Health TAPESTRY Ontario: A Multi-Site Randomized Controlled Trial Testing Implementation and Reproducibility.

PURPOSE: Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a complex primary care program aimed at assisting older adults to stay healthier for longer. This study evaluated the feasibility of implementation across multiple sites, and the reproducibility of the effects found in the previous randomized controlled trial. METHODS: This was a pragmatic, unblinded, 6-month parallel group randomized controlled trial. Participants were randomized (intervention or control) using a computer-generated system. Eligible patients, aged 70 years and older, were rostered to 1 of 6 participating interprofessional primary care practices (urban and rural). In total, 599 (301 intervention, 298 control) patients were recruited from March 2018 through August 2019. Intervention participants received a home visit from volunteers to collect information on physical and mental health, and social context. An interprofessional care team created and implemented a plan of care. The primary outcomes were physical activity and number of hospitalizations. RESULTS: Based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, Health TAPESTRY had widespread reach and adoption. In the intention-to-treat analysis (257 intervention, 255 control), there were no statistically significant between-group differences for hospitalizations (incidence rate ratio = 0.79; 95% CI, 0.48-1.30; P = .35) or total physical activity (mean difference = -0.26; 95% CI, -1.18 to 0.67; P = .58). There were 37 non-study related serious adverse events (19 intervention, 18 control). CONCLUSIONS: We found Health TAPESTRY was successfully implemented for patients in diverse primary care practices; however, implementation did not reproduce the effect on hospitalizations and physical activity found in the initial randomized controlled trial.

Understanding collaborative implementation between community and academic partners in a complex intervention: a qualitative descriptive study.

BACKGROUND: Community-academic partnerships (CAPs) can improve the relevance, sustainability, and uptake of new innovations within the community. However, little is known about what topics CAPs focus on and how their discussions and decisions impact implementation at ground level. The objectives of this study were to better understand the activities and learnings from implementation of a complex health intervention by a CAP at the planner/decision-maker level, and how that compared to experiences implementing the program at local sites. METHODS: The intervention, Health TAPESTRY, was implemented by a nine-partner CAP including academic, charitable organizations, and primary care practices. Meeting minutes were analyzed using qualitative description, latent content analysis, and a member check with key implementors. An open-answer survey about the best and worst elements of the program was completed by clients and health care providers and analyzed using thematic analysis. RESULTS: In total, 128 meeting minutes were analyzed, 278 providers and clients completed the survey, and six people participated in the member check. Prominent topics of discussion categories from the meeting minutes were: primary care sites, volunteer coordination, volunteer experience, internal and external connections, and sustainability and scalability. Clients liked that they learned new things and gained awareness of community programs, but did not like the volunteer visit length. Clinicians liked the regular interprofessional team meetings but found the program time-consuming. CONCLUSIONS: An important learning was about who had "voice" at the planner/decision-maker level: many of the topics discussed in meeting minutes were not identified as issues or lasting impacts by clients or providers; this may be due to differing roles and needs, but may also identify a gap. Overall, we identified three phases that could serve as a guide for other CAPs: Phase (1) recruitment, financial support, and data ownership; Phase (2) considerations for modifications and adaptations; Phase (3) active input and reflection.

Facilitators and Barriers to Clinical Pathway Uptake and Utilization Among Primary Care Providers in Saskatchewan - A Qualitative Study.

PURPOSE: Clinical Pathways (CPWs) are multidisciplinary, evidence-based, complex interventions designed to standardize patient care. In Saskatchewan, development, implementation and evaluation of the seven provincial CPWs (Hip & Knee, Spine, Pelvic Floor, Prostate Assessment, Fertility Care, Lower Extremity Wound Care and Acute Stroke) present significant challenges, leading to low utilization. This study aimed to identify facilitators and barriers to CPW utilization by Saskatchewan family physicians. METHODS: To identify the facilitators and barriers to CPWs, a qualitative interpretive approach consisted of eight one-on-one key informant interviews and five focus groups held with 30 family physicians in two larger urban and two smaller Saskatchewan cities. Inductive, thematic analysis of the interviews based on the Theoretical Domain Framework for behavioral changes was used to identify facilitators and barriers to CPW uptake and utilization. RESULTS: Fifty-one themes were mapped under 14 Theoretical Domain Framework domains. Major barriers included the following: system-level (knowledge and communication, social/professional identity, family physician engagement and education); objective clarification (goals, belief about consequences of implementing CPW); and technical and resource related (administrative, access to local specialists, enforcement and incentives). The most prominent barrier was lack of systematic CPW promotion and inconsistencies in communication between the following: organization-to-practitioner; organization-to-organization; and practitioner-to-practitioner. Facilitators who mitigated barriers were need for optimized and integrated information technology services (i.e., Electronic Medical Records) and optimism towards CPW usage and patient outcomes. CONCLUSIONS: This exploratory study identified specific improvements and recommendations required to promote uptake of CPWs based on perceived facilitators and barriers.

