Information and Communications Technologies Enabling Integrated Primary Care for Patients With Complex Care Needs: Scoping Review.

BACKGROUND: Information and communications technologies (ICTs) are recognized as critical enablers of integrated primary care to support patients with multiple chronic conditions. Although ICT-enabled integrated primary care holds promise in supporting patients with complex care needs through team-based and continued care, critical implementation factors regarding what ICTs are available and how they enable this model are yet to be mapped in the literature. OBJECTIVE: This scoping review addressed the current knowledge gap by answering the following research question: What ICTs are used in delivering integrated primary care to patients with complex care needs? METHODS: The Arksey and O'Malley method enhanced by the work by Levac et al was used to guide this scoping review. In total, 4 electronic medical databases were accessed-MEDLINE, Embase, CINAHL, and PsycINFO-collecting studies published between January 2000 and December 2021. Identified peer-reviewed articles were screened. Relevant studies were charted, collated, and analyzed using the Rainbow Model of Integrated Care and the eHealth Enhanced Chronic Care Model. RESULTS: A total of 52,216 articles were identified, of which 31 (0.06%) met the review's eligibility criteria. In the current literature, ICTs are used to serve the following functions in the integrated primary care setting: information sharing, self-management support, clinical decision-making, and remote service delivery. Integration efforts are supported by ICTs by promoting teamwork and coordinating clinical services across teams and organizations. Patient, provider, organizational, and technological implementation factors are considered important for ICT-based interventions in the integrated primary care setting. CONCLUSIONS: ICTs play a critical role in enabling clinical and professional integration in the primary care setting to meet the health system-related needs of patients with complex care needs. Future research is needed to explore how to integrate technologies at an organizational and system level to create a health system that is well prepared to optimize technologies to support patients with complex care needs.

Information and Communication Technologies (ICTs) enabling integrated primary care for complex patients: a protocol for a scoping review.

INTRODUCTION: An increasing number of individuals are living with multiple chronic conditions, often combined with psychosocial complexities. For these patients with complex conditions, an integrated primary care model that provides care coordination and a team-based approach can help manage their multiple needs. Information and communication technologies (ICTs) are recognized as a critical enabler of integrated primary care. A better understanding of the use of ICTs in an integrated care setting and how ICTs are being leveraged would be beneficial to identify knowledge gaps and could lead to successful implementation for ICT-based interventions. OBJECTIVE: This study will systematically scope the literature on the topic of ICT-enabled integrated healthcare delivery models for patients with complex care needs to identify which technologies have been used in integrated primary care settings. METHOD: This study protocol outlines a scoping review of the peer-reviewed literature, using Arksey and O'Malley's (enhanced by Levac et al.) scoping review methodology. Peer-reviewed literature will be identified using a multi-database search strategy. The results of the search will be screened, abstracted, and charted in duplicate by six research team members. DISCUSSION: The key findings of the study will be thematically analyzed to describe the implemented ICTs aimed for complex patients within the integrated primary care model. The finding will highlight what types of ICTs are being put in place to support these models, and how these ICTs are enabling care integration. This review will be the first step to formally identify how ICT is used to support integrated primary health care models. The results will be disseminated through peer-reviewed publications, conference presentations, and special interest groups.

A qualitative study of hospital and community providers' experiences with digitalization to facilitate hospital-to-home transitions during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has triggered substantial changes to the healthcare context, including the rapid adoption of digital health to facilitate hospital-to-home transitions. This study aimed to: i) explore the experiences of hospital and community providers with delivering transitional care during the COVID-19 pandemic; ii) understand how rapid digitalization in healthcare has helped or hindered hospital-to-home transitions during the COVID-19 pandemic; and, iii) explore expectations of which elements of technology use may be sustained post-pandemic. METHODS: Using a pragmatic qualitative descriptive approach, remote interviews with healthcare providers involved in hospital-to-home transitions in Ontario, Canada, were conducted. Interviews were analyzed using a team-based rapid qualitative analysis approach to generate timely results. Visual summary maps displaying key concepts/ideas were created for each interview and revised based on input from multiple team members. Maps that displayed similar concepts were then combined to create a final map, forming the themes and subthemes. RESULTS: Sixteen healthcare providers participated, of which 11 worked in a hospital, and five worked in a community setting. COVID-19 was reported to have profoundly impacted healthcare providers, patients, and their caregivers and influenced the communication processes. There were several noted opportunities for technology to support transitions. INTERPRETATION: Several challenges with technology use were highlighted, which could impact post-pandemic sustainability. However, the perceived opportunities for technology in supporting transitions indicate the need to investigate the optimal role of technology in the transition workflow.

