Exploring Harm Reduction in Supportive Housing for Formerly Homeless Older Adults.

Background: Exclusionary care policy contributes to the growing number of older adults experiencing homelessness and complex health challenges including substance misuse. The aim of this study was to examine how harm reduction policy and practices are experienced and enacted for older adults with homeless histories and care staff in congregate supportive housing. Methods: Drawing on harm reduction (HR) principles, Rhodes' risk environment framework, and 15 semi-structured interviews (six residents, nine staff) at a 70-bed supportive housing facility in Western Canada, this qualitative constructivist grounded theory study aimed to determine: How is harm reduction experienced and enacted from the perspectives of older adults and their care staff? Results: HR policy and practices helped residents to feel respected and a sense of belonging, due largely to staff's understanding of structural vulnerability related to homelessness and their efforts to earn and maintain residents' trust. Physical and program structures in the facility combined with the social environment to mitigate harms due to substance- and nonsubstance-related risk behaviours. Conclusion: HR policy and practices in supportive living empower care providers and older adults to work together to improve housing and health stability. Wider adoption of HR approaches is needed to meet the needs of a growing number of older people experiencing homelessness and substance use challenges.

"A right place for everybody": Supporting aging in the right place for older people experiencing homelessness.

While policies and practices that promote aging in place have risen in prominence over the last two decades, marginalised older adults have largely been overlooked. 'Aging in the right place' is a concept that recognises the importance of adequate and appropriate age-related health and psychosocial supports in shelter/housing settings and their impact on the ability of older people to age optimally. To understand the unique shelter/housing challenges and solutions that affect aging in the right place for older people experiencing homelessness (OPEH), we conducted three World Café workshops in three Canadian cities-Montreal, Calgary, and Vancouver. In total, 89 service providers and OPEH engaged in the workshops, which involved guided, small-table discussions with the goal of stimulating creative ideas and fostering a productive atmosphere. Findings revealed two overarching themes 1) Discrepancies, between the need and availability of housing options and community supports for OPEH, such as affordable transportation, case management, access to healthcare, and system navigation; and 2) Desires, for more peer support, participatory planning, service-enriched housing, social programming, and policies that promote agency, independence, and choice for OPEH. These findings provide evidence to inform the development or modification of housing and supports for OPEH that promote aging in the right place.

Impact of health system engagement on the health and well-being of people who use drugs: a realist review protocol.

BACKGROUND: Although community-level benefits of health system engagement (i.e., health service planning, delivery, and quality improvement, engaged research and evaluation, and collaborative advocacy) are well established, individual-level impacts on the health and well-being of community members are less explored, in particular for people who use or have used illegal drugs (PWUD). Capacity building, personal growth, reduced/safer drug use, and other positive outcomes may or may not be experienced by PWUD involved in engagement activities. Indeed, PWUD may also encounter stigma and harm when interacting with healthcare and academic structures. Our objective is to uncover why, how, and under what circumstances positive and negative health outcomes occur during health system engagement by PWUD. METHODS: We propose a realist review approach due to its explanatory lens. Through preliminary exploration of literature, lived experience input, and consideration of formal theories, an explanatory model was drafted. The model describes contexts, mechanisms, and health outcomes (e.g., mental health, stable/safer drug use) involved in health system engagement. The explanatory model will be tested against the literature and iteratively refined against formal theories. A participatory lens will also be used, wherein PWUD with lived experience of health system engagement will contribute throughout all stages of the review. DISCUSSION: We believe this is the first realist review to explore the contextual factors and underlying mechanisms of health outcomes for PWUD who participate in health system engagement. A thorough understanding of the relevant literature and theoretical underpinnings of this process will offer insights and recommendations to improve the engagement processes of PWUD.

Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study.

BACKGROUND: Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay. METHODS: Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use). RESULTS: Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis. CONCLUSIONS: After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

Being Vulnerable: A Qualitative Inquiry of Physician Touch in Medical Education.