Service providers' perceptions of support needs for Indigenous cancer patients in Saskatchewan: a needs assessment.

BACKGROUND: In Saskatchewan, Canada, Indigenous cancer care services at the municipal, provincial, and federal levels are intended to improve quality care but can result in a complex, fragmented, and multi-jurisdictional health care system. A multi-phase needs assessment project was initiated to document Indigenous cancer care needs. Guided by Indigenous patient partners, clinicians, academics, and policy makers, the present study reflects a needs assessment of Indigenous cancer supports from the perspectives of cancer care service providers. METHODS: Qualitative data were collected through three focus groups with 20 service providers for cancer patients and their families at three Saskatchewan cities. Participants included chemotherapy and radiation nurses, social workers, a patient navigator, dieticians, and practicum students. A semi-structured interview guide was used to conduct the sessions to allow for freedom of responses. Data were recorded, transcribed verbatim, and analyzed using thematic analysis. RESULTS: Service providers' perspectives were categorized into five themes: 1) addressing travel-related issues, 2) logistical challenges, 3) improvements to Indigenous-specific health care supports, 4) cultural sensitivity in health care, and 5) consistency in care. Supports provided differed for the two Indigenous groups, First Nations and Métis. Service providers made recommendations regarding how needs could be met. They saw language translation providers and Elder supports as important. Recommendations for improving travel were for medical taxis to include breaks so that passengers may alleviate any uncomfortable side effects of their cancer treatment. Further, Indigenous-specific accommodations were recommended for those requiring medical travel. These recommendations aligned with supports that are available in four other Canadian provinces. CONCLUSIONS: These results identified gaps in supports and outlined recommendations to address barriers to cancer care from the perspectives of service providers. These recommendations may inform evidence-based health system interventions for Indigenous cancer patients and ultimately aim to improve cancer care services, quality of life, and health outcomes of Indigenous patients throughout their cancer journey.

Combined lumbar spine MRI and CT appropriateness checklist: a quality improvement project in Saskatchewan, Canada.

BACKGROUND: As rates of advanced imaging for lower back pain (LBP) continue to increase, there is a need to ensure the appropriateness of imaging. OBJECTIVE: The goal of this project was to reduce the number of inappropriate magnetic resonance imaging (MRI) and computed tomography (CT) requests for LBP patients and facilitate appropriate imaging by developing a combined imaging appropriateness checklist for lumbar spine MRI and CT. METHODS: In prior work, we developed and adopted individual evidence-based lumbar spine MRI and CT checklists into the radiology requisition process. In the current project, a combined checklist was developed and trialed in one of the former Saskatchewan health regions (Five Hills) beginning in May 2018. Using statistical process control, control charts compared the monthly number of imaging requests pre-checklist implementation and post-checklist implementation from May 2017 to February 2020. The monthly number of lumbar spine MRI and CT requisitions in the nearby former Saskatchewan Regina Qu'Appelle Health Region, in which the combined checklist was not trialed, was also plotted and compared as a balancing measure. RESULTS: In Five Hills, a shift (decrease) was observed in the monthly number of lumbar spine MRI requisitions 7 months following the implementation of the combined checklist. However, the monthly number of lumbar spine CT requisitions did not change significantly. In the Regina Qu'Appelle Health Region, there was a shift (increase) in the monthly number of lumbar spine MRI requisitions, while the monthly number of lumbar spine CT requests decreased after the implementation of the combined checklist. CONCLUSIONS: The combined checklist with evidence-based indications for lumbar spine MRI and CT imaging in LBP patients appeared to reduce the complexity associated with two previous individual checklists and facilitate imaging appropriateness. Accountable benefits may include the reduction of radiation exposure as a result of unnecessary and repeated imaging and reduction in wait times for CT and/or MRI.

