clustered chronic conditions. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12875-023-02073-x.