PURPOSE: Effective nonverbal communication is associated with empathic behavior and improved patient outcomes. Touch, as a form of nonverbal communication, is relatively unexplored in medical education. This study sought to gain in-depth insights into physicians' experiences communicating with touch and to examine how these insights could inform communication skills curricula. METHOD: Collaborative inquiry, a form of action research, was used. Six experienced physician-educators from the University of Calgary met 8 times between 2015 and 2018 to critically reflect on their experiences of touch in clinical practice, teaching, and learning. Data comprised meeting transcripts, individual narrative accounts, and digital recordings of role-plays. Interpretative phenomenology, the study of lived experience, guided analysis. RESULTS: Two themes were identified-touch as presence and touch as risk. Participants used touch to demonstrate presence and a shared humanity with patients, to express "being with" a patient. Risk was not associated with the physical experience of touch but, rather, with its social meaning, interpreted through gender, culture, relationships, and context. Individual experiences were open to many interpretations. Participants expressed tension between their personal experience communicating with touch to express empathy and formal curricular structures. Reflection, role-modeling, and clinical debriefs were suggested as ways to encourage situational awareness and sensitive use of touch. CONCLUSIONS: Touch is a powerful means to communicate with patients but is highly subjective. Rather than avoiding touch for fear of misinterpretation, encouraging dialogue about its complexity could promote a more balanced understanding of touch and its potential to convey empathy and help physicians more effectively manage risk when using touch.

Patient perspectives on a harm reduction-oriented addiction medicine consultation team implemented in a large acute care hospital.

BACKGROUND: Addiction medicine consultation teams [AMCTs] are a promising strategy for improving hospital care for patients with substance use disorders. Yet very little research has examined AMCT implementation in acute care settings. To address this gap, we conducted a process evaluation of a novel harm reduction-oriented AMCT. Our specific aims included examining patients' perspectives on factors that facilitated or hindered AMCT delivery, and its impact on their hospital care and outcomes. METHODS: The AMCT provided integrated addiction medicine, harm reduction services, and wraparound health and social supports for patients of a large, urban acute care hospital in Western Canada. We adopted a focused ethnographic design and recruited 21 patients into semi-structured interviews eliciting their views on the care they received from the team. RESULTS: Participants highlighted the AMCT's harm reduction approach; reputation amongst peers; and specialized training as especially important intervention facilitators. Key barriers that constrained the impact of the team included unmet expectations; difficulty accessing follow-up care; and residual conflicts between the AMCT's harm reduction approach and the abstinence-only orientation of some hospital staff. For a few participants these conflicts led to negative experiences. Despite this, participants reported that the AMCT had positive impacts overall, including declines in substance use, enhanced mental and emotional wellbeing, and improved socio-economic circumstances. CONCLUSIONS: A novel harm reduction-oriented AMCT led to better hospital experiences and perceived outcomes for patients. However, further efforts are needed to ensure adequate post-discharge follow-up, and a consistent approach to substance use disorder care amongst all hospital staff.

Barriers and facilitators to office-based opioid agonist therapy prescribing and effective interventions to increase provider prescribing: protocol for a systematic review.

BACKGROUND: Opiate agonist therapy (OAT) prescribing rates by family physicians are low in the context of community-based, comprehensive primary care. Understanding the factors that support and/or inhibit OAT prescribing within primary care is needed. Our study objectives are to identify and synthesize documented barriers to, and facilitators of, primary care opioid agonist prescribing, and effective strategies to inform intervention planning and support increased primary care OAT prescribing. METHODS/DESIGN: We will systematically search EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, MEDLINE, and gray literature in three domains: primary care providers, opioid agonist therapy, and opioid abuse. We will retain and assess primary studies reporting documented participation, or self-reported willingness to participate, in OAT prescribing; and/or at least one determinant of OAT prescribing; and/or strategies to address determinants of OAT prescribing from the perspective of primary care providers in comprehensive, community-based practice settings. There will be no restrictions on study design or publication date. Studies limited to specialty clinics with specialist prescribers, lacking extractable data, or in languages other than English or French will be excluded. Two reviewers will perform abstract review and data extraction independently. We will assess the quality of included studies using the Joanna Briggs Institute Critical Appraisal Tool. We will use a framework method of analysis to deductively code barriers and facilitators and to characterize effective strategies to support prescribing using a combined, modified a priori framework comprising the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. DISCUSSION: To date, no synthesis has been undertaken of the barriers and facilitators or effective interventions promoting OAT prescribing by primary care clinicians in community-based comprehensive care settings. Enacting change in physician behaviors, community-based programming, and health services is complex and best informed by using theoretical frameworks that allow the analysis of the available data to assist in designing and implementing interventions. In light of the current opioid crisis, increasing the capacity of primary care clinicians to provide OAT is an important strategy to curb morbidity and mortality from opioid use disorder. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD86835.

Drama to promote non-verbal communication skills.