Development of a program theory for shared decision-making: a realist synthesis.

BACKGROUND: Shared Decision-making (SDM), a medical decision-making model, was popularized in the late 1980s in reaction to then predominate paternalistic decision-making, aiming to better meet the needs of patients. Extensive research has been conducted internationally examining the benefits of SDM implementation; however, existing theory on how SDM works, for whom, in which circumstances, and why is limited. While literature has shown positive patient, health care provider, and system benefits (SDM outputs), further research is required to understand the nuances of this type of decision-making. As such, we set out to address: "In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved engagement in the Shared Decision-making process?" METHODS: To achieve our study goals we conducted a seven-step realist synthesis process, which included: (1) preliminary program theory development, (2) search strategy development, (3) selection and appraisal of literature in accordance with realist methodology, (4) data extraction, (5) identification of relevant formal theories, (6) data analysis and synthesis, and (7) formation of a revised program theory with the input of stakeholders. This process was done in accordance with RAMESES guidelines and publication standards for a realist synthesis. Expert consultations were also held to ensure consistency within the SDM literature. RESULTS: Through our realist synthesis, we developed a program theory of SDM which includes three contexts (pre-existing relationship, difficulty of decision, and system support), eight mechanism sets (anxiety, trust, perception of other party capacity, perception of time, self-efficacy, world view, perception of capacity to external support, and recognition of decision), and one outcome (engagement in SDM). CONCLUSIONS: As far as the authors of this paper are aware, this paper is the first to begin unpacking how SDM works, for whom, in which circumstances, and why. By examining key mechanism sets and exploring how they facilitate or inhibit SDM, we have produced a program theory that may assist health care professionals, policy makers, and patients. While further research is suggested to further unpack the concepts identified within this paper, this provides an initial understanding into the theory behind SDM. REGISTRATION: PROSPERO: CRD42017062609.

Decisions on cancer care by Indigenous peoples in Alberta and Saskatchewan: a narrative analysis.

INTRODUCTION: The prevalence of cancer is increasing among Indigenous peoples in Canada. To enhance quality of life of those Indigenous people affected by cancer, their decision-making experiences must be understood. This article presents the findings of a qualitative study exploring the treatment decision-making practices among Indigenous peoples with cancer in rural and remote Alberta and Saskatchewan, Canada. METHODS: This study employed a qualitative narrative-based approach using the Indigenous research method of storytelling. Seventeen Indigenous participants (14 women, three men) with various forms of cancer were interviewed. Open-ended questions were used that were designed to understand participants' decision-making processing regarding their cancer treatment. RESULTS: Keeping with Indigenous methodology, the interview transcripts were analysed by a narrative method, with the intent that the data would be presented in story format. Eight vignettes relating to decision making were created: being strong for family; family support; strength and independence; denial and not wanting to know; fear-based decision making; finding the blessing; the spiritual journey; and traditional medicine and doctors. Participants were involved in validating the analysis to ensure that data were accurately interpreted. CONCLUSION: The vignettes demonstrate the similarities and differences among Indigenous people with cancer from other countries. A primary feature is that family members play a central role in participants' cancer treatment decisions. While some participants embraced and relied upon traditional medicines, others were supported by the providers of Western health care. A healthcare system that provides access to both traditional and Western medicine can be essential to culturally safe, high-quality cancer care for Indigenous peoples.

Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial.

BACKGROUND: The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes. METHODS: We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. RESULTS: There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation [SD] 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). INTERPRETATION: Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723.

Yoga as palliation in women with advanced cancer: a pilot study.

OBJECTIVE: The purpose of this pilot study was to investigate the palliative potential of home-based yoga sessions provided to women with advanced cancer. METHOD: Personalised 45-minute yoga sessions were offered to three women with advanced cancer by an experienced yoga teacher. Each woman took part in a one-to-one interview after the completion of the yoga programme and was asked to describe her experiences of the programme's impact. RESULTS: The personalised nature of the yoga sessions resulted in similar positive physical and psychosocial effects comparable to those demonstrated in other studies with cancer patients. Participants described physical, mental, and emotional benefits as well as the alleviation of illness impacts. The enhancement of mind-body and body-spirit connections were also noted. CONCLUSION: Personalised home-based yoga programmes for people with advanced cancer may produce similar benefits, including palliation, as those institutionally-based programmes for people with non-advanced cancer.

