"Can you hear me now?": a qualitative exploration of communication quality in virtual primary care encounters for patients with intellectual and developmental disabilities.

BACKGROUND: High quality communication is central to effective primary care. The COVID-19 pandemic led to a dramatic increase in virtual care but little is known about how this may affect communication quality. Adults with intellectual and developmental disabilities (IDD) can experience challenges communicating or communicate in non-traditional ways. This study explored how the use of virtual modalities, including telephone and video, affects communication in primary care interactions for patients with IDD. METHODS: This qualitative descriptive study included semi-structured interviews with a multi-stakeholder sample of 38 participants, including 11 adults with IDD, 13 family caregivers, 5 IDD support staff and 9 primary care physicians. Interviews were conducted in Ontario, Canada between March and November 2021 by video-conference or telephone. A mixed inductive and deductive thematic analysis approach was used to code the data and identify themes. Themes were reviewed and refined with members of each stakeholder group. RESULTS: Four elements of communication were identified that were affected by virtual care: (1) patient engagement in the virtual appointment; (2) the ability to hear other participants and have the time and space to be heard; (3) the ability to use nonverbal communication strategies; and (4) the ability to form trusting relationships. In some cases, the virtual platform hindered these elements of communication. Video offered some advantages over telephone to support nonverbal communication, and stimulate engagement; though this could be limited by technical challenges. For adults with IDD who find it difficult to attend in-person appointments, virtual care improved communication quality by allowing them to participate from a space where they were comfortable. CONCLUSION: Though there are circumstances in which virtual delivery can improve communication for patients with IDD, there are also challenges to achieving high quality patient-provider communication over telephone and video. Improved infrastructure and training for providers, patients and caregivers can help improve communication quality, though in some cases it may never be appropriate. A flexible patient-centred approach is needed that includes in-person, telephone and video options for care.

Accessibility of Virtual Primary Care for Adults With Intellectual and Developmental Disabilities During the COVID-19 Pandemic: Qualitative Study.

BACKGROUND: The COVID-19 pandemic has led to an unprecedented increase in the delivery of virtual primary care. Adults with intellectual and developmental disabilities (IDDs) have complex health care needs, and little is known about the value and appropriateness of virtual care for this patient population. OBJECTIVE: The aim of this study was to explore the accessibility of virtual primary care for patients with IDDs during the pandemic. METHODS: We conducted semistructured interviews with 38 participants in Ontario, Canada between March and November 2021. A maximum variation sampling strategy was used to achieve a diverse sample including 11 adults with IDDs, 13 family caregivers, 5 IDD support staff members, and 9 primary care physicians. An iterative mixed inductive and deductive thematic analysis approach was used to code the data and synthesize higher-level themes. The analysis was informed by the Levesque Patient-Centered Access to Health Care Framework. RESULTS: We identified themes related to 4 of 5 access-to-care dimensions that highlighted both the benefits and challenges of virtual care for adults with IDDs. The benefits included saving time spent traveling and waiting; avoiding anxiety and challenging behavior for patients who struggle to attend in-person visits; allowing caregivers who live far away from their loved ones to participate; reducing illness transmission; and allowing health care providers to see patients in their home environments. The challenges included lack of access to necessary technology, lack of comfort or skill using technology, and lack of nonverbal communication; difficulty engaging and establishing rapport; patient exclusion from the health care encounter; and concerns about privacy and confidentiality. An overarching theme was that "one size does not fit all," and the accessibility of virtual care was dependent on the interaction between the following 5 categories of factors: patient characteristics, patient context, caregiver characteristics, service context, and reason for a particular primary care visit. Though virtual care was not always appropriate, in some cases, it dramatically improved patients' abilities to access necessary health care. CONCLUSIONS: This study suggests that a flexible patient-centered system including multiple delivery modalities is needed to ensure all patients have access to primary care. Implementing this system will require improved virtual care platforms, access to technology for patients and caregivers, training for primary care providers, and appropriately aligned primary care funding models.

Improving capacity to care for patients with intellectual and developmental disabilities: The value of an experiential learning model for family medicine residents.

