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. 2026 May;72(5):332–340. doi: 10.46747/cfp.7205332

Impact of grassroots development of interprofessional team–based practices

Retrospective matched cohort study using ICES data

Aimun Q Shah 1, Asiana Elma 2, Hila Shnitzer 3, Laurie Yang 4, David J Price 5, Michelle Howard 6, José François 7, Alan Katz 8, Lawrence Grierson 9,✉
PMCID: PMC13171069  PMID: 42128648

Abstract

Objective

To evaluate the impact of self-initiated and community-driven “grassroots” interprofessional teams relative to formally designated family health teams (FHTs) supported by government transition programs and non-team practices in Ontario.

Design

Retrospective matched cohort study.

Setting

Health administrative data spanning 2016 to 2021 from ICES in Ontario.

Participants

Grassroots practices were matched to FHTs and non-team physician practices in the health administrative data set.

Main outcome measures

Patient attachment, visits, continuity, and preventive care metrics were compared using descriptive and inferential statistics.

Results

Grassroots clinics had significantly more attached patients per physician (n=1371) than FHTs (n=1227; P<.0001) and non-team clinics (n=586; P<.0001). Annual patient visits per physician were also higher in grassroots clinics (n=2792) compared to FHTs (n=2321; P=.0002) and non-team clinics (n=1378; P<.0001). Continuity of care measures were higher for grassroots and FHTs than non-team practices (P=.02). Preventive care delivery was significantly higher in grassroots clinics compared to non-team practices for most metrics (P<.01) except for lipid screening (P=.18).

Conclusion

Grassroots team-based care in Ontario is associated with positive impacts on primary care access and delivery of preventive services, inspiring confidence in these developments. Initiatives that encourage family practices to pursue their own conceptualization of effective team-based care may be beneficial, although there is a need for further research to assess the broader effects and scalability of such models.

In Canada, primary care is the cornerstone of a well-functioning health care system, supporting health promotion, illness prevention, and system navigation.1,2 Family physicians provide comprehensive, community-based services throughout the life span (ie, cradle to grave) while considering the holistic context of their patients’ lives, tailoring care, and advocating for them in all parts of the health care system. Despite its crucial role, access to care remains a substantial challenge, with millions of Canadians either lacking a family physician or facing long wait times to see one.2,3 This issue is expected to worsen as physicians face growing administrative burdens, financial constraints, and burnout.3-5

Accordingly, the College of Family Physicians of Canada (CFPC) advocates for the uptake of the Patient’s Medical Home (PMH), a vision for enhancing community-adaptive family medicine.6,7 A central tenet of the PMH is interprofessional team–based care.7 In this model, family physicians work collaboratively alongside nurses, social workers, and other primary health care professionals to provide a wider array of services.7,8 Early initiatives, such as the Ontario Medical Association and the Ministry of Health and Long-Term Care Family Health Network initiative in 2000, set the stage for this vision. These networks offered a blended funding model, extended service hours, and incentives for comprehensive care, and were later formalized into Ontario’s family health teams (FHTs) in 2005.9 FHTs are publicly funded, government-led, community-based primary care organizations that bring together family physicians, nurses, social workers, dietitians, and other health professionals to deliver coordinated, patient-centred care, with a focus on health promotion, disease prevention, and chronic disease management.9,10 To be part of an FHT, patients must formally enroll with a physician affiliated with the team.9

While research has demonstrated the effectiveness of these models,11-13 the widespread adoption of the PMH-aligned FHT practices has been slow and fragmented.14-16 Although nearly 200 FHTs have been implemented since the early 2000s,8 broad health care funding freezes beginning in 2010 and the absence of expansion plans have limited their reach.8,17 This resulted in gaps in the development of formal team-based care, particularly in underserved communities associated with rural and remote populations and those with low socioeconomic status.18 In response, some family physicians, recognizing need in their local communities, self-initiated transformation to an interprofessional team practice outside of explicit government mandates or support.19,20 These grassroots teams vary in size, composition, and funding model, but often include nurses, social workers, and other health care professionals who are funded directly by the family physician lead through applications to regional health authorities or through an independent business model that is organized adjacent to the physician.19,20 To date, no research has evaluated the primary care efficacy of grassroots teams relative to formally designated PMH or non-team practices. This study uses health administrative data pertaining to patient access and preventive care delivery to address this gap. Our analyses were supported by ICES.