Time while waiting: patients' experiences of scheduled surgery.

Research on patients' experiences of wait time for scheduled surgery has centered predominantly on the relative tolerability of perceived wait time and impacts on quality of life. We explored patients' experiences of time while waiting for three types of surgery with varied wait times--hip or knee replacement, shoulder surgery, and cardiac surgery. Thirty-two patients were recruited by their surgeons. We asked participants about their perceptions of time while waiting in two separate interviews. Using interpretative phenomenological analysis (IPA), we discovered connections between participant suffering, meaningfulness of time, and agency over the waiting period and the lived duration of time experience. Our findings reveal that chronological duration is not necessarily the most relevant consideration in determining the quality of waiting experience. Those findings helped us create a conceptual framework for lived wait time. We suggest that clinicians and policy makers consider the complexity of wait time experience to enhance preoperative patient care.

"Somebody That can Meet you on Your Level:" Cancer Survivors' Perspectives on the Role of Indigenous Patient Navigators in Cancer Care.

BACKGROUND: Cancer incidence has increased for First Nations and Métis Peoples in Canada over recent years. Despite a growing cancer burden, there remain challenges to accessing culturally appropriate and quality care in Saskatchewan. OBJECTIVE: The study aimed to explore, from cancer survivors' perspectives, the potential of Indigenous patient navigators to enhance the healthcare experiences of First Nations and Métis cancer survivors in Saskatchewan. METHODS: We conducted semi-structured interviews with 19 First Nations and Métis cancer survivors. Participants were interviewed by phone between May 2022 to March 2023. Thematic analysis was conducted to generate themes, categories, and codes reflecting participants' experiences with patient navigators. RESULTS: Participants reported several supports to help patients with cancer through their cancer journey, including family, community, traditional ways, and First Nations and Métis health support services. Challenges to accessing care included language and communication barriers, logistical challenges, cultural differences, financial challenges, and gaps in care. Indigenous patient navigators may play a critical role in overcoming barriers by providing communication, translation, coordination, education, advocacy, and guidance to Indigenous cancer survivors. In participants' view, the tasks of Indigenous patient navigators could vary, ranging from helping schedule appointments to advocating for the patient's treatment preferences. In addition, Indigenous patient navigators could be helpful bridging Western medicine with traditional medicine when supporting patients seeking cancer care. CONCLUSION: According to study participants, Indigenous patient navigators could be beneficial to Indigenous cancer survivors in Saskatchewan.

Sepsis screening protocol implementation: a clinician-validated rapid realist review.

INTRODUCTION: The failed or partial implementation of clinical practices negatively impacts patient safety and increases systemic inefficiencies. Implementation of sepsis screening guidelines has been undertaken in many settings with mixed results. Without a theoretical understanding of what leads to successful implementation, improving implementation will continue to be ad hoc or intuitive. This study proposes a programme theory for how and why the successful implementation of sepsis screening guidelines can occur. METHODS: A rapid realist review was conducted to develop a focused programme theory for the implementation of sepsis screening guidelines. An independent two-reviewer approach was used to iteratively extract and synthesise context and mechanism data. Theoretical context-mechanism-outcome propositions were refined and validated by clinicians using a focus group and individual realist interviews. Implementation resources and clinical reasoning were differentiated in articulating mechanisms. RESULTS: Eighteen articles were included in the rapid review. The theoretical domains framework was identified as the salient substantive theory informing the programme theory. The theory consisted of five main middle-range propositions. Three promoting mechanisms included positive belief about the benefits of the protocol, belief in the legitimacy of using the protocol and trust within the clinical team. Two inhibiting mechanisms included pessimism about the protocol being beneficial and pessimism about the team. Successful implementation was defined as achieving fidelity and sustained use of the intervention. Two intermediate outcomes, acceptability and feasibility of the intervention, and adoption, were necessary to achieve before successful implementation. CONCLUSION: This rapid realist review synthesised key information from the literature and clinician feedback to develop a theory-based approach to clinical implementation of sepsis screening. The programme theory presents knowledge users with an outline of how and why clinical interventions lead to successful implementation and could be applied in other clinical areas to improve quality and safety.

Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation.

