Background

Primary care services are the foundation of health care systems. Ensuring access to high-quality primary care is critical to meeting population health needs, managing health care costs, and promoting population health [1, 2]. Person-centered care is a core component of high-quality primary care and is broadly defined as a relationship-based approach, oriented to the whole person, that recognizes service users and their families as core members of the care team [3]. In a person-centered approach, care is organized around the unique and comprehensive needs of people rather than individual diseases [4]. It extends beyond clinical encounters and involves understanding patients as people, their families, their social world, and the communities in which they work and live [1, 2, 4]. Despite widespread support for person-centered care, primary care practitioners do not always have the capacity or resources to apply this approach in routine practice [1, 5,6,7]. The Patient-Centered Medical Home model has thus been advanced as an organizing concept for modern primary care systems aligned with the principles of patient-centeredness. This model promotes an interdisciplinary team structure and the delivery of holistic, evidence-based care that is easily accessible, coordinated across providers and settings, and respectful of diverse needs, cultures, and values [8].

Originally developed in the U.S. in the 2000s, the Patient-Centered Medical Home model has since spread to many other countries, including Canada. Ontario’s Family Health Teams (FHTs) are one of Canada’s best examples of the Patient-Centered Medical Home in action. FHTs were first introduced in 2005 and created to improve access to broad, person-centered primary health care services to communities across Ontario [9]. Today, 187 FHTs serve over 3 million people, or approximately 22% of the province’s population [10]. In FHTs, family physicians work alongside other health professionals in a team-based approach to provide continuous and coordinated care to their communities. Community needs can influence the services of individual sites but overall the FHT model aligns well with the principles of the Patient-Centered Medical Home [11] and attributes of the Patient’s Medical Home model promoted by the College of Family Physicians of Canada [12].

Among the defining features of these medical home models are their emphasis on whole-person care and the seamless integration of services within teams and the broader health system [11,12,13]. This includes a capacity to meet the needs of people experiencing mental health concerns. Indeed, numerous reports have emphasized the importance of integrated mental health care as a central and necessary component of the medical home model [14,15,16,17]. In Ontario, most FHTs include professionals that focus on mental health care, such as social workers, mental health counsellors, psychologists, and general mental health workers [18]. However, the delivery of high-quality, integrated mental health care in primary care remains a challenge, even in settings like FHTs that are aligned to the Patient-Centered Medical Home model [19,20,21,22].

An important challenge for FHTs and other clinics adhering to the medical home model is ensuring that the mental health services they do provide are truly person-centered. It is not uncommon for people with common mental disorders (e.g., depression, anxiety disorders) to report negative care experiences, such as encountering unsupportive or paternalistic attitudes, experiencing poor communication with providers, or having limited involvement in treatment decisions [23,24,25]. While the medical home model may be the appropriate vision for how care should be provided, investigations into the person-centeredness of mental health care in medical homes specifically and even primary care more generally have been sparse [6]. Authors have notably insisted on the need for more studies exploring the perspectives of those people directly involved in providing or receiving integrated mental health care [6, 26,27,28]. We found only one qualitative study examining providers’ perspectives on the person-centeredness of mental health care in diverse clinical settings (including primary care) in the Veterans Administration system [6], and no studies on this topic from Canada. Most other qualitative studies on the quality of care for mental disorders in primary care have instead focused on the technical aspects of managing these conditions (e.g., diagnosing, treating) [29,30,31,32] or have examined experiences of care broadly without a specific focus on patient-centeredness [26, 33,34,35,36].

To address these knowledge gaps, we aimed to explore the perspectives of FHT providers regarding their experiences providing care for common mental disorders to determine whether, and to what extent, they believed this care was person-centered.

To address these knowledge gaps, we aimed to explore the perspectives of FHT providers on the person-centeredness of care delivered within FHTs to people with common mental disorders. Our research question was: What are the experiences of FHT providers regarding the delivery of person-centered care to people with common mental disorders and what are the challenges they encounter delivering person-centered mental health care? We hoped that a deeper understanding of these providers’ experiences would enable us to identify potential areas to strengthen the quality and person-centeredness of mental health care in FHTs.