BACKGROUND: Non-verbal communication skills (NVCS) help physicians to deliver relationship-centred care, and the effective use of NVCS is associated with improved patient satisfaction, better use of health services and high-quality clinical care. In contrast to verbal communication skills, NVCS training is under developed in communication curricula for the health care professions. One of the challenges teaching NVCS is their tacit nature. In this study, we evaluated drama exercises to raise awareness of NVCS by making familiar activities 'strange'. METHODS: Workshops based on drama exercises were designed to heighten an awareness of sight, hearing, touch and proxemics in non-verbal communication. These were conducted at eight medical education conferences, held between 2014 and 2016, and were open to all conference participants. Workshops were evaluated by recording narrative data generated during the workshops and an open-ended questionnaire following the workshop. Data were analysed qualitatively, using thematic analysis. Non-verbal communication skills help doctors to deliver relationship-centred care RESULTS: One hundred and twelve participants attended workshops, 73 (65%) of whom completed an evaluation form: 56 physicians, nine medical students and eight non-physician faculty staff. Two themes were described: an increased awareness of NVCS and the importance of NVCS in relationship building. Drama exercises enabled participants to experience NVCS, such as sight, sound, proxemics and touch, in novel ways. Participants reflected on how NCVS contribute to developing trust and building relationships in clinical practice. DISCUSSION: Drama-based exercises elucidate the tacit nature of NVCS and require further evaluation in formal educational settings.

How clinicians integrate humanism in their clinical workplace-'Just trying to put myself in their human being shoes'.

INTRODUCTION: Humanism has been identified as an important contributor to patient care and physician wellness; however, what humanism means in the context of medicine has been limited by opinion and a focus on personal characteristics. Our aim was to describe attitudes and behaviours that enable clinicians to integrate humanism within the clinical setting. METHODS: We conducted semi-structured individual interviews with ten clinical faculty to explore how they enact and experience humanism in patient care and clinical teaching. Interpretive description was used to analyze the data qualitatively. RESULTS: Humanism in medicine was described through five themes representing core attitudes and behaviours: whole person care, valuing, perspective-taking, recognizing universality, and relational focus. Whole person care involved recognizing the multiple dimensions of personhood and sensitivity to others' needs; valuing involved respecting and appreciating others; perspective-taking consisted of considering others' perspectives, suspending judgment, and listening; recognizing universality involved acknowledging the shared human condition, finding common ground, transcending roles, and humility; and relational focus was described through multiple relationships between patients, families, clinicians and learners, becoming part of another's story, reciprocal influence, and accompaniment. CONCLUSIONS: Whereas previous descriptions of humanism have focused on clinicians' personal qualities, our research describes a number of attitudinal and behavioural foundations of humanistic care and teaching, grounded in the experiences of clinical faculty. In drawing attention to the holistic and relational elements of humanism, our work highlights how these foundational elements can be more explicitly integrated into patient care, workplace culture, and clinical education.

Experience of Touch in Health Care: A Meta-Ethnography Across the Health Care Professions.

Touch mediates health professionals' interactions with patients. Different professionals have reported their practices but what is currently lacking is a well-theorized, interprofessional synthesis. We systematically searched eight databases, identified 41 studies in seven professions-nursing (27), medicine (4), physiotherapy (5), osteopathy (1), counseling (2), psychotherapy (1), dentistry (1)-and completed a meta-ethnographic line-of-argument synthesis. This found that touch is caring, exercises power, and demands safe space. Different professions express care through the medium of touch in different ways. They all, however, expect to initiate touch rather than for patients to do so. Various practices negotiate boundaries that define safe spaces between health care professions and patients. A metaphor-the waltz-integrates the practice of touch. Health care professionals connect physically with patients in ways that form strong relationships between them while "dance steps" help manage the risk that is inherent in such an intimate form of connection.