BACKGROUND: In Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of Saskatchewan. OBJECTIVES: The aim of the project was to conduct a resident-oriented realist evaluation of an innovative supportive housing programme, Sanctum, for people living with HIV/AIDS who also face social care issues, such as homelessness. This project took place in Saskatchewan, a province that is seeking innovative approaches to improve quality of life and HIV/AIDS management for its citizens. Our evaluation addressed how and why participants were successful (or not) within the Sanctum programme. DESIGN AND SETTING: Sanctum is a housing programme located in an inner-city location within the province of Saskatchewan. A unique component of this evaluation was the inclusion of an individual with lived experience, a resident partner, as a member of the research team. PARTICIPANTS: 11 recent Sanctum graduates, seven men and four women, were recruited for client partner-led in-depth, semistructured interviews. INTERVENTIONS: Prior to the evaluation, we developed a realist programme theory with potential causal explanations, known as context-mechanism-outcomes (CMO) configurations. Interview data from the evaluation and ongoing discussions with Sanctum board members and our resident partner were used to test, refine and validate the final programme theory and CMO configurations. RESULTS: CMO configurations at the micro (individual), meso (interpersonal) and macro (community) levels complement the over-arching programme theory. Key findings were the importance of Sanctum's harm reduction philosophy, accompanied by a non-judgmental and patient-oriented approach. Participants were supported to reduce risky behaviour, improve self-care management and develop healthier relationships within a 'safe' home-like setting. Underlying mechanisms that contributed to participants' success in the programme included: intrinsic motivation, self-worth, belongingness, empowerment and self-efficacy. Evidence-informed recommendations are offered to support Sanctum-like programme development for individuals with holistic health needs related to HIV/AIDS diagnoses and lack of access to necessary social determinants of health. CONCLUSIONS: Stigma associated with HIV/AIDS and living circumstances, such as homelessness, were successfully addressed using harm reduction principles and judgement-free approaches within a family-like environment.

Cancer Prevention and Cultural Continuity for Métis Peoples in Canada: A Scoping Review.

The purpose of this scoping review was to map the literature on the relationship between cultural continuity and health among Métis people as well as how this knowledge could be translated into cancer prevention initiatives. We included any Métis-specific literature evaluating connections between culture, health, and well-being. We conducted electronic searches of Medline, PubMed, Embase, PsychInfo, I-Portal, and hand-searched journals, and reviewed the grey literature. Based on our inclusion criteria, articles were screened and assessed for eligibility, resulting in a sample of 22 publications. Qualitative, quantitative, and mixed methods designs were considered. The 22 publications included in this review were diverse, ranging from population-based studies to reports and news articles. There were no limitations to publication year, and most of the data presented in this review were published more than five years ago. Nevertheless, the results demonstrate the potential role of Métis cultural continuity in cancer prevention. The scoping review revealed the current lack of Métis-specific data regarding health and its intersectionality with culture. However, the existing literature indicates that cultural continuity for Métis appears to influence health and well-being positively. As such, there may be benefits to incorporating cultural continuity in cancer prevention efforts.

Exploring Indigenous Traditional Healing programs in Canada, Australia, and New Zealand: A scoping review.

OBJECTIVE: To explore and catalog ways Indigenous Traditional Healing practices are supported within the mainstream healthcare system through policies and programs in Canada, Australia, and New Zealand. DATA SOURCES: A scoping review was conducted, guided by the PRISMA extension for Scoping Reviews. Databases for sources of information include CINAHL, Medline, Embase, Web of Science, Public Health ProQuest, Global Health EBSCO, iPortal, and grey literature. STUDY SELECTION: 2 reviewers screened the titles and abstracts of the studies for inclusion against the selection criteria independently. Studies that met the inclusion criteria were transferred to Covidence for further abstract and full-text review. DATA EXTRACTION: Of a total of 2,017 articles identified, 22 met the inclusion criteria for data extraction for this scoping review. Data items extracted include study title, authors, year of publication, publication type, publication source, support policy or program, health system or service, Indigenous Traditional Healing practices, and significant findings. DATA SYNTHESIS: 2 categories emerged from the analysis of the source of evidence. That is, healthcare systems and services with programs and policies supporting Indigenous Traditional Healing practices, and ways Indigenous Traditional Healing was adopted and utilized within the identified support programs. CONCLUSIONS: This study demonstrated the various ways Indigenous Traditional Healing practices are supported within the mainstream healthcare systems in Canada, Australia, and New Zealand. Indigenous Traditional Healing practices can be utilized as either the primary choice of treatment, to support Western biomedical treatment or through the adoption of Indigenous Traditional knowledge within the mainstream healthcare system.