BACKGROUND: Patients with intellectual and developmental disabilities (IDD) are more likely to experience poor health outcomes and family physicians receive inadequate training to provide appropriate care to this patient group. Little prior research has studied how to effectively train family physicians to care for patients with IDD. OBJECTIVE: The aim of this pilot study was to assess the value of adding an experiential component to didactic education strategies to improve family medicine resident perceived comfort, skills and knowledge related to caring for patients with IDD. METHODS: Structured education programs for residents were implemented at three primary care practices in Ontario, Canada. Two practices received didactic information only (didactic-only group); one received didactic information and an experiential training model including clinical interactions and a written reflection on that experience (didactic plus experiential group). In this separate-sample pre-post design, residents were invited to complete a brief anonymous survey prior to and following the training assessing their perceived comfort, skills and knowledge related to patients with IDD. RESULTS: At baseline, there were no significant differences between the two groups of residents. At follow up, the experiential group reported significantly higher levels of comfort, skills, and knowledge compared to baseline for most items assessed, while in the didactic-only group most items showed little or no improvement. CONCLUSION: This pilot study suggests that providing residents the opportunity to participate in clinical encounters with patients with IDD, as well as a structured process to reflect on such encounters, results in greater benefit than didactic training alone.

The Nuts and Bolts of Health Care: Evaluating an initiative to build direct support professional capacity to support the health care of individuals with intellectual disabilities.

BACKGROUND: Direct support professionals (DSP) are instrumental in supporting the health care of individuals with intellectual disabilities, yet receive little training and support for this role. We implemented a capacity building intervention for DSPs in a community agency in Ontario, Canada. This study evaluated the perceived value and feasibility of the intervention and the value of a structured implementation approach. METHOD: The intervention included communication tools, a health resource toolkit, and training. A mixed methods evaluation was used to collect feedback from DSPs and people with intellectual disabilities. RESULTS: Participants generally found the intervention valuable and feasible. Although practice change is difficult, extensive engagement and being responsive to feedback were helpful strategies. The primary concern reported by DSPs was resistance from health care providers. CONCLUSION: An important next step is to engage health care providers to ensure the tools are valuable and feasible for everyone involved in the health encounter.

Virtual health care for adult patients with intellectual and developmental disabilities: A scoping review.

BACKGROUND: The COVID-19 pandemic led to an abrupt shift to virtual health care for many patients, including adults with intellectual and developmental disabilities (IDD). Approaches to virtual care that are successful for people without IDD may need to be adapted for adults with IDD. OBJECTIVE: The aim of this scoping review was to examine what is known about virtual health care for adults with IDD and in particular, the impact of virtual delivery on access to care for this population. METHODS: A comprehensive search was conducted of the academic and grey literature. A two-stage screening process was conducted by two independent reviewers and a structured data extraction template was populated for each included study. Findings were analyzed thematically using Access to Care Framework domains. RESULTS: In total, 22 studies met inclusion criteria. The majority were published in the past three years and focused on specialized IDD services. A subset of 12 studies reported findings on access to care for adults with IDD. Participants generally reported high acceptability of virtual care, though some preferred face-to-face encounters. Initial results on effectiveness were positive, though limited by small sample sizes. Challenges included internet quality and technical skill or comfort. CONCLUSIONS: This review suggests that it is possible to deliver accessible, high quality virtual care for adults with IDD, however, relatively little research has been conducted on this topic. Due to COVID-19 there is currently a unique opportunity and urgency to learn when and for whom virtual care can be successful and how it can be supported.

Feasibility and acceptability of a volunteer peer fidelity assessment model in early psychosis intervention programmes in Ontario: Results from a pilot study.

