Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers

Thank you to Taylor et al. for this special report that continues to expand our current understandings and conceptions of these roles in primary care. This work addresses the complex nature of developing primary care teams. Having clearer understandings of facilitator/care manager roles and how they fit into the 'whole' is vitally important.

This report also highlights some interesting points about primary care team functioning. Developing strong relationships (with practice members, patients, community resources, etc.) are fundamental to both of these roles. Indeed, the authors emphasize the importance of trust and effective communication for relationship building and there is extensive research both within the healthcare literature and more broadly that supports this claim. But these roles do have different functions. Facilitation is more about the process of change - having tools, skills, and competencies to facilitate effective communication, build teamwork, and develop a culture of change. It could be said, then, that care management is more about the content (e.g., improving diabetes care) that is being focused on. While this distinction does not necessarily reflect an automatic division of labor (and skills or competencies) between facilitators and care managers, the authors' push to consider the synergies between these roles on a team is quite valuable.

I also appreciated the commentaries on this article. In particular, Dr. Nagykaldi noted the ongoing developments for a national facilitator training curriculum. Facilitators should be skilled in handling group dynamics and conflict, managing meetings, building a sense of 'teamness,' etc. Developing such competencies requires time and training. Existing models such as that of the International Association of Facilitators may provide some insights for these efforts. While not geared towards primary care or health care, this organization has a well-established curriculum, tools, etc. for developing core competencies in facilitation.

Lastly, I'll emphasize that the work by Taylor et al. serves as a call for additional research on this area. Ethnographic research approaches would be ideal to understand what it looks like when teams have both a facilitator and care manager working on a quality improvement project over time. How do their roles overlap? How do they rely on and communicate with one another (and others)? How do such team efforts affect desired outcomes? Developing an evidence-base for understanding some of these 'how' questions may put efforts to transform care and maintain quality improvements on even more solid footing.

Competing interests:   None declared

I thoroughly enjoyed reading the article by Taylor and colleagues on the roles of practice facilitators and care managers. There has been more than 20 years of practice-based research on facilitation. Despite this I have experienced numerous occasions in my own research where questions have been raised about the differences or benefits of an external versus an internal practice facilitator as well as ambiguity about the role of practice facilitators. Taylor and colleagues' contribution brings greater clarity and a logical framework for understanding the distinct and complementary roles of practice facilitators and care managers in improving primary care delivery.

The article also highlights the important issue of sustainability for practice facilitation services. Many jurisdictions are struggling to support and sustain practice facilitation efforts that have to-date been funded primarily as pilot projects with sunset funding. As more context specific evidence on the success of primary care quality improvement initiatives, such as practice facilitation and the patient-centered medical home in the US, is shared with engaged stakeholders and policy- makers -- sustainability will be less of an issue.

I will certainly be citing Taylor and colleagues in future publications on practice facilitation and systems level approaches to improving the implementation of evidence-based practices.

Competing interests:   None declared