Virtual surgical consultation during the COVID-19 pandemic: a patient-oriented, cross-sectional study using telephone interviews.

BACKGROUND: Health care delivery shifted rapidly during the COVID-19 pandemic, whereby virtual consultations replaced many face-to-face interactions. We sought to gather patient perspectives on their experiences with virtual surgical consultation, the advantages and disadvantages of this delivery method and their overall satisfaction with virtual appointments. METHODS: We conducted a patient-oriented, cross-sectional study. Adult patients (age > 18 yr) who had a virtual consultation with a participating general surgeon in Saskatoon, Saskatchewan, from April to May 2020 were eligible. We conducted telephone interviews using open- and close-ended questions. We used thematic analysis to determine themes from the qualitative data. As research team members, 2 patient partners were involved in identifying priorities, developing the research question, designing research methods, analyzing data and disseminating findings. We analyzed and presented quantitative data descriptively. RESULTS: We interviewed 45 participants from 7 general surgery practices; the average age was 62 years. Most participants lived outside Saskatoon and had virtual follow-up appointments. The 3 themes related to advantages of virtual consultations were convenience, cost savings and decreased exposure to pathogens. The 4 themes related to their disadvantages were that they were not as personal, the surgeon was not able to perform a physical examination, and there were issues with scheduling and issues with technology. Most participants were satisfied with the care they received (n = 41) and would be willing to use virtual consultation in the future (n = 31). INTERPRETATION: We found that virtual consultations are an effective and efficient way to deliver surgical care but are not appropriate for every situation and cannot completely replace face-to-face interactions. Our study identified the advantages and disadvantages of virtual surgical consultation to help better guide the delivery of virtual care in the future.

Evaluating a learning health system initiative: Lessons learned during COVID-19 in Saskatchewan, Canada.

Introduction: Evaluating a learning health system (LHS) encourages continuous system improvement and collaboration within the healthcare system. Although LHS is a widely accepted concept, there is little knowledge about evaluating an LHS. To explore the outputs and outcomes of an LHS model, we evaluated the COVID-19 Evidence Support Team (CEST) in Saskatchewan, Canada, an initiative to rapidly review scientific evidence about COVID-19 for decision-making. By evaluating this program during its formation, we explored how and to what extent the CEST initiative was used by stakeholders. An additional study aim was to understand how CEST could be applied as a functional LHS and the value of similar knowledge-to-action cycles. Methods: Using a formative evaluation design, we conducted qualitative interviews with key informants (KIs) who were involved with COVID-19 response strategies in Saskatchewan. Transcripts were analyzed using reflexive thematic analysis to identify key themes. A program logic model was created to represent the inputs, activities, outputs, and outcomes of the CEST initiative. Results: Interview data from 11 KIs were collated under three overarching categories: (1) outputs, (2) short-term outcomes, and (3) long-term outcomes from the CEST initiative. Overall, participants found the CEST initiative improved speed and access to reliable information, supported and influenced decision-making and public health strategies, leveraged partnerships, increased confidence and reassurance, and challenged misinformation. Themes relating to the long-term outcomes of the initiative included improving coordination, awareness, and using good judgment and planning to integrate CEST sustainably into the health system. Conclusion: This formative evaluation demonstrated that CEST was a valued program and a promising LHS model for Saskatchewan. The future direction involves addressing program recommendations to implement this model as a functional LHS in Saskatchewan.

Developing a rapid evidence response to COVID-19: The collaborative approach of Saskatchewan, Canada.