Methods

Study design

This study was part of a larger, 4-year qualitative study investigating the influence of financial and non-financial incentives on the quality of mental health care in Ontario’s FHTs [20, 37]. This study relied on a constructivist grounded theory methodology that informed our study sampling, data collection, and data analysis [38]. Charmaz’s constructivist approach was considered appropriate given our interest in using an inductive approach to grounded theory that could be informed by sensitizing concepts from the literature on quality of care. Indeed, several concepts drawn from previous frameworks [39,40,41] and reviews [42,43,44] were considered useful in our analyses of data on person-centeredness. Here, we present the findings from our in-depth analysis of the data on person-centeredness from the larger parent study. The reporting of our findings is consistent with COREQ reporting standards [45].

This study received Research Ethics Board Approval from the University of Waterloo, University of Toronto, the Centre for Addiction and Mental Health (CAMH), Bruyère Continuing Care, St. Joseph’s Health Centre/Unity Health Toronto, and Université Laval.

Sampling and recruitment

Study sampling was conducted in two phases. First, we used purposive sampling to select a diverse sample of FHTs that varied in their geographic location (urban/rural), team size, and team composition, using information from the Ontario ministry of health. Second, we used a combination of maximum variation and theoretical sampling approaches to sample participants from the FHTs. Any provider within the FHT was eligible to participate, including executive directors, family physicians, nurse practitioners, nurses, social workers, mental health workers, and other professionals. Psychiatrists working in a shared care model that delivered care with FHTs were also eligible for inclusion. The larger parent study also featured interviews with several policymakers and community providers in Ontario but data from these interviews was not considered for the current study. We sent invitational letters by email to the executive directors or medical leaders of the FHT, who were invited to share information about the study with their team. Providers interested in participating in the study were invited to contact the lead investigator (RA) and/or the research coordinator by email or phone. When additional recruitment at a site was deemed necessary, executive directors or medical leaders facilitated recruitment by identifying potential participants with specific profiles (e.g., family physicians, mental health workers, etc.) and helping to connect them to the research team, who then proceeded to inform them about the study.

Data collection

Data was collected through individual, semi-structured interviews conducted at the FHT sites (e.g., participants’ offices). The interviews were conducted by the study’s lead investigator (RA), an experienced qualitative researcher and professor with a background in social work. All participants were informed about the study’s goals and provided written consent to participate prior to their interview. Interview guides were used to structure the interviews and included questions about providers’ role and experience at the FHT, the mental health care delivered at the FHT, and their experiences providing care to people common mental disorders. The interview guides included prompts specific to person-centeredness, including providers’ person-centered practices (e.g., involving patients in care, supporting self-management) and the challenges and facilitators of this approach to care (see Appendix). Interviews had an average duration of just over 60 min (range 27–105 min). Repeat interviews to clarify previously collected information and capture additional data for analyses occurred with 14 participants (their duration was similar to the initial interviews). Interviews were audio-recorded, transcribed verbatim, and reviewed for accuracy immediately following the interview. The lead investigator also used memo-writing immediately after each interview to record her impressions of the interview and notes to consider during the analysis [38].

Data analysis

We relied on an iterative approach to analysis in which data collection and data analysis occurred simultaneously [38, 46]. Analysis began immediately following the transcription of each interview. The coding process involved three steps: initial, focused, and axial coding [38, 46]. Initial coding involved line-by-line open coding of interviews to tie concepts to blocks of raw data. Focused coding then entailed a constant comparative approach to reconcile codes and identify those that appeared frequently or were considered more significant. Focused codes were often labelled with gerunds, which builds action into the data and helps makes processes and meanings explicit [38, 47]. Focus codes were grouped into similar categories related to practices or challenges of person-centered mental health care, and constructed categories were compared with each other. Axial coding involved identifying relationships between the constructed categories and refining our themes. Sensitizing concepts on person-centeredness informed our axial coding process. Specifically, we regrouped our main themes into several broad domains that reflect key concepts in the person-centered care literature: [1] Patient as unique person, [2] Patient-provider relationships, [3] Sharing power and responsibility, [4] Connecting to family and community, and [5] Promoting person-centered care environments.