METHODS

Study setting and design

This retrospective matched cohort study uses health administrative data spanning 2016 to 2021 from Ontario. The impact of grassroots team–based practices (grassroots) on metrics associated with access and delivery of preventive care services were assessed relative to a cohort of formally designated PMHs (FHTs) and a virtually constructed cohort of family physician providers not associated with team-based practices (non-team). Given our primary interest was in the model of care, the analysis focused on practice-level outcomes rather than individual physician- or patient-level characteristics. Accordingly, the cohorts were constructed for comparison at the clinic level. Because grassroots clinics were located in diverse regions across Ontario, health region peer groups (HRPGs) were considered to minimize contextual differences between the comparison groups. HRPGs cluster regions with similar socioeconomic and health system profiles.21 Aggregating FHT practices and non-team physicians within the HRPGs that the grassroots clinics were located in allowed for an adequate sample from which to derive meaningful descriptive comparisons while reducing the impact of regional variation.

Data sources

The following established databases and data sets were used: Corporate Provider Database, Genomic Applications Partnership Program Decision Support Systems, Postal CodeOM Conversion File, Primary Care Population, Ontario Health Insurance Plan Claims Database, Ontario Diabetes Dataset, and the chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) ICES-derived cohorts.22 These data sets were linked using unique encoded identifiers and analyzed at ICES.

Cohort characteristics

Six grassroots practices were identified through previous research findings, news reports, and verification by key contacts who were part of the CFPC’s Patient’s Medical Home Steering Committee (now defunct).20 These practices spanned diverse geographic contexts: 3 urban, 2 suburban, and 1 rural. Across the 2016 to 2021 study window, the average number of physicians in the clinic teams ranged from 1 small practice with 3 physicians, 2 medium-sized practices with between 7 and 9 physicians, 1 large practice with 12 physicians, and 1 very large practice with 20 physicians. To minimize the risk of site identification, and because team compositions fluctuated across the study window, general site characteristics are reported in aggregate. All sites included physicians, nurses (nurse practitioners or registered nurses), and administrative personnel. To varying degrees, these sites also incorporated other interprofessional team members including physician assistants, dietitians, social workers, and mental health professionals. As is typical in team-based primary care models, the composition of interprofessional teams was not stable; roles and staffing evolved over time based on local needs, resource availability, and care priorities.

To conduct the analysis, all 6 grassroots sites were aggregated into a single cohort, and family physicians associated with these practices were identified through health administrative data. Patients attached with these physicians were identified as being either formally or virtually rostered to the physician according to pre-established ICES definitions.22,23 To create matched FHT and non-team cohorts, each grassroots practice was first labelled according to an HRPG.21 The FHT cohort was constructed by bringing together all Ontario FHTs located in the same HRPGs as the grassroots cohort, identifying the family physicians and their formally or virtually rostered patients.

Similarly, the non-team cohort was constructed by identifying Ontario Public Health Units (PHUs) in the same HRPGs as the grassroots clinics. The PHUs were used as geographic anchors to identify all physicians in these regions who were practising in a non–patient enrollment model (PEM). At ICES, PEM physicians are those who have entered into alternative funding agreements with the Ministry of Health and formally enroll patients onto a roster, including FHTs, family health groups, and family health organizations.24,25 In contrast, physicians outside of a PEM typically work under traditional fee-for-service arrangements and do not maintain formally enrolled patient panels. We included these non-PEM physicians as part of our non-team group, and attached patients based on ICES’s virtual rostering method, which links each patient to the physician who billed the highest total amount for their care over a 2-year period.26,27

To ensure that physicians across all cohorts were engaged in comprehensive (rather than part-time, focused, or specialized) family medicine practice, we excluded those with fewer than 500 patient billings in the fiscal year before ICES record indexing. This threshold was based on the first percentile point of the billing distribution in our data (497 billings), which was rounded up to 500. This method aligns with approaches used in previous research to exclude physicians who may not be practising comprehensively.26,27