Introduction: The COVID-19 Evidence Support Team (CEST) was a provincial initiative that combined the support of policymakers, researchers, and clinical practitioners to initiate a new learning health cycle (LHS) in response to the pandemic. The primary aim of CEST was to produce and sustain the best available COVID-19 evidence to facilitate decision-making in Saskatchewan, Canada. To achieve this objective, four provincial organizations partnered to establish a single, data-driven system. Methods: The CEST partnership was driven by COVID-19 questions from Emergency Operational Committee (EOC) of the Saskatchewan Health Authority. CEST included three processes: (a) clarifying the nature and priority of COVID-19 policy and clinical questions; (b) providing Rapid Reviews (RRR) and Evidence Search Reports (ESR); and (c) seeking the requestors' evaluation of the product. A web-based repository, including a dashboard and database, was designed to house ESRs and RRRs and offered a common platform for clinicians, academics, leaders, and policymakers to find COVID-19 evidence. Results: In CEST's first year, 114 clinical and policy questions have been posed resulting in 135 ESRs and 108 RRRs. While most questions (41.3%) originated with the EOC, several other teams were assembled to address a myriad of questions related to areas such as long-term care, public health and prevention, infectious diseases, personal protective equipment, vulnerable populations, and Indigenous health. Initial challenges were mobilization of diverse partners and teams, remote work, lack of public access, and quality of emerging COVID-19 literature. Current challenges indicate the need for institutional commitment for CEST sustainability. Despite these challenges, the CEST provided the Saskatchewan LHS with a template for successful collaboration. Conclusions: The urgency of COVID-19 pandemic and the implementation of the CEST served to catalyze collaboration between different levels of a Saskatchewan LHS.

Lessons Learned Through Two Phases of Developing and Implementing a Technology Supporting Integrated Care: Case Study.

BACKGROUND: As health care becomes more fragmented, it is even more important to focus on the provision of integrated, coordinated care between health and social care systems. With the aging population, this coordination is even more vital. Information and communication technology (ICT) can support integrated care if the form of technology follows and supports functional integration. Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a program centered on the health of older adults, supported by volunteers, primary care teams, community engagement and connections, and an ICT known as the Health TAPESTRY application (TAP-App), a web-based application that supports volunteers in completing client surveys, volunteer coordinators in managing the volunteer program, and primary care teams in requesting and receiving information. OBJECTIVE: This paper describes the development, evolution, and implementation of the TAP-App ICT to share the lessons learned. METHODS: A case study was conducted with the TAP-App as the case and the perspectives of end users and stakeholders as the units of analysis. The data consisted of researchers' perspectives on the TAP-App from their own experiences, as well as feedback from other stakeholders and end user groups. Data were collected through written retrospective reflection with the program manager, a specific interview with the technology lead, key emailed questions to the TAP-App developer, and viewpoints and feedback during paper drafting from other research team members. There were 2 iterations of Health TAPESTRY and the TAP-App and we focused on learnings from the second implementation (2018-2020) which was a pragmatic implementation scale-up trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework at 6 primary care sites across Ontario, Canada. RESULTS: TAP-App (version 1.0), which was iteratively developed, was introduced as a tool to schedule volunteer and client visits and collect survey data using a tablet computer. TAP-App (version 2.0) was developed based on this initial experience and a desire for a program management tool that focused more on dual flow among users and provided better support for research. The themes of the lessons learned were as follows: iterative feedback is valuable; if ICT will be used for research, develop it with research in mind; prepare for challenges in the integration of ICT into the existing workflow; ask whether interoperability should be a goal; and know that technology cannot do it alone yet-the importance of human touch points. CONCLUSIONS: Health TAPESTRY is human-centered. The TAP-App does not replace these elements but rather helps enable them. Despite this shift in supporting integrated care, barriers remained to the uptake of the TAP-App that would have allowed a full flow of information between health and social settings in supporting patient care. This indicates the need for an ongoing focus on the human use of ICT in similar programs.

Community Volunteers and Primary Care Providers Supporting Older Adults in System Navigation: A Mixed Methods Study.

Introduction: Primary care providers and community volunteers have important roles in supporting patient system navigation and utilization of community-based health and social services (CBHSS). This study aimed to explore the experiences and impacts of system navigation in a complex intervention supporting older adults. Methods: We used a convergent mixed methods design. Participants included primary care team members (n = 67), community volunteers (n = 38), and programme clients (n = 128) across six communities in Ontario, Canada. Data sources included focus groups, interviews, system navigation function survey for volunteers, CBHSS use survey for clients, and implementation data on CBHSS recommended by providers and volunteers and used by clients. Results: Results showed the different patterns of how CBHSS categories were recommended and ultimately used. Exercise-related CBHSS were both recommended and used, independence-related CBHSS were mostly only recommended with less uptake, and chronic health condition and diet/nutrition CBHSS were most often used by clients. Discussion: Primary care teams' practice of system navigation was impacted by programme participation, including through learning about local CBHSS. However, volunteers felt more confident in tasks that did not include connecting to CBHSS. The programme did seem to result in many referrals, though the actual client uptake tended to be to more clinical rather than healthy lifestyle resources.