Data analysis was achieved through a team process that included the coding of an initial set of ten interviews by three team members (RA, MM, JB), followed by pairs of team members (RA, MM, JB, ME) parallel-coding the remaining interviews. Our data analysis team met monthly to discuss progress with coding, interpret and make sense of data, and consider implications for data collection (e.g., recruiting new informants, revising our interview guide). Emerging findings were also discussed at regular meetings with other team members (SD, JS, KM). The analysis process was collegial and drew on the different disciplinary perspectives of team members (social work, family medicine, psychiatry, health services, public health). Rigor and trustworthiness were established through prolonged engagement with the data, reflexive memo-writing, and team discussions. NVivo11 supported data management and analysis.

Results

Participant characteristics

We conducted 79 interviews with 65 FHT health professionals and administrators. Participants’ professional roles are presented in Table 1. Participants practiced within 18 FHTs spread across 9 health administrative regions of Ontario (covering the west, east, north, central and Toronto regions). Among the 18 FHTs, 11 were located in urban areas and 7 were in rural areas and they varied from having a smaller number of patients enrolled (< 8 000 patients, N = 6) to moderate (8001–20 000 patients, N = 6) or large numbers of patients (> 20 000 patients, N = 6).

Table 1 Professional roles of participants (N = 65)
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Domains and themes

Themes related to perceived practices of person-centered care for common mental disorders are reported for each of the five conceptual domains deemed most relevant in our analyses. Perceived challenges in the delivery of care to patients with common mental disorders and their relationship to person-centered care are presented in Table 2. All themes are visually summarized in Fig. 1.

Fig. 1
figure 1

Visual summary of person-centeredness domains and themes

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Domain 1: patient as unique person

Sharing a biopsychosocial perspective

Participants emphasized that their role was not limited to managing a person’s mental or physical illness but rather to consider each person’s unique situation and psychosocial needs. This was a view widely shared within FHT teams, as much by physicians as other members of the interprofessional team. Participants recognized that psychosocial issues (e.g., family relationships, housing problems, employment issues or poverty) were “prominent” among people with common mental disorders and that these issues were sometimes at the root of their concerns.

Our social worker here is not surprised when she hears me think about mental health. She’s very used to hearing me, especially with diagnostic formulations, and looking at the social factors that drove this particular crisis or this relapse. (Physician 125)

Several participants mentioned that their patients would often present with multiple other non-mental health concerns, commonly related to their social context, highlighting the need to consider patients as ‘whole persons’ with multiple types of needs that required attention as opposed to seeing them simply as ‘patients with a disease’ requiring medical treatment for their mental illness.

When I ask the patient “What’s important to you?” or “If you could change one thing that matters to you right now, what would you say that is?” And 9 times out of 10, the response is not, “get the infection cleared in my leg” or it’s not “get my blood sugars within an A1C of point zero five”. (…) What matters to them is “I don’t have anybody in my life”, “My distance from my family”, “I can’t get to my appointments”, “I don’t know who to contact”, “I don’t know who these people are”, “I don’t have enough to eat”, “I’m worried about paying my bills.” You know, it’s those psychosocial things… (Systems Navigator 120).

…I don’t see people coming forward identifying to me that they’re depressed. They’re identifying that, you know, they need better housing. They can’t make ends meet or they’re angry about, just kind of like frustrated with their situation but they’re not coming in identifying as depressed and I’m certainly not talking to them as a depressed person. (Social Worker 206)

Good care is responsive and flexible

FHT providers placed an importance on personalizing their care to meet an individual’s unique needs and circumstances. They most often used the term “responsive” to describe not only their ability to provide care in a timely manner but also adjust care to better meet a person’s particular needs. This was an active process of “figuring out what they need” by seeking information from the person, considering options and potential barriers to care, and finding the therapeutic approach that best suits the person. Being responsive included taking into consideration the person’s beliefs and preferences.

Other things are people’s personal preferences about different, and beliefs about different, the effectiveness of different therapies. So a patient who’s very skeptical about medication… We’ll sort of choose to not go down that route. (Physician 145)

Most participants expressed the belief that being flexible in their approach was necessary in FHT settings. This included being flexible with respect to the types of needs that they addressed as a priority and trying to ensure access to a broad range of treatments, care delivery modalities (e.g., in-person at the FHT, at home, via telehealth), and types of providers. Again, participants emphasized the need to find the approach that fit each person best.