Methodological Insights From a Virtual, Team-Based Rapid Qualitative Method Applied to a Study of Providers' Perspectives of the COVID-19 Pandemic Impact on Hospital-To-Home Transitions.

Background: During the COVID-19 pandemic, rapid virtual qualitative methods have gained attention in applied health research to produce timely, actionable results while complying with the pandemic restrictions. However, rigour and analytical depth may be two areas of concern for rapid qualitative methods. Methods: In this paper, we present an overview of a virtual team-based rapid qualitative method within a study that explored health care providers' perspectives of how the COVID-19 pandemic has impacted hospital-to-home transitions, lessons learned in applying this method, and recommendations for changes. Using this method, qualitative data were collected and analyzed using the Zoom Healthcare videoconferencing platform and telephone. Visual summary maps were iteratively created from the audio recordings of each interview through virtual analytic meetings with the team. Maps representing similar settings (e.g. hospital providers and community providers) and Sites were combined to form meta-maps representing that group's experience. The combinations of data that best fit together were used to form the final meta-map through discussion. Results: This case example is used to provide a description of how to apply a virtual team-based rapid qualitative method. This paper also offers a discussion of the opportunities and challenges of applying this method, in particular how the virtual team-based rapid qualitative method could be modified to produce timely results virtually while attending to rigour and depth. Conclusions: We contend that the virtual team-based rapid qualitative data collection and analysis method was useful for generating timely, rigorous, and in-depth knowledge about transitional care during the COVID-19 pandemic. The recommended modifications to this method may enhance its utility for researchers to apply to their qualitative research studies.

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review.

BACKGROUND: Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions. OBJECTIVE: To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions. METHODS: This 2-phase rapid review involved a selective review of providers' roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults' hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1. RESULTS: In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients' status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions. CONCLUSIONS: This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-045596.

Synthesising evidence regarding hospital to home transitions supported by volunteers of third sector organisations: a scoping review protocol.

INTRODUCTION: Given the risks inherent in care transitions, it is imperative that patients discharged from hospital to home receive the integrated care services necessary to ensure a successful transition. Despite efforts by the healthcare sector to develop health system solutions to improve transitions, problems persist. Research on transitional support has predominantly focused on services delivered by healthcare professionals; the evidence for services provided by lay navigators or volunteers in this context has not been synthesised. This scoping review will map the available literature on the engagement of volunteers within third sector organisations supporting adults in the transition from hospital to home. METHODS AND ANALYSIS: Using the well-established scoping review methodology outlined by the Joanna Briggs Institute, a five-stage review is outlined: (1) determining the research question, (2) search strategy, (3) inclusion criteria, (4) data extraction and (5) analysis and presentation of the results. The search strategy will be applied to 10 databases reflecting empirical and grey literature. A two-stage screening process will be used to determine eligibility of articles. To be included in the review, articles must describe a community-based programme delivered by a third sector organisation that engages volunteers in the provisions of services that support adults transitioning from hospital to home. All articles will be independently assessed for eligibility, and data from eligible articles will be extracted and charted using a standardised form. Extracted data will be analysed using narrative and descriptive analyses. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review. Members of an international special interest group focused on the voluntary sector will be consulted to provide insight and feedback on study findings, help with dissemination of the results and engage in the development of future research proposals. Dissemination activities will include peer-reviewed publications and academic presentations.

How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol.