Outcomes of interest

The following variables were used to evaluate the impact of team-based care: the average number of rostered patients per physician (formal and virtual as defined by ICES)22; the total number of annual patient visits overall and by unique patients, as well as by elderly patients (≥65 years), and those with chronic conditions (at least 1 of diabetes mellitus [DM], COPD, or CHF) per physician; continuity of care; and the proportion receiving the following preventive care services: colonoscopy, colonoscopy screening, fecal occult blood test or fecal immunochemical test, diabetes eye examination, hemoglobin A1c test, lipid screening, mammogram, or Papanicolaou test. Our outcomes reflect core indicators of access,28-30 continuity,31,32 and preventive care28,30,33 that have been used to assess the effectiveness of primary care for patient outcomes in previous work. To provide additional context and understanding, we also generated the proportion of patients diagnosed with at least 1 of 3 chronic conditions (DM, COPD, CHF) within each cohort.

Statistical analyses

Descriptive (means, standard deviations [SDs]) and inferential statistics (P values) were used to describe and compare cohorts. Aggregated data within each cohort (grassroots, FHT, non-team) were averaged across the time window for comparison. The outcome variables reflecting metrics spanning the analysis time were further subjected to a 1-way analysis of variance (ANOVA) with aggregated practice group as the only factor. Statistical significance was set at α=.05. Significant effects were decomposed via the Tukey honestly significant difference post hoc method.

Ethics approval

This study received approval from the Hamilton Integrated Research Ethics Board (Project #16635). The protocol was subjected to an internal privacy assessment at ICES Central and a data sharing agreement was established to import information on grassroots practices for data linkage.

RESULTS

The grassroots family medicine clinics were distributed across the following HRPGs: group B (n=2), group C (n=2), group D (n=1), and group H (n=1). Fourteen total FHTs and 22 PHUs located across these 4 HRPGs were identified (Figure 1). Grassroots (mean [SD] 17.65% [0.66%]) and FHTs (16.35% [0.55%]) had a significantly greater proportion (P<.001) of all patients at the practice diagnosed with at least 1 comorbidity of DM, COPD, or CHF than non-team practices (11.05% [0.33%]) (Figure 1).

Figure 1.

Figure 1.

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Flowchart of grassroots, family health team, and non-team cohort selection between 2016 and 2021

Attached patients per physician

Analysis revealed the grassroots clinics had significantly more attached patients than both FHTs and non-team practices, with FHTs also significantly exceeding non-team practices (P<.0001; grassroots mean [SD] 1371.06 [45.64]; FHT 1227.64 [15.91]; non-team 586.64 [26.00]; Table 1).

Table 1.

Access to primary care between grassroots, family health team, and non-team practices across years 2016 to 2021

VARIABLE COHORT, MEAN (SD) P VALUE* POST HOC ANALYSIS
GRASSROOTS FHT NON-TEAM
Virtually rostered patients per physician 87.40 (19.45) 74.19 (3.37) 586.64 (26.00) <.0001 Grassroots > FHT > non-team
Percentage of virtually rostered patients per physician 6.35 (1.29) 6.05 (0.34) 100.00 (0.00) <.0001 Grassroots and FHT > non-team
Physicians included in the cohort 56.33 (4.08) 164.00 (2.97) 865.00 (36.89) <.0001 Grassroots > FHT > non-team
Virtually and formally rostered patients per physician 1371.06 (45.64) 1227.64 (15.91) 586.64 (26.00) <.0001 Grassroots > FHT > non-team
Annual visits per physician 2791.94 (114.73) 2321.24 (160.23) 1378.31 (120.56) <.0001 Grassroots > FHT > non-team
Annual visits by unique patients per physician 823.91 (52.79) 737.37 (56.94) 294.55 (36.65) <.0001 Grassroots > FHT > non-team
Annual visits by adults ≥65 years per physician 976.25 (55.06) 867.40 (56.73) 458.29 (35.40) <.0001 Grassroots > FHT > non-team
Annual visits by individuals with chronic conditions† per physician 934.56 (42.59) 725.49 (49.37) 385.36 (27.98) <.0001 Grassroots > FHT > non-team
Percentage annual visits with the same physician (COC) 48.00 (0.01) 48.00 (0.01) 41.00 (0.02) <.0001 Grassroots and FHT > non-team
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CHF—congestive heart failure, COC—continuity of care, COPD—chronic obstructive pulmonary disease, DM—diabetes mellitus, FHT—family health team, SD—standard deviation.

