Of the 5955 unique titles, 97 peer-reviewed articles and 45 gray literature sources were included. Most studies were conducted in North America (n=117/142, 82%). Table 1 (available from CFPlus*) shows the characteristics of included studies. Appendix 1 includes the supporting references for all key themes.*

Attachment in the context of PC refers to the confirmed affiliation between a provider and a patient, characterized by the mutual agreement to engage in longitudinal care and establish a therapeutic relationship across the care trajectory. This definition encapsulates the key concepts identified through the synthesis of explicit and implicit definitions of attachment and aligns with the overarching goals of provider-patient attachment within PC settings. The scoping review identified 12 explicit definitions of attachment6,7,29,46-54 and 4 implicit definitions of provider-patient attachment.10,11,55,56 The term attachment is sometimes used interchangeably with enrolment (also known as registration,57,58rostering, and empanelment51). Enrolment and empanelment are also sometimes used interchangeably. Explicit definitions of attachment indicate it consists of 6 elements in which 4 key concepts are most frequently identified (Table 2).6,7,29,46-53 The first key concept of attachment is that a patient has an affiliation with a regular PCP.6,7,29,46,47,50,51 This affiliation represents a commitment between the patient and the PCP to engage in ongoing, longitudinal care.29,46 Patients with a regular PCP benefit from continuity and consistency in health care delivery.46,54 The definitions of attachment are also tied to the goals of affiliation and include the delivery of longitudinal care7,29,47,49,50,52 (the second key concept) and the establishment of a long-term therapeutic relationship (relational continuity) between provider and patient (the third key concept).7,47-52 Attachment to a regular PCP is closely linked to the delivery of longitudinal care, which involves the patient’s repeated interactions with the provider over an extended period.7,29,47,49,50,52 Relational continuity refers to the ongoing and consistent therapeutic relationship between patient and provider over time.7 The fourth concept is tied to the notion that the affiliation is “confirmed.”7,48,49,50,51,53 This affiliation can be formal49,51-53 or informal.51,52 Formal confirmation might involve official registration or enrolment processes, where patient and provider explicitly agree to the formal relationship.58 Informal confirmation, on the other hand, might involve a mutual understanding or verbal agreement between the patient and the provider regarding their ongoing care relationship.58 In explicit and implicit definitions of attachment, most definitions identify the FP or GP as the regular PC provider.6,7,46

Key elements of attachment definition

Definition of enrolment. Fifteen explicit definitions were reviewed for enrolment (or registration).1,52,54,57-68 Enrolment is a formal process during which a patient and provider enter into a reciprocal agreement whereby the provider agrees to be a patient’s regular provider, and the patient agrees to receive care exclusively from the provider.

In many jurisdictions, a physician or group must enroll patients to receive capitation-based payments.52,54,58,65,67,69 The PCP can be the FP or GP1,70 or the practice.62,71 Generally, the affiliation between patient and provider occurs through the mutual completion of an agreement developed by the government or payers and facilitates accountability.58 The confirmed affiliation can be recorded in information systems.54,57,65 The shift to patient enrolment in capitation-based models has improved coordination of care for older, chronically ill patients with multiple conditions; increased continuity of care; and facilitated cost savings.72-76 Fee-for-service group practices decreased provider-level continuity and coordination of specialist care and had little impact on reducing ED visits.66

Definition of empanelment. Twenty-three explicit definitions of empanelment were reviewed.2,77-98Empanelment is the deliberate process of assigning78 or linking2,96 a patient to a provider. It assumes the provider will accept responsibility for the patient.81 It has 3 goals: longitudinal care,2 relational continuity,2 and population health management.90,94 Empanelment does not require formal agreements; the affiliation can be informally confirmed and optionally recorded in information systems.95 Much of the literature on empanelment focuses on the Patient’s Medical Home vision, in which a care team assumes responsibility for PC services. Panels can be assigned to an FP,99 a physician assistant,87 a nurse practitioner,81 a midwife,100,101 or the care team.90 Attachment is more common between the patient and the most responsible FP or GP and a care team of interprofessional providers. Informational continuity is important for supporting the team because information systems enable each provider to access the patient’s health information.92 Patients can be prospectively assigned to a PCP based on patient choice or be retroactively assigned to providers. There is considerable literature on panel sizes, approaches, and algorithms for assigning patients. In fee-for-service models, a patient is not formally tied to a PCP,86 which dilutes the power of linking payment to provider-patient affiliation and accurately assigning patients to providers.

A few studies show that patient empanelment using the Patient’s Medical Home vision positively affected continuity and quality of care81,102 and reduced rates of ED use.102