Well, I guess to be flexible, because one treatment does not suit all. Like, CBT [cognitive behavioral therapy] is evidence-based, but it’s not going to treat everyone who walks in the door with anxiety and depression. I mean, I think it has a really good protocol to be able to follow, but that may not be the right fit for many. (Mental Health Counselor 220)

Being responsive also sometimes meant working outside the parameters of their normal role or the FHT’s usual working hours to meet individuals’ needs under more difficult circumstances. Several participants shared stories about how they went above and beyond for patients that were in a crisis situation, despite being in a position of professional liability or in what could be perceived as a boundary violation. Such examples were considered cases of “good care” that were supported by other members of the team.

Collaborating to provide holistic care

Providing team-based care was widely viewed as central to the FHT identity, which was perceived as a facilitator to delivering holistic care. Physicians and mental health providers alike spoke about how it was routine within the FHT to “look at the whole picture” and “deal with the whole person in many aspects.” Addressing mental health needs as part of a holistic approach was facilitated by the co-location of mental health professionals within the FHT, which facilitated communication and teamwork.

So for them to be able to refer to other professionals who are working in collaboration, I’m sure has eased greatly the load for physicians and really improved the care overall for a patient because they access their primary care, but they can also access many different doors. And we, like I work very diligently with people, I let them know right away that we’re a team. So I want them to know who are the players on their team. If they’re seeing their doctor, a nurse practitioner and a nurse for different things, then I know right away who their team members are and I’m going to be collaborating with them in lots of different kinds of ways. (Social Worker 137)

Domain 2: provider-patient relationships

Building long-term trusting relationships

Participants overwhelmingly viewed relationship-building as one of the main components of their work and a strength of the FHT model. As one mental health counselor stated, “it’s all about the relationship.” Providers, and especially family physicians and nurse practitioners, were in positions to develop long-term relationships lasting many years with their patients, which fostered trust among them. Providers’ knowledge of the persons in their care and the trust between them facilitated the detection of mental health problems and helped people feel more comfortable opening up.

And then I feel like most of patients now, they’ve been my patients for at least 10 years. So I kind of feel like I know them and I know what their normal state of mind is and so if they present with mental illness I’ll have an idea what they’re presenting with and what their normal personality is. (Physician 207)

I think people with mental health have trouble reaching out and admitting to them having an issue or concern and, you know, having that trusting relationship with them that they know they can approach you and that I can reach out to them when I feel that they need it as well. It’s kind of reading between the lines with them, and once you get to know them quite well, then you’re able to pick up on those cues. (Systems Navigator 227)

Grounding relationships in honesty and empathy

Participants explained that it was important for them to be authentic and genuine in their relationships with people with common mental disorders and that this facilitated person-centered care. They also felt it was important to establish a standard of openness and honesty in their communications (e.g., “being straight with them”) and to interact with people with common mental disorders in a compassionate, non-judgemental, and empathetic way. One participant stated that it was often important to “look at it from the patient’s point of view” and “put yourself in their shoes”, a sentiment echoed by other participants.

Creating safe spaces

Because of the stigma surrounding mental illness, one of the main challenges that participants faced was encouraging people with common mental disorders to disclose their symptoms and discuss their problems openly. Participants mentioned that the FHT setting made it easier for people to open up and receive mental health care.

When I came here, it was very clear to me that people are much more comfortable seeking out services in their family physician’s office because their family physician’s office is familiar and comfortable. Their family physician knows them better than anybody else in their life, most of the time. Their doc knows everything about them. And so, when they come here, it’s a familiar and comfortable place, so it’s not so onerous or scary or intimidating to go for mental health support. (Psychologist 224)

In addition to the familiarity of the setting, several participants mentioned that the key to creating safe spaces for patients was making time for those difficult conversations during consultations and really listening to patients.