*

Overall significance calculated from 1-way analysis of variance with group as the only factor.

†

At least 1 of DM, COPD, or CHF.

Annual patient visits

Grassroots practices had significantly greater annual patient visits per physician compared to both FHTs and non-team practices, and FHTs also significantly exceeded non-team practices (P<.0001; grassroots mean [SD] 2791.94 [114.73]; FHT 2321.24 [160.23]; non-team 1378.31 [120.56]; Table 1).

Grassroots clinics also saw a significantly greater number of unique visiting patients per physician compared to the FHT and non-team practices, and FHT practices saw a significantly greater number of patients than non-team practices (P<.0001; (grassroots mean [SD] 823.91 [52.79]; FHT 737.37 [56.94]; non-team 294.55 [36.65]).

Annual patient visits for patients 65 years and older

Grassroots practices had significantly greater annual patient visits per physician for the subgroup of patients 65 years and older compared to FHT and non-team groups, and FHT practices had significantly greater annual visits for this subgroup compared to the non-team cohort (P<.0001; grassroots mean [SD] 976.25 [55.06]; FHT 867.40 [56.73]; non-team 458.29 [35.40]; Table 1).

Annual patient visits for individuals with chronic conditions

The grassroots cohort had significantly greater annual visits per physician for the subgroups of individuals with at least 1 chronic condition (DM, COPD, CHF) compared to FHT and non-team cohorts, and FHT practices had significantly greater visits from this subgroup than the non-team cohort (P<.0001; grassroots mean [SD] 934.56 [42.59]; FHT 725.49 [49.37]; non-team 385.36 [27.98]; Table 1).

Continuity of care

The proportion of annual patient visits that occurred with the same provider was equivalent in the grassroots and FHT cohorts, and both cohorts had a significantly greater proportion of these visits than the non-team cohort (P<.0001; grassroots and FHT mean [SD] 48% [0.01%]; non-team 41% [0.02%]; Table 1).

Delivery of preventive care services

There was a significantly greater proportion of patients in the grassroots cohort receiving preventive care services compared to patients in the non-team group for all outcomes except lipid screening, where there were no differences between groups (Table 2). However, the FHT cohort was associated with significantly more colonoscopy screening, colonoscopies, and DM eye examinations than the grassroots cohort. The grassroots and FHT cohorts did not differ for measures of fecal occult blood tests and fecal immunochemical tests, glycated hemoglobin testing, lipid testing, mammograms, and Papanicolaou tests. Compared to the non-team group, a significantly greater proportion of eligible patients in the FHT group had access to all included preventive care services, except lipid testing, where the differences were not significant (Table 2).

Table 2.

Proportion of preventive care services delivered between grassroots, family health team, and non-team practices across years 2016 to 2021: Proportions were calculated only out of patients who were eligible for the respective preventive care service.

PREVENTIVE CARE SERVICE (FREQUENCY) COHORT, MEAN (SD) % P VALUE* POST HOC ANALYSIS
GRASSROOTS FHT NON-TEAM
Colonoscopy† (10-y) 43.94 (2.15) 53.20 (1.01) 38.57 (0.91) <.0001 FHT > grassroots > non-team
Colonoscopy screening† (10-y) 65.11 (1.96) 72.38 (2.17) 52.22 (2.09) <.0001 FHT > grassroots > non-team
FOBT or FIT (2-y) 37.27 (3.28) 40.71 (3.46) 21.82 (2.36) <.0001 Grassroots and FHT > non-team
Eye examination for DM (2-y) 69.98 (1.92) 72.76 (1.73) 63.91 (1.81) <.0001 FHT > grassroots > non-team
≥2 HbA1c tests (1-y) 49.18 (5.00) 53.78 (6.01) 40.92 (4.00) .0018 Grassroots and FHT > non-team
≥1 Lipid screening (1-y) 59.86 (4.74) 64.60 (4.20) 63.20 (3.14) .1523 Grassroots; FHT; non-team
Mammogram (2-y) 61.77 (5.21) 65.91 (5.78) 47.81 (4.68) <.0001 Grassroots and FHT > non-team
Papanicolaou test (2-y) 43.46 (4.71) 46.71 (6.25) 33.19 (3.89) .0009 Grassroots and FHT > non-team
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DM—diabetes mellitus, FHT—family health team, FIT—fecal immunochemical test, FOBT—fecal occult blood test; HbA1c—glycated hemoglobin, SD—standard deviation.

