Family Medicine Supervisors' Preferences for Improving Their Teaching Skills in Senior Care.

BACKGROUND AND OBJECTIVES: Many clinical supervisors in family medicine feel ill-equipped to teach senior care to their family medicine residents (trainees). We therefore sought to explore their preferred learning strategies for improving their clinical and teaching skills with regard to senior care. METHODS: In this qualitative study, we conducted focus groups and interviews with supervisors from four family medicine clinics, to explore their preferred educational strategies. We selected four clinics using a maximum-variation strategy, based on a survey assessing continuing professional development (CPD) needs. The qualitative thematic analysis followed an inductive/deductive approach based on McGuire's attributes of persuasive communication. RESULTS: The four focus groups and nine interviews with 53 supervisors (37 physicians, 9 nurses, 4 psychologists, 1 social worker, 1 nutritionist, 1 sexologist) revealed that supervisors preferred being trained by experienced trainers specialized in senior care, from various professional backgrounds, and knowledgeable about local community resources. They valued practical training the most, such as clinical case discussions based on real cases, clinical tools, and mentoring. The findings also suggest that training in senior care should be adapted to the supervisors' experience, profession, workload, and scope of intervention. Supervisors valued repeated CPD with longitudinal follow-up and easy access to trainers and to up-to-date training content. CONCLUSIONS: The findings of this project will allow those who design CPD activities to adapt such activities to the preferences of supervisors, so as to improve their clinical and teaching skills in senior care. This, in turn, may help supervisors to embody an appealing professional role model for learners.

How interprofessional teams of students mobilized collaborative practice competencies and the patient partnership approach in a hybrid IPE course.

To develop collaborative competencies of future health and social services professionals, the Université de Montréal (UdeM) offers interprofessional education (IPE) in partnership with patients. To meet the challenges of IPE, UdeM turned to digital tools to enable interprofessional teams of students to collaborate online and face-to-face. The collaborative flipped classroom for IPE with patient partnership is the conceptual framework for the pedagogical method used for this study. It is based on: 1) a competency framework and 2) collaborative learning concept and dimensions. The study aimed to: 1) demonstrate how interprofessional teams of students mobilize framework competencies and care approaches during online and face-to-face collaborative learning activities; and 2) analyze how students collaborate during a hybrid IPE course using a patient partnership approach. Using a qualitative methodology, the contents of the online collaborative journals (OCJs) of 12 interprofessional student teams were analyzed, along with the individual comments (n = 994) of IPE course learners collected through the Interprofessional Team Collaboration questionnaire (n = 321). The results suggest that the course under study enabled teams to collaborate online and face-to-face throughout the term, and indicate that students were better prepared to adopt a patient partnership approach.

Development of Patient-Inclusive Teams: Toward a Structured Methodology.

Over the last few years, the role of patients in the health system has become essential to improving the quality of care and services. However, the literature shows that patient engagement is not always ideally applied to improve the quality and safety of care and that patient engagement can be tokenistic. Through experiences conducted in Quebec, it is possible to outline a structured process involving both professional stakeholders and patients that illustrates optimal conditions to be applied for successful teamwork involving patients.

What Do Clinical Supervisors Require to Teach Residents in Family Medicine How to Care for Seniors?

We assessed clinicians' continuing professional development (CPD) needs at family practice teaching clinics in the province of Quebec. Our mixed methodology design comprised an environmental scan of training programs at four family medicine departments, an expert panel to determine priority clinical situations for senior care, a supervisors survey to assess their perceived CPD needs, and interviews to help understand the rationale behind their needs. From the environmental scan, the expert panel selected 13 priority situations. Key needs expressed by the 352 survey respondents (36% response rate) included behavioral and psychological symptoms of dementia, polypharmacy, depression, and cognitive disorders. Supervisors explained that these situations were sometimes complex to diagnose and manage because of psychosocial aspects, challenges of communicating with patients and families, and coordination of interprofessional teams. Supervisors also reported more CPD needs in long-term and home care, given the presence of caregivers and complexity of senior care in these settings.

Informational role self-efficacy: a validation in interprofessional collaboration contexts involving healthcare service and project teams.

BACKGROUND: Healthcare professionals perform knowledge-intensive work in very specialized disciplines. Across the professional divide, collaboration becomes increasingly difficult. For effective teamwork and collaboration to occur, it is considered necessary for individuals to believe in their ability to draw on their expertise and provide what others need to perform their job well. To date, however, no instruments exist to measure such a construct. METHODS: A two-study design is used to test the psychometric properties, factor structure and incremental validity of a five-item questionnaire measuring informational role self-efficacy. RESULTS: Based on parallel analysis and exploratory factor analysis, Study 1 shows a robust and reliable one-dimensional construct. Study 2 cross-validates this factor structure using confirmatory factor analysis. Study 2 also shows that informational role self-efficacy predicts proactive teamwork behaviors over and above goal similarity, interdependence, coordination and intra-team trust. CONCLUSIONS: The instrument can be used in