AIM: Fidelity monitoring can support high-quality service delivery but is resource-intensive to implement. A fidelity assessment model utilizing volunteer assessors was trialled as a low-cost strategy for conducting fidelity assessments. This article reports on the acceptability and feasibility of this model. METHODS: Twenty volunteer assessors were trained to conduct fidelity assessments in nine Early Psychosis Intervention programmes across Ontario, Canada. Assessments were conducted using the First-Episode Psychosis Services Fidelity Scale based on a 2-day site visit, during which assessors interviewed staff, clients and families; reviewed charts; observed a team meeting and reviewed programme materials. The model was evaluated based on assessor focus groups, programme interviews, consensus meeting data and time-tracking logs. General inductive analysis was used to code and synthesize qualitative data. Quantitative data were aggregated and summarized. RESULTS: Participant feedback was positive and indicated that use of peer assessors and the in-person site visit added value to the process. The model was perceived to provide valuable information to support internal quality improvement efforts. Assessors reported direct benefits from participating, including networking and learning opportunities. Key challenges were the high time demand on assessors and turnover in the assessor team. CONCLUSIONS: The volunteer peer fidelity model was perceived to be a valuable improvement process by participants, but the high cost and reliance on ongoing volunteerism makes its sustainability uncertain. Next steps may include exploring remote assessment strategies or direct payments, although these strategies risk reducing the acceptability, and therefore uptake, of the assessment.

Emergency department nurses' knowledge, skills, and comfort related to caring for patients with intellectual disabilities.

INTRODUCTION: Individuals with intellectual disabilities (ID) are more likely to visit the emergency department (ED) more frequently than their counterparts without ID. Nurses play an integral role in caring for all patients in the ED, including those with ID, although training to work with this population is limited. The aim of this study was to examine the self-perceived knowledge, skills, and comfort of ED nurses when caring for a patient with ID. METHODS: Questionnaires were returned from 151 nurses from a total of six EDs within Ontario, Canada. The questionnaire contained fourteen items related to knowledge, comfort, practice and skills, readiness for change, prior exposure to patients with ID, and awareness of strategies to identify patients in this population. RESULTS: Although the majority of nurses reported an interaction with a patient with a suspected ID in the past year, only 28% of respondents reported awareness of strategies to help identify if a patient may have an ID, and only half reported feeling skilled in adapting their communication and approach. DISCUSSION: ED nurses are the first point of contact in caring for patients with ID, thus it is crucial that they understand how to provide accessible and inclusive care for this population.

Using Fidelity Measurement to Assess Quality of Early Psychosis Intervention Services in Ontario.

OBJECTIVES: The First Episode Psychosis Services Fidelity Scale (FEPS-FS) is a validated measure of program delivery in relation to international standards. This study assessed fidelity in Ontario programs and the utility of the FEPS-FS for program improvement. METHODS: Assessments were conducted in a volunteer sample of nine early psychosis intervention (EPI) programs. Thirty components of care were each rated on a 5-point scale; a rating of 4 indicates satisfactory performance. Trained assessor teams conducted site visits, and ratings were made by consensus. RESULTS: Program mean fidelity ratings ranged from 3.1 to 4.4 and exceeded 4 in five programs. Across the programs, item mean fidelity ratings ranged from 2.1 to 5 and exceeded 4 for 14 of 30 items. CONCLUSIONS: The FEPS-FS captured variation in program implementation and provided a baseline for measuring change. Additions to the scale are planned to address components of the Ontario EPI standards not covered by the FEPS-FS.

Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders.

Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.

Improving the quality of primary care for adults with intellectual and developmental disabilities: Value of the periodic health examination.

OBJECTIVE: To implement a Health Check protocol for patients with intellectual and developmental disabilities (IDD) and assess outcomes. DESIGN: Retrospective chart review and staff survey. SETTING: Two Ontario family health teams. PARTICIPANTS: Of 276 patients with IDD identified, 139 received the Health Check (Health Check group). A convenience sample (N = 147) of clinical staff participated in the survey. MAIN OUTCOME MEASURES: The protocol included patient identification, invitation, and modified health examination. Chart review assessed completion of 8 preventive maneuvers, and clinical staff were surveyed on their comfort, knowledge, and skills in care of patients with IDD. Logistic regression analyses were used to compare outcomes for the Health Check and non-Health Check groups, adjusted for practice site. RESULTS: Documentation of blood pressure, weight, body mass index, and influenza vaccination was significantly higher (P < .001) in the Health Check group, exceeding 70% of patients. Screening rates were higher for mammograms (63% vs 54%), fecal occult blood testing (39% vs 23%), and diabetes testing (80% vs 61%), but not significantly so, and they were similar to general population rates. Papanicolaou test rates were low for both groups (34% vs 32%). Staff comfort and skills were rated significantly higher (P < .05) for those who performed the Health Check. Still, fewer than half thought they had the necessary skills and resources to care for patients with IDD. CONCLUSION: Performing the Health Check was associated with improved preventive care and staff experience. Wider implementation and evaluation is needed, along with protocol adjustments to provide more support to staff for this work.