INTRODUCTION: Older adults may experience challenges during the hospital to home transitions that could be mitigated by digital health solutions. However, to promote adoption in practice and realise benefits, there is a need to specify how digital health solutions contribute to hospital to home transitions, particularly pertinent in this era of social distancing. This rapid review will: (1) elucidate the various roles and functions that have been developed to support hospital to home transitions of care, (2) identify existing digital health solutions that support hospital to home transitions of care, (3) identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions for older adults (eg, the pre-trial results of the Digital Bridge intervention; ClinicalTrials.gov Identifier: NCT04287192). METHODS AND ANALYSIS: A two-phase rapid review will be conducted to meet identified aims. In phase 1, a selective literature review will be used to generate a conceptual map of the roles and functions of individuals that support hospital to home transitions for older adults. In phase 2, a search on MEDLINE, EMBASE and CINAHL will identify literature on digital health solutions that support hospital to home transitions. The ways in which digital health solutions can support the roles and functions that facilitate these transitions will then be mapped in the analysis and generation of findings. ETHICS AND DISSEMINATION: This protocol is a review of the literature and does not involve human subjects, and therefore, does not require ethics approval. This review will permit the identification of gaps and new opportunities for digital processes and platforms that enable care transitions and can help inform the design and implementation of future digital health interventions. Review findings will be disseminated through publications and presentations to key stakeholders.

Goal-Oriented Care: A Catalyst for Person-Centred System Integration.

INTRODUCTION: Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation. DESCRIPTION: This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels. DISCUSSION: The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care. LESSONS LEARNED: By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift.

Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study.

BACKGROUND: Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE: This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS: The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure-3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS: This project is underway and expected to be complete by Spring 2024. CONCLUSIONS: Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/20220.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review.

CONTEXT: Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined. OBJECTIVE: Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit. STUDY DESIGN: Systematic rapid realist review. DATASET: Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation. RESULTS: 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion. CONCLUSIONS: Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

Sahaj Samadhi Meditation versus a Health Enhancement Program for depression in chronic pain: protocol for a randomized controlled trial and implementation evaluation.

BACKGROUND: Despite the high prevalence of comorbid chronic pain and depression, this comorbidity remains understudied. Meditation has demonstrated efficacy for both chronic pain and depression independently, yet there have been few studies examining its effectiveness when both conditions are present concurrently. Furthermore, while meditation is generally accepted as a safe and effective health intervention, little is known about how to implement meditation programs within or alongside the health care system. METHODS: We will conduct a hybrid type 1 effectiveness-implementation evaluation. To measure effectiveness, we will conduct a randomized controlled trial comparing Sahaj Samadhi Meditation and the Health Enhancement Program in 160 people living with chronic pain, clinically significant depressive symptoms, and on long-term opioid therapy. Changes in depressive symptoms will be our primary outcome; pain severity, pain-related function, opioid use, and quality of life will be the secondary outcomes. The primary end point will be at 12 weeks with a secondary end point at 24 weeks to measure the sustainability of acute effects. Patients will be recruited from a community-based chronic pain clinic in a large urban center in Mississauga, Canada. The meditation program will be delivered in the clinical environment where patients normally receive their chronic pain care by certified meditation teachers who are not regulated health care providers. We will use a mixed-methods design using the multi-level framework to understand the implementation of this particular co-location model. DISCUSSION: Results of this hybrid evaluation will add important knowledge about the effectiveness of meditation for managing depressive symptoms in people with chronic pain. The implementation evaluation will inform both effectiveness outcomes and future program development, scalability, and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04039568. Registered on 31 July 2019.

Face-to-face communication between patients and family physicians in Canada: A scoping review.

OBJECTIVE: Patient-provider communication is critical in primary care. Canada's unique health system, population distribution, and cultural context suggest there is value in addressing the topic in the Canadian context. We conducted a scoping review to synthesize recent Canadian literature to inform practice in primary care settings and identify research agendas for patient-provider communication in Canada. METHODS: Using Arksey and O'Malley's framework we searched four literature databases: Medline, Web of Science, CINAHL and EMBASE. We extracted 21,932 articles published between 2010 and 2017. A total of 108 articles met the inclusion criteria. The articles were analyzed qualitatively using thematic analysis to identify major themes. RESULTS: Four major themes were identified: information sharing, relationships, health system challenges, and development and use of communication tools. CONCLUSION: Our review identified a need for Canadian research regarding: communication in primary care with Aboriginal, immigrant, and rural populations; the impact of medical tourism on primary care; and how to improve communication to facilitate continuity of care. PRACTICE IMPLICATIONS: Challenges providers face in primary care in Canada include: communicating with linguistically and culturally diverse populations; addressing issues that emerge with the rise of medical tourism; a need for decision aids to improve communication with patients.