*

Overall significance calculated from 1-way analysis of variance with group as the only factor.

†

Colonoscopy screening refers to proactive, preventive examinations for asymptomatic individuals. Colonoscopy is a reactive procedure to investigate symptoms.

DISCUSSION

This study provides an important description of the efficacy of grassroots team practices—clinics that have self-initiated transformation to interprofessional team–based care—relative to FHTs and physicians practising outside of an interprofessional team (non-team). Grassroots teams are associated with more attached patients per physician, and more patient visits per physician, including for older adults and individuals with chronic conditions, than both FHT and non-team practices. FHT practices also outperformed non-team practices on these metrics, indicating an overall benefit of team-based care. Both grassroots and FHT clinics also demonstrated greater care continuity and delivery of preventive care services than non-team practices. Notably, both the grassroots and FHT clinics studied were associated with a higher overall proportion of patients with at least 1 comorbidity (DM, COPD, or CHF) relative to non-team practices. This may partly explain the higher number of patient visits among patients with chronic conditions in team-based models. However, given that the practices were sampled from the same HRPG regions, and in turn similar socioeconomic and health system contexts, we are surprised by the disparity in proportional patient complexity. We speculate this may reflect the way in which team-based practices, grassroots or otherwise, are better equipped to care for complex patients and more likely to attract and retain them.

Overall, our findings align with research on the effectiveness of team-based care in improving access,34,35 chronic disease management,35-38 and continuity of care,39-41 and may have an impact on health system effectiveness.42,43 Several studies have shown that team-based care reduces reliance on walk-in clinics and emergency departments.44-47 Relational continuity, where patients see the same provider consistently over time,47,48 is also consistently linked to better health outcomes.39,49,50 However, our results also reveal that self-initiated interprofessional teams were found to have higher numbers of attached patients and annual patient visits per physician, which introduces a new dimension to the team-based care literature. A possible explanation is that grassroots teams may be organized to deliver care in a manner more bespoke to local community needs, increasing their capacity to effectively serve their patients. Indeed, while formal PMH practices benefit from integrated funding models and allocated resources,48 they may face slower adaptation processes influenced by negotiations with health authorities, as well as accountability to particular quality metrics to maintain funding, which can prioritize target outcomes over local responsiveness.20,51-53

These findings are particularly salient in light of Ontario’s current primary care context. The province has invested heavily in primary care reform over the past 2 decades, including the creation of nearly 200 FHTs, widespread adoption of group-based practice models, and a shift toward capitation-based physician remuneration.8,17,18 These reforms laid the groundwork for team-based care; however, funding freezes and limited expansion plans left many communities without access to formal team-based models,18 prompting some physicians to develop grassroots teams in response to local needs. Currently, the province is pursuing a new Primary Care Action Plan, which represents a renewed commitment to expanding access through formal infrastructure.54 With a mandate to connect every Ontarian to a primary care provider by 2029, the plan includes the creation and expansion of interprofessional teams, recruitment of internationally trained physicians, and targeted investments in underserved areas.54,55 While this approach focuses on formalized models, our findings suggest that grassroots innovations may offer valuable lessons in adaptability, responsiveness, and community alignment, particularly in regions where formal expansion is slow or resources are constrained. Both grassroots and FHT models offer unique strengths. Grassroots clinics, often emerging in response to local needs, are at the forefront of community-driven innovation. In contrast, FHTs leverage formal structures and data-driven decision making, allowing for standardized care pathways and the use of integrated resources to drive care improvements.51 Future primary care developments could benefit from a hybrid approach that combines the adaptability of grassroots clinics with the systematic innovations of FHTs. Policy-makers should consider initiatives that leverage inputs from local family physicians in the building of interprofessional teams, perhaps through flexible funding and guidance on sustaining such models.56