Untapped Potential: Performance of Procedural Skills in the Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: While family medicine residency directors have expressed concern about low procedural skills proficiency among incoming residents, curricular recommendations do not provide widely accepted guidance. This study was designed to describe requirements and experiences in procedural skill training during the family medicine clerkship and test the hypothesis that more rural placements may support this training. METHODS: The survey was conducted as part of the CAFM Educational Research Alliance (CERA) Family Medicine Clerkship Director (CD) 2013 survey. All Liaison Committee on Medical Education (LCME)-accredited medical schools in the US and Canada with a family medicine educator as family medicine or primary care CD were surveyed. CDs answered questions about clerkship structure and procedure experience and requirements for students. Choosing from a list of procedures, respondents detailed how often students perform specific skills during a rotation. RESULTS: The response rate was 73% (94 out of 129). Thirty-six procedures were performed during the family medicine clerkship. Of the procedures performed at least once, the most common were Pap test (57.1%), vaginal swab (42.9%), ECG recording (41.9%), urinalysis (40.0%), and throat swab (39.0%). Of the procedures performed more than three times, the most common were Pap test (21.0%) and sterile technique (20.0%). Learners in rural rotations were more likely to perform a range of procedures. CONCLUSIONS: Though exposed to a wide range of procedures during the family medicine clerkship, students did not often repeat procedures. Creation of a core list of procedures and taking better advantage of rural placements may improve procedural skill training in the family medicine clerkship.

Listening with a narrative ear: Insights from a study of fall stories in older adults.

OBJECTIVE: To determine the value of adding a patient narrative to the clinical assessment of falls in the elderly. DESIGN: Qualitative study of interviews. SETTING: A fall prevention clinic in Calgary, Alta. PARTICIPANTS: Fifteen older adults on a wait list for assessment by the fall clinic and the physiotherapists who assessed them. METHODS: Participants' stories were audiorecorded and later transcribed and summarized. Stories were collected using open-ended questions, first inviting participants to tell the interviewer about themselves, and then the circumstances of their falls and their reflections on them. In a subsequent visit, transcriptions or summaries were returned to patients for member checking. Narratives were read and analyzed by all 4 investigators using a narrative approach and a close-reading technique. With the patients' additional consent, stories were shared with the fall prevention team for their insights and reactions. Interviews with physiotherapists were audiorecorded and transcribed. MAIN FINDINGS: The narrative analysis provided new insights into the attitudes about and perceptions of the causes of falls, their effects, and rehabilitation. Close reading exposed presentation of self, locus of control, and underlying social and emotional issues. CONCLUSION: The addition of patient narratives to clinical assessments offers clinicians an understanding of patients' perspectives, which can be used to better engage patients in rehabilitation.

Using visual art and collaborative reflection to explore medical attitudes toward vulnerable persons.

BACKGROUND: Vulnerable persons often face stigma-related barriers while seeking health care. Innovative education and professional development methods are needed to help change this. METHOD: We describe an interdisciplinary group workshop designed around a discomfiting oil portrait, intended to trigger provocative conversations among health care students and practitioners, and we present our mixed methods analysis of participant reflections. RESULTS: After the workshop, participants were significantly more likely to endorse the statements that the observation and interpretive skills involved in viewing visual art are relevant to patient care and that visual art should be used in medical education to improve students' observational skills, narrative skills, and empathy with their patients. Subsequent to the workshop, significantly more participants agreed that art interpretation should be required curriculum for health care students. Qualitative comments from two groups from two different education and professional contexts were examined for themes; conversations focused on issues of power, body image/self-esteem, and lessons for clinical practice. CONCLUSIONS: We argue that difficult conversations about affective responses to vulnerable persons are possible in a collaborative context using well-chosen works of visual art that can stand in for a patient.

Seniors' perspectives on care: a case study of the Alex Seniors health clinic, Calgary.

BACKGROUND: Primary care initiatives face an imperative to not only reduce barriers to care for their patients but also to uniquely accommodate the complex needs of at-risk patient populations. Patient-centered multidisciplinary care team models for primary care, like the Alex Seniors Clinic, are one approach for providing comprehensive care for marginalized seniors. The purpose of this qualitative study was to explore patient perspectives on the responsiveness of the Alex Seniors Clinic to their stated health needs. RESULTS: Themes reflected participants' perspectives on factors impacting their health needs as vulnerable seniors as well as on the measures that the Alex Seniors Clinic has taken to meet those needs. Factors impacting health included: the nature of their relationships to the physical environment in which they lived, the nature of the relationships they had to others in that environment, and independence and autonomy. Participants identified accessibility, respect and support, and advocacy as the ways in which the clinic was working to address those health needs. CONCLUSIONS: While respect and support, as well as advocacy, effectively addressed some patient needs, participants felt that accessibility problems continue to be health-related barriers for clinic patients. This may be due to the fact that issues of accessibility reflect larger community and social problems. Nevertheless, it is only through engaging the patient community for input on clinic approaches that an understanding can be gained of how closely a clinic's care goals are currently aligning with patient perspectives of the care and services they receive.