It’s about listening. I think if a patient feels like they can trust you and that you’re only listening and not judging, they can open up. (Executive Director 212)

…I frequently hear back about the nurse practitioners and doctors like, “She really listens to me. She picked up on it. I didn’t really make the connection that that’s what was going on.” I do hear that feedback. The majority of people will really, really feel safe and heard by their primary care providers. They tell them things they normally would perhaps not. And like I said, our care providers are really good at probing for this. And because of the probing, the person will open up. But they feel safe. (Mental Health Counselor 107)

Having mental health providers co-located with medical staff within the FHT made warm hand-offs possible, further enhancing access to mental health care while ensuring the person’s comfort and sense of safety.

It’s helpful when the family doctor or the nurse practitioner would have somebody actually present for the appointment. And if I’m available they might say “Hey, you know, I think it would be a good idea to talk to [participant], I can bring her down, you could just say ‘hi’”. So I think that’s sometimes a helpful thing. It’s not as scary, they’ve already met me. (Social Worker 148)

Domain 3: sharing power and responsibility

Patient education as a starting point

Several participants described patient education as being an important part of how they engaged patients early in their relationships with them. This included education around their mental health conditions and treatments but also around their role as professionals and how the team members work together to provide mental health care. According to one psychologist, “people don’t know what psychology is, so you have to educate them”, and this was echoed by other professionals (e.g., social workers, occupational therapists) who felt the need to explain their roles in mental health treatment to patients.

Expanding care options and reducing care gaps

Participants described a range of services and treatment options that people with common mental disorders could access at the FHTs. This included medications but also psychotherapy, group therapies and workshops, as well as psychosocial services. As expressed by one social worker, “it’s just about giving people choices.” Expanding choices beyond drug treatments was seen as especially important, “Not everybody wants to take drugs, not everybody can take drugs. We need something that we can offer to our patients” (Nurse Practitioner 124). In some FHTs, providers active in scientific research actively sought to integrate new treatments in care for people with common mental disorders (e.g., neurofeedback) to close gaps in treatment in their communities.

Domain 4: connecting to family and community

Connecting people to community resources

Participants perceived that a strength of their FHT was the connections made within their community, and people with common mental disorders were routinely referred to community resources that could help meet their needs. Several FHTs also had professionals working in formal roles as ‘System Navigators’ that were knowledgeable about community resources and that made linkages to those resources easier for team members and vulnerable patients.

If you took a look at that data, I think you’d see a dramatic, dramatic difference in how the patient reports quality of life. You know, and prevention of caregiver burnout… by linking them to the resources that can support them with their needs. It’s not that the navigator is doing all of that, but linking people to the resources that people by themselves don’t know how to access, or don’t know how to get in the door. Um or they’re too overwhelmed and exhausted and frustrated, and sick to put the work in. (Systems Navigator 120)

Patients did however sometimes experience barriers to accessing community services. Several participants described how important it was to advocate on behalf of people with common mental disorders, stating “sometimes we have to push a little bit and try to get them in (to a service)” (Mental Health Counselor 104) and “patients fall down waitlists without advocacy” (Nurse Practitioner 124).

Domain 5: creating person-centered care environments

Managing patient information and privacy concerns

FHTs are interprofessional environments where team members share information and interact often, including electronically via their shared electronic medical records (EMR) system. Sharing an EMR allowed teams to work in a more efficient, coordinated way but it also meant that they had to routinely manage patients’ privacy concerns. Participants reported that they would often inform and reassure patients about how their personal information would be managed; however, they made it a point to explain to patients that information sharing was part of the team-based approach at the FHT.

Our notes are all in one place, right? So, doc, dietician, nurse practitioners can see what folks are talking about in counselling. And our clients know that, like I tell them when I’m first meeting with them, “Just so you know, there’s one central file, we’re all writing on the same thing. Anybody who is in contact with you will have access to those files.” (Mental Health Counselor 101).

Privacy concerns were viewed as particularly noticeable among people with common mental disorders, especially those living in smaller or rural communities where stigma remains a problem and anonymity is difficult to achieve.

