A multi-step approach to developing a health system evaluation framework for community-based health care.

BACKGROUND: Community-based health care (CBHC) is a shift towards healthcare integration and community services closer to home. Variation in system approaches harkens the need for a conceptual framework to evaluate outcomes and impacts. We set out to develop a CBHC-specific evaluation framework in the context of a provincial ministry of health planning process in Canada. METHODS: A multi-step approach was used to develop the CBHC evaluation framework. Modified Delphi informed conceptualization and prioritization of indicators. Formative research identified evaluation framework elements (triple aim, global measures, and impact), health system levels (tiers), and potential CBHC indicators (n = 461). Two Delphi rounds were held. Round 1, panelists independently ranked indicators on CBHC relevance and health system tiering. Results were analyzed by coding agreement/disagreement frequency and central tendency measures. Round 2, a consensus meeting was used to discuss disagreement, identify Tier 1 indicators and concepts, and define indicators not relevant to CBHC (Tier 4). Post-Delphi, indicators and concepts were refined, Tier 1 concepts mapped to the evaluation framework, and indicator narratives developed. Three stakeholder consultations (scientific, government, and public/patient communities) were held for endorsement and recommendation. RESULTS: Round 1 Delphi results showed agreement for 300 and disagreement for 161 indicators. Round 2 consensus resulted in 103 top tier indicators (Tier 1 = 19, Tier 2 = 84), 358 bottom Tier 3 and 4 indicators, non-CBHC measure definitions, and eight Tier 1 indicator concepts-Mortality/Suicide; Quality of Life, and Patient Reported Outcome Measures; Global Patient Reported Experience Measures; Cost of Care, Access to Integrated Primary Care; Avoidable Emergency Department Use; Avoidable Hospitalization; and E-health Penetration. Post Delphi results refined Tier 3 (n = 289) and 4 (n = 69) indicators, and identified 18 Tier 2 and 3 concepts. When mapped to the evaluation framework, Tier 1 concepts showed full coverage across the elements. 'Indicator narratives' depicted systemness and integration for evaluating CBHC. Stakeholder consultations affirmed endorsement of the approach and evaluation framework; refined concepts; and provided key considerations to further operationalize and contextualize indicators, and evaluate CBHC as a health system approach. CONCLUSIONS: This research produced a novel evaluation framework to conceptualize and evaluate CBHC initiatives. The evaluation framework revealed the importance of a health system approach for evaluating CBHC.

Needs assessment for the creation of a community of practice in a community health navigator cohort.

BACKGROUND: Community Health Navigators (CHNs) are members of a patient's care team that aim to reduce barriers in accessing healthcare. CHNs have been described in various healthcare settings, including chronic disease management. The ENhancing COMmunity health through Patient navigation, Advocacy, and Social Support (ENCOMPASS) program of research employs CHNs, who are trained to improve access to care and community resources for patients with multiple chronic diseases. With complex and demanding roles, it is essential that CHNs communicate with each other to maintain knowledge exchange and best practices. A Community of Practice (CoP) is a model of situated learning that promotes communication, dedication, and collaboration that can facilitate this communication. The objective of this study was to engage with CHNs to determine how a CoP could be implemented to promote consistency in practices and knowledge for CHNs across primary care sites. METHODS: A needs assessment for a CHN CoP was conducted using sequential steps of inquiry. A preliminary focused literature review (FLR) was done to examine the ways in which other healthcare CoPs have been implemented. Results from the FLR guided the creation of an exploratory survey and group interview with key informants to understand best approaches for CoP creation. Political, economic, social, and technological (PEST) and strengths, weaknesses, opportunities, and threats (SWOT) analyses synthesized results in a comprehensive manner for strategic recommendations. RESULTS: The FLR identified different approaches and components of healthcare CoPs and guided analyses of mitigatable risk factors and leverageable assets for the intervention. The survey and group interview revealed an informal and effective CoP amongst current CHNs, with preferred methods including coffee meetings, group trainings, and seminars. A well-maintained web platform with features such as an encrypted discussion forum, community resource listing, calendar of events, and semi-annual CHN conferences were suggested methods for creating an inter-regional, formal CoP. CONCLUSION: The study findings recognise the presence of an informal CoP within the studied CHN cohort. Implementation of a formal CoP should complement current CoP approaches and aid in facilitating expansion to other primary care centres utilizing digital communication methods, such as a comprehensive web platform and online forum.

Variations in Workplace Safety Climate Perceptions and Outcomes Across Healthcare Provider Positions.

EXECUTIVE SUMMARY: Injury rates reported among healthcare practitioners tend to vary depending on position. Nurses and healthcare aides report different rates of injury, which suggests that position and job duties may be key injury antecedents. The outcomes related to workplace safety climate perceptions (e.g., injury rates, job satisfaction, turnover) require reflection to identify antecedents of safety perception. The purpose of this study was to examine workplace safety perceptions and well-being (e.g., stress, job satisfaction) of healthcare practitioners by position. A cross-sectional survey of care teams (e.g., nurses, healthcare aides, allied health professionals) was conducted across three inpatient units. Data (N = 144) were analyzed using hierarchical linear regression and binomial logistic regression to examine the relationship between safety climate and self-reported injuries and ANOVA to determine variations in safety climate perceptions by position. Results indicated that nurses, healthcare aides, and allied health professionals report differing levels of workplace safety climate perceptions. Nurses reported the poorest safety perceptions, lowest job satisfaction, and highest stress, while allied health professionals reported the highest safety perceptions and job satisfaction and the lowest stress. Safety climate perceptions were found to be significantly related to care practitioner reported stress, turnover intent, and job satisfaction. Considering the importance of safety climate perceptions for the well-being of care practitioners, healthcare organizations need to prioritize workplace safety to optimize practitioners' perceptions. This study makes a unique contribution to the safety climate literature by identifying the variation in safety climate perceptions by care practitioner position. Practical implications are offered for enhancing workplace safety perceptions.

The Quest for Value in Canadian Healthcare: The Applied Value in Healthcare Framework.

The exponential rise in healthcare costs in developed nations has sharpened the need for greater "value" in healthcare. Porter's (2010) seminal work is one of the most cited definitions and equation for value-based care. The pursuit of greater value in our healthcare system is of paramount importance, yet translating value-based healthcare (VBHC) into a framework that can be effectively utilized in the Canadian system remains a challenge. To address this challenge, we propose that VBHC can be adapted to fit the Canadian healthcare system through (1) visionary leadership for and conceptualization of VBHC at the federal government level and (2) thoughtful application of VBHC at the provincial government level. Our applied value in healthcare framework serves as a platform from which VBHC initiatives, programs and outcome measures can be systematically organized and executed within provincial healthcare systems. This methodical approach could support both provincial ministries and their health systems in pursuit of VBHC and provide the basis for explicit measurement of VBHC success, thereby helping to address the pressing issue of sustainability of the Canadian healthcare system while optimizing patient-centred outcomes of care.