Table 3.

The benefits and challenges of different approaches aimed at increasing system permeability

Characteristic	How it improves permeability	Challenges
intersectional person-centredness and holism	Health care systems that took the whole person into account offered flexibility through service configuration and policies that allowed providers to attend to challenges that could negatively influence the PlwRA’s alignment with care options that were narrowly defined through a biomedical lens (i.e., tailoring services to PlwRA’s specific needs re: location, frequency, type, and goals of care) (e.g., [75, 78, 79, 112, 113]). At the systemic level, barriers such as lack of patient parking and poor communication re: appointments etc. were addressed [64].	An Elderly Multimorbidity Centre for PlwRA was established around principles of person-centred care, but “patients and rheumatologists mentioned high (caregiver) burden because of extra visits as reasons for not attending follow-up” [114]
outreach	Rheumatology nurse practitioners (NPs) who set up clinics in rural primary care practices saw patients more quickly than if they had to see a rheumatologist in an urban centre [79].	Even though a rheumatology outreach clinic in an on-reserve primary healthcare center increased accessibility and treatment targets for Indigenous PlwRA, it did not substantially improve patient reported outcomes, ostensibly because cultural safety had yet to be fully established and providers did not fully understand the reasons behind the limited compliance with treatment regimens [67, 69, 72, 93]
multidisciplinary teams	Wait-times were reduced (e.g., through Early Arthritis Clinics), and care could be provided between specialist appointments when other healthcare professionals (e.g., NPs, physiotherapists pharmacists, etc.) could meet with the PlwRA to provide care or self-management information [52, 64, 75, 78, 113].	All team members must agree on the information to be provided to PlwRA to ensure that they do not receive detrimental or conflicting advice [74]. A communication infrastructure to promote collaboration must be established [75, 78].
central intake and triage	Timely access to rheumatology services was achieved when primary care practitioners referred people with suspected RA to a central intake system that determined how quickly they were seen using triage principles [32, 61, 78, 115, 116].	The effectiveness of the triage depends on the quality of the assessment, which is ideally made by an allied health professional with advanced musculoskeletal training. Incentivizing and funding system reorganization in this manner is challenging in some jurisdictions [61].