Table 2 Challenges of providing person-centered mental health care
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Discussion

Summary

This study sought to explore the perspectives and experiences of FHT providers related to the delivery of care to people with common mental disorders to shed light on the person-centeredness of this care. FHT providers perceived their care to be person-centered several ways. Teams adopted a biopsychosocial perspective and aimed to deliver care in a responsive, flexible manner that considered each person’s unique needs, preferences, and circumstances. They often worked interprofessionally to address mental, physical, and psychosocial needs in a holistic, whole-person approach. They valued building long-term relationships with their patients and the genuine, trusting, and empathetic nature of these relationships was considered essential in care for common mental disorders. In most cases, the FHT was the regular source of primary care for patients, and patients’ familiarity with the site and its providers was thought to facilitate mental health care by helping them feel comfortable, safe and less stigmatized. FHT providers provided people with information and access to a variety of treatments and services, aiming to provide them with as much choice as possible and reduce gaps in care. When additional mental health supports were needed, providers linked people to community resources that could provide those supports.

Yet, providers also reported several challenges to delivering person-centered mental health care (Table 2). These included practicing in settings in which mental health concerns were sometimes regarded as a lesser priority than physical health problems, witnessing gaps in continuity of care, struggling to engage and involve people with common mental disorders in services and the self-management of their conditions, facing barriers to family involvement, and the limited “patient voice” in FHT service planning and quality improvement activities. To our knowledge, this is the first qualitative study focusing on provider perspectives of person-centered mental health care in Canadian primary care settings. This is also one of the few studies focused on this topic in primary care settings generally, especially in team-based settings aligned to the medical home model.

Comparison with existing literature

Previous studies on the quality of mental health care in primary care have found that providers strive to balance the need to address patients’ mental health concerns while adopting a holistic approach and addressing the full spectrum of their needs [6, 26, 48]. Our study extends this finding by illustrating how biopsychosocial and whole-person approaches were widely valued within FHT teams, thus laying a strong foundation for holistic, team-based care. Previous work has also shown that providers also recognize the importance of tailoring treatments and services to people’ unique needs and being flexible in their approach to mental health care [6, 34, 49]. Dobscha and colleagues described this as a process of discovery [6], consistent with FHT providers’ practices of “figuring out” their patients’ needs like a puzzle to solve. This individualization of care was facilitated by genuine, ongoing and trusting provider-patient relationships, and the centrality of these relationships to person-centered mental health care has been widely reported, both from the perspectives of providers [6, 27, 48, 50] and patients [26, 27, 33, 36, 49]. The relevance of empathetic listening and non-judgemental attitudes to creating the safe, comfortable conditions needed for conversations about mental health concerns has also been underscored [35, 49, 50]. Finally, in FHTs as in other primary care settings, the presence of mental health professionals working in a co-located model of care not only expands treatment options and patient choice but also facilitates care coordination and patients’ ability to navigate and connect to other helpful resources in the community [28, 51].

Our study also builds on and extends previous work revealing important challenges faced by FHT providers, notably in their ability to engage people with common mental disorders in FHT services and involve them as partners in their care. In particular, we found that providers experienced frustrations about patients missing opportunities to receive care, missing appointments, and dropping out of treatment, consistent with other studies describing problems of disengagement from mental health services in primary care and community settings [52, 53]. People with common mental disorders want to share responsibility over their care with providers and participate in care decisions and planning [54], but this has been shown to be poorly implemented in primary care [24, 54, 55]. Previous studies have also revealed that providers tend to attribute the causes of poor engagement and involvement to factors external to them, including patients’ disorganization or lack of insight, language or cultural barriers, and societal stigma [52, 55]. In the current study, the problems of engagement and involvement were laid mostly at the feet of patients, who were seen as often lacking readiness or motivation. Some providers expressed frustrations when patients seemed unable to take responsibility for their own self-care and recovery. This contrasts with results from Dobscha and colleagues, who found that providers practicing in a person-centered approach were sometimes worried about giving patients too much responsibility, putting them in the position to feel overwhelmed or discouraged if a care plan failed [6]. Providers in our study also did not routinely engage service users’ families in the care they provided, though they were open to doing this in some circumstances. These findings are consistent with other studies illustrating the apparent complexity of working with families and involving them in mental health care [56, 57]. Our findings highlight a clear need for investments in training and supports for engaging patients and families in the mental health care delivered within FHTs.

