Table 2 Normalization Process Theory Constructs, Themes and Elements

 Generating comprehensive assessments of older adults

1. Better information about client’s needs, goals, risks, wants obtained through volunteer visits

2. Data collection screening processes improved

3. New patient information generated to support more comprehensive care and follow up

 Strengthening health promotion, disease prevention, and self-management for aging at home

1. Care shifting to be more proactive and focused on health promotion and disease prevention

2. Seniors supported to age at home

3. Improvements in self-management

4. Enhancements in health education

 Enhancing patient-focused care

1. Caring and open relationship with patients and volunteers as confidantes

2. Patient engagement in care enhanced wherein patients are more connected and have a voice

3. Patients feel valued and cared for by clinic staff

 Strengthening interprofessional care delivery

1. Strengthened team-based approach to care

2. Role of volunteers in supporting primary health care explored

 Improving coordination of health and community services

1. Knowledge of community resources by patients and team increased

2. Improvements to access to community-based resources

 Tackling new ways of working

1. Huddle teams experience the biggest changes in ways of working, while those not in the huddle teams experience the least

2. Huddle coordinator facilitates MDs, residents and multi-disciplinary team to contribute new patient information to huddle and coordinate care

3. Volunteer role accepted by patients as part of the health care team, but could be misinterpreted as health professionals by patients

 Attaining role clarity

1. Challenges for primary care providers outside of huddles (i.e., MDs, residents) to understand their roles in relation to the huddle team, HT reports and alerts and follow up with patients

2. Lack of clarity by volunteers regarding their role with patients (e.g., advice giving) (for some)

3. Huddle team members learn one another’s roles and perceive benefits through increased teamwork and collaboration

 Changing Team Processes

1. Improved care coordination and case management process changes related to the new huddle team structure (e.g., ‘chart and chat’, follow up, case conferences, and referrals)

2. Improved flow, content and sources of patient information changes

3. New proactive approaches for the care of aging developed (e.g., prevention and promotion)

4. Some challenges exist in relation to primary care follow up and potential loss to follow up

5. Communication challenges existed with team members outside the huddle re. action plans

 Reconfiguring Resources

1. Shifts in structure and increases in workload for primary care huddle team

2. Clinic human resources took time to get organized for best use, (i.e., providers understanding their own role and part in the process)

 Improving teamwork and collaboration

1. A more effective model for collaboration is now embedded in the clinic

2. Team communication and understanding of one other’s roles improved

3. Interprofessional team huddle perceived to be valuable and worth maintaining

4. Patients experienced satisfaction with healthcare team and system

 Reconfiguring roles and processes

1. Changes to flow of information, patient referral and follow up

2. Clarification of roles of huddle team members and wider primary care team

3. Explore efficiencies and sustainability of the program