Barriers and facilitators to improving health care for adults with intellectual and developmental disabilities: what do staff tell us? / Éléments qui favorisent ou freinent l'amélioration des soins de santé destinés aux adultes souffrant d'une déficience intellectuelle ou développementale : qu'en dit le personnel?

INTRODUCTION: Adults with intellectual and developmental disabilities (IDD) have high rates of morbidity and are less likely to receive preventive care. Emergency departments and primary care clinics are important entry points into the health care system. Improving care in these settings can lead to increased prevention activities, early disease identification, and ongoing management. We studied barriers and facilitators to improving the care of patients with IDD in three primary and three emergency care sites in Ontario. METHODS: Data sources included structured implementation logs at each site, focus groups (n = 5) and interviews (n = 8). Barriers and facilitators were coded deductively based on the Consolidated Framework for Implementation Research (CFIR). Synthesis to higher level themes was achieved through review and discussion by the research team. Focus was given to differences between higher and lower implementing sites. RESULTS: All sites were challenged to prioritize care improvement for a small, complex population and varied levels of implementation were achieved. Having national guidelines, using local data to demonstrate need and sharing evidence on value were important engagement strategies. Factors present at higher implementing sites included strong champions, alignment with site mandate, and use of electronic prompts/reminders. Lower implementing sites showed more passive endorsement of the innovation and had lower capacity to implement. CONCLUSION: Providing effective care for small, complex groups, such as adults with IDD, is critical to improving long-term health outcomes but is challenging to achieve. At a systemic level, funding incentives, access to expertise and improved electronic record systems may enhance capacity.

INTRODUCTION: Les adultes souffrant d'une déficience intellectuelle ou développementale (DID) présentent des taux de morbidité élevés et risquent davantage de ne pas recevoir de soins préventifs. Les services d'urgence des hôpitaux et les cliniques de soins primaires sont d'importants points d'entrée dans le système de soins de santé. Améliorer les soins dans ces lieux est susceptible d'améliorer les activités préventives, le dépistage précoce des maladies et la gestion courante. Nous avons étudié les éléments qui favorisent ou freinent l'amélioration des soins de santé destinés aux patients souffrant d'une DID dans trois établissements de soins primaires et trois services d'urgences de l'Ontario. MÉTHODOLOGIE: Les sources de données consistaient notamment en des journaux de mise en oeuvre structurée sur chacun des sites, des discussions de groupe (n=5) et des entrevues (n=8). Les éléments qui favorisent ou freinent l'amélioration des soins de santé ont été codés par déduction à partir du Consolidated Framework for Implementation Research (CFIR). Les thèmes de plus haut niveau ont été obtenus en faisant la synthèse des discussions et des examens de l'équipe de recherche. L'accent a été mis sur les différences entre les sites de mise en oeuvre de haut et de bas niveau. RÉSULTATS: Mis au défi de privilégier l'amélioration des soins destinés à une population complexe de petite taille, les sites ont atteint divers niveaux de mise en oeuvre. Disposer de lignes directrices à l'échelle nationale, utiliser des données locales pour montrer les besoins et mettre en commun les données probantes sur l'intérêt du projet ont constitué des stratégies de mobilisation importantes. Les sites de mise en oeuvre de haut niveau ont présenté des facteurs particuliers, comme la présence de fervents partisans, la conformité avec la mission du site et l'utilisation d'invitations ou de rappels électroniques. Les sites de mise en oeuvre de bas niveau ont accueilli l'innovation plus passivement et ont présenté des capacités de mise en oeuvre inférieures. CONCLUSION: Il est indispensable de permettre aux groupes complexes de petite taille, comme celui les adultes souffrant d'une DID, de recevoir des soins efficaces afin de voir leur état de santé s'améliorer à long terme, mais cet objectif est difficile à atteindre. À l'échelle du système, des mesures d'incitation au financement, des moyens d'accès à l'expertise et l'amélioration des systèmes de dossiers électroniques pourraient améliorer les choses.