Future directions

Future research should quantify the impact of interprofessional team–based practice on additional outcomes such as the number and types of services provided per primary care visit, the number of emergency department visits, and health system costs. Additionally, more research is needed on the impact of different remuneration models for physicians on primary care access and delivery. Building on our clinic-level analysis, future studies could explore the role of specific team members and how variations in team composition or size influence care delivery. Further, deeper investigation into the factors driving the success of grassroots models compared to standardized approaches is warranted. Understanding how self-initiated interprofessional models are structured, supported, or aligned with local needs could reveal crucial elements for improved patient care and more adaptable health care models. Finally, comparative studies across different provinces or health care systems may provide valuable insights into the potential for scalability.

Limitations

Our design is primarily descriptive and cannot establish causal relationships between team-based care and patient outcomes. The data extraction period (April 2016 to April 2021) does not fully capture more recent developments in primary care, including the expansion of virtual care and evolving provincial reforms that aim to connect every Ontarian with a primary care provider.54 Health administrative data, while robust for broad analysis of trends, may undercount patient contacts in cases where care was delivered outside of billable encounters or shared among providers within a team.54 The cohort construction, particularly the reliance on virtual rosters, may introduce biases affecting generalizability. Comparisons involving the non-team group should be viewed cautiously. Although we know the physicians in this group practise outside formal patient enrollment models, we do not have information about the specific organizational structures of their practices. Notably, cohorts were constructed and matched at the HRPG level rather than the physician or patient level, which may not fully control for differences in individual characteristics. Furthermore, given the limits of the available administrative data, our commitments to protecting the identity of clinics in this research, and the dynamic nature of primary care team members, we are unable to report the exact composition of health professionals within each team or to reflect our findings through specific characteristics of individual grassroots sites across the 2016 to 2021 time period. Finally, there may be heterogeneity in the types of funding models for physicians across team-based practices that could have impacted the outcomes, as different models may offer different incentives for physicians.57

Conclusion

Interprofessional team–based care conveys access, continuity, and comprehensiveness of preventive care benefits to patients. That this is true for practices that self-initiate team-based care underscores the potential of locally driven, tailor-fit developments of health care practice.

Footnotes

Acknowledgment

This work was supported by the College of Family Physicians of Canada, and the Research, Analysis and Evaluation Branch of the Ontario Ministry of Health (MOH) via their Applied Health Research Question program. Asiana Elma is supported by a Canadian Institutes of Health Research Canada Graduate Scholarship—Doctoral Award. This study was supported by ICES, which is funded by an annual grant from the Ontario MOH and the Ministry of Long-Term Care. This document used data adapted from the Statistics Canada Postal CodeOM Conversion file, which is based on data licensed from Canada Post Corporation, and-or data adapted from the Ontario MOH Postal Code Conversion File, which contains data copied under licence from Canada Post Corporation and Statistics Canada. Parts of this material are based on data and or information compiled and provided by Canadian Institute for Health Information, the Ontario MOH, and Ontario Health. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. The authors also acknowledge Anastasia Gayowsky, Refik Saskin, and Richard Perez for their support with data coding and analysis.

Contributors

All authors meet the International Committee of Medical Journal Editors standards for authorship. Dr Lawrence Grierson conceptualized the study, and both Dr Grierson and Dr Michelle Howard supervised all aspects of the study. Aimun Q. Shah, Asiana Elma, Dr Howard, and Dr Grierson contributed to data analysis. Aimun Q. Shah led the writing of the manuscript. All authors contributed to data interpretation and provided critical revisions to the paper. All authors have read and approved the final manuscript for publication and have agreed to be accountable for all aspects of the work.

Competing interests

Dr Lawrence Grierson serves as a member of the College of Family Physicians of Canada’s Education Reform Task Force. No other competing interests were declared.

This article has been peer reviewed.

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