The perceived challenges related to continuity and prioritization of care for common mental disorders have similarly been observed elsewhere, though this remains understudied in primary care settings. Breakdowns of relational continuity (when provider-patient relationships did not “click” or when time-limited services ended) have previously been reported [26, 33, 58], as have problems of informational continuity (communication problems and concerns about patients having to retell their stories to multiple providers) [58, 59]. Issues of management continuity have also been raised in the literature [58] but may have been less problematic in the current study given the co-location of mental health providers within the FHT and shared EMR systems. Continuity of care issues were seen as stemming from a lack of government funding for mental health resources, a situation echoed and deplored by other authors [6, 34, 37, 60]. Such problems and the lack of priority given to mental health care within FHTs and the broader system may also reflect the limited role that people with mental health concerns have historically played in service planning and improvement in Ontario and other jurisdictions [61,62,63].

Strengths and limitations

A major strength of our study was the number and types of perspectives that were included in our study sample. Studies investigating the quality of mental health care in primary care from the perspective of providers have often relied on a single perspective (e.g., family physicians) whereas we interviewed FHT administrators and a diverse group of health professionals. This diversity and the number of interviews we conducted provided a richness to our dataset and lends confidence to the findings we reported. Another strength was our focus on services delivered within the FHT model and resulting ability to explore the way team dynamics contributed to the practice of person-centered mental health care. Team-based care is central to both primary care and mental health care and our study highlights how the values, practices and challenges of teams can help or hinder person-centeredness.

At the same time, focusing on FHTs may limit the transferability of our findings to other clinical contexts within and outside Ontario. FHTs are not the only type of primary care clinics aligned to the medical home model in Canada thus how mental health services are structured and integrated within them may differ. Another limitation of the study relates to the recent changes in Ontario’s service and policy contexts. This includes service transformations sparked by the COVID-19 pandemic, such as changes to providers’ scopes of practice and the growth in virtual care. Recent work by our team found that the pandemic and its consequences placed major strains on FHT providers and may have impacted person-centered mental health care in multiple ways, such as by improving patient service engagement through telehealth but impeding providers’ ability to establish or maintain therapeutic relationships with patients [64]. In addition, recent health reforms in Ontario were also introduced with an aim to strengthen person-centered care through the creation of Ontario Health Teams, groups of organizations providing an integrated continuum of care to communities across the province [65]. FHTs have begun joining these Teams, thus strengthening their ties to acute, long-term and home care providers in their regions. However, no evidence to date suggests that the above service and policy changes have significantly changed providers’ practices of person-centered mental health care in primary care and we remain confident that our findings are relevant and actionable given their consistency with other studies. Still, further research to examine the possibility of recent shifts in practices related to person-centered mental health care in Canadian and international contexts seems warranted.

Implications for practice and policy

According to the College of Family Physicians of Canada, a core pillar of the Patient’s Medical Home model is care that it is patient- and family-partnered [12]. This includes strategies that FHTs have already largely adopted, such as delivering a range of care options beyond the traditional office visit and providing personalized care that is responsive to patients’ needs and preferences. However, our study suggests that other strategies of this pillar are not fully in place, notably to involve patients and families in shared decision-making processes, support self-management for each patient, and involve patients in FHT’s ongoing planning and quality improvement activities [12]. These three strategies seem ideal as targets for quality improvement efforts that could enhance the experiences of people with common mental disorders in their care. Interventions that target patients’ readiness and motivation, such as motivational interviewing, should be more widely practiced to reduce barriers to care and involvement [66, 67]. We further endorse the College’s position that mental health services in the Patient’s Medical Home should be empowering, strengths-based, and foster hope, consistent with a recovery-oriented approach [14]. Finally, our study findings also highlight the relevance of a ‘whole of society’ approach mental health policy for Ontario. Providers recognized the important influence that social factors have on the mental health of FHT patients. This calls for a greater focus on social interventions in primary care [68] as well as intersectoral and public health actions that address upstream social determinants, reduce inequities, and promote sustainable population mental health and well-being [69, 70].

Conclusion

Family Health Teams provide comprehensive, team-based primary care services to communities across Ontario aligned to the Patient-Centered Medical Home model. However, if these clinics are to achieve this vision, they must deliver integrated, person-centered mental health services as a core element of their design [71]. Our study suggests that many FHTs have built a strong foundation of person-centered practices for people with common mental disorders but that additional strategies should be implemented to improve care experiences and adhere more closely to recent medical home models.