The Mental Health of Adults with Developmental Disabilities in Ontario: Lessons from Administrative Health Data.

Adults with developmental disabilities have increased rates of mental illness and addiction, in addition to being more likely to experience physical health issues. This can lead to high rates of hospital and community-based healthcare. Population-based administrative health data can help in identifying the extent of problems experienced and target areas for policy and practice changes.

Health checks for adults with intellectual and developmental disabilities in a family practice.

OBJECTIVE: To provide tips and tools for primary care practitioners carrying out health checks for adult patients with intellectual and developmental disabilities (IDD) and for implementing a systematic program of health checks in a group or team practice. SOURCES OF INFORMATION: The "Primary Care of Adults with Intellectual and Developmental Disabilities. 2018 Canadian Consensus Guidelines" literature review and interdisciplinary input. Experience in implementing health checks in family practices was obtained through the primary care project of H-CARDD (Health Care Access Research and Developmental Disabilities). MAIN MESSAGE: Annual comprehensive health assessments ("health checks") are a recommendation of the 2018 Canadian consensus guidelines for primary care of adults with IDD because of evidence of benefit in this population. Although health checks might require more time to complete for people with IDD than is usual for encounters in primary care, family physicians are in an ideal position to provide this service because of the attributes of family medicine, which include both an orientation to proactive care and the ability to provide continuity of care. Tips and tools are provided for carrying out health checks for adult patients with IDD and for implementing a systematic program of health checks in a group or team practice. CONCLUSION: Health checks can help enhance a family physician's approach to providing care for adults with IDD.

Assessing care-giving demands, resources and costs of family/friend caregivers for persons with mental health disorders: A scoping review.

As mental health (MH) care has shifted from institutional settings to the community, families and friends are responsible for providing the majority of the care at home. The substantial literature on the adverse effects experienced by caregivers has focused mainly on psychological morbidity. Less attention has been paid to how caregivers for persons with MH disorders interact with larger social systems and the impacts of factors such as financial strain, lost time from leisure activities, and the availability of health and social services. We conducted a scoping review of MH and other caregiver questionnaires published between 1990 and 2016 to determine whether they addressed four key domains: caregiver work demands, resource needs, resource utilisation and costs. A range of health and social care databases were searched, including MEDLINE and Health and Psychosocial Instruments. After screening for relevance and quality, our search identified 14 instruments addressing elements related to one or more of our domains. Because these instruments covered only a small portion of our domains, we conducted a second targeted search of the general care-giving literature and consulted with experts, identifying an additional 18 instruments. A total of 32 questionnaires were reviewed, 14 specific to care-giving for mental health problems and 18 for other health conditions. Our search identified instruments or items within instruments that assess constructs in each of our domains, but no one instrument covered them completely. Additionally, some constructs were evaluated in detail and others only addressed by single items. While these instruments are helpful for moving measurement beyond the psychological impacts of care-giving, our results serve only as an initial guide. Additional methodological work is needed to more comprehensively measure the impact of care-giving for individuals with MH disorders and to contribute to the development of more meaningful and effective policies and programmes.

All-Cause, 30-Day Readmissions Among Persons With Intellectual and Developmental Disabilities and Mental Illness.

OBJECTIVE: Early hospital readmissions within 30 days of discharge are common and costly. This research describes predictors of all-cause, 30-day hospital readmissions among persons with intellectual and developmental disabilities (IDD), a group known to experience high rates of hospitalization. METHODS: A cohort of 66,484 adults with IDD from Ontario, Canada, was used to create two subgroups: individuals with IDD only and those with IDD and mental illness. The rates of hospital readmission were determined and contrasted with a comparison subgroup of people without IDD who have mental illness. RESULTS: Compared with those with mental illness only, individuals with IDD and mental illness were 1.7 times more likely to experience a hospital readmission within 30 days. Predictors of their readmission rates included being a young adult and having high morbidity levels. CONCLUSIONS: The high rate of hospital readmission suggests that individuals with IDD and mental illness need attention regarding discharge planning and outpatient follow-up.

A Survey of Health Equity Practices in Early Psychosis Intervention Programs: A Starting Point for Improvement.

Equity has been identified as a core component of quality healthcare in Ontario. However, translating policy into practice can be challenging. This paper reports results from a province-wide survey of early psychosis intervention programs to assess the extent to which equity has been incorporated into program delivery. All 56 programs (100%) completed the survey. Results found that while most programs perceive that they are meeting equity aims, they reported limited use of practices to support this aim, and few systematically collect information on performance. Strategies to improve equity in practice are discussed.

Barriers and facilitators to implementing family support and education in Early Psychosis Intervention programmes: A systematic review.

Family support is a core component of the Early Psychosis Intervention (EPI) model, yet it continues to have relatively low rates of implementation in practice. This paper reports results of a literature review on facilitators and barriers to delivering family interventions in EPI programmes. A search was conducted of 4 electronic databases, Medline, EMBASE, PsycINFO and Joanna Briggs, from 2000 to 2015 using terms related to early onset psychosis, family work and implementation. Four thousand four hundred and two unique studies were identified, 7 of which met inclusion criteria. Barriers and facilitators were coded and aggregated to higher-level themes using a consensus approach. Five of 7 studies examined structured multifamily psychoeducation. Uptake by families was affected by: family/client interest and readiness to participate; ability to access supports; and support needs/preferences. Implementation by programmes was affected by staff access to training and resources to provide family support. A key finding across the identified studies was that families have different needs and preferences regarding the timing, length, intensity and content of the intervention. One size does not fit all and many families do not require the intensive psychoeducational programmes typically provided. The reviewed literature suggests that flexible, tiered approaches to care may better meet family needs and increase rates of uptake of family support. However, more research is needed on the effectiveness of different models of family support in early psychosis and how they can be successfully implemented.

Substance-related and addictive disorders among adults with intellectual and developmental disabilities (IDD): an Ontario population cohort study.

OBJECTIVES: Describe the prevalence of substance-related and addictive disorders (SRAD) in adults with intellectual and developmental disabilities (IDD) and compare the sociodemographic and clinical characteristics of adults with IDD and SRAD to those with IDD or SRAD only. DESIGN: Population-based cohort study (the Health Care Access Research and Development Disabilities (H-CARDD) cohort). SETTING: All legal residents of Ontario, Canada. PARTICIPANTS: 66 484 adults, aged 18-64, with IDD identified through linked provincial health and disability income benefits administrative data from fiscal year 2009. 96 589 adults, aged 18-64, with SRAD but without IDD drawn from the provincial health administrative data. MAIN OUTCOME MEASURES: Sociodemographic (age group, sex, neighbourhood income quintile, rurality) and clinical (psychiatric and chronic disease diagnoses, morbidity) characteristics. RESULTS: The prevalence of SRAD among adults with IDD was 6.4%, considerably higher than many previous reports and also higher than found for adults without IDD in Ontario (3.5%). Among those with both IDD and SRAD, the rate of psychiatric comorbidity was 78.8%, and the proportion with high or very high overall morbidity was 59.5%. The most common psychiatric comorbidities were anxiety disorders (67.6%), followed by affective (44.6%), psychotic (35.8%) and personality disorders (23.5%). These adults also tended to be younger and more likely to live in the poorest neighbourhoods compared with adults with IDD but no SRAD and adults with SRAD but no IDD. CONCLUSIONS: SRAD is a significant concern for adults with IDD. It is associated with high rates of psychiatric and other comorbidities, indicating that care coordination and system navigation may be important concerns. Attention should be paid to increasing the recognition of SRAD among individuals with IDD by both healthcare and social service providers and to improving staff skills in successfully engaging those with both IDD and SRAD.

Evaluating the Implementation of Health Checks for Adults With Intellectual and Developmental Disabilities in Primary Care: The Importance of Organizational Context.

Compared to other adults, those with intellectual and developmental disabilities have more health issues, yet are less likely to receive preventative care. One strategy that has shown success in increasing prevention activities and early detection of illness is the periodic comprehensive health assessment (the health check). Effectively moving evidence into practice is a complex process that often receives inadequate attention. This qualitative study evaluates the implementation of the health check at two primary-care clinics in Ontario, Canada, and the influence of the clinic context on implementation decisions. Each clinic implemented the same core components; however, due to contextual differences, some components were operationalized differently. Adapting to the setting context is important to ensuring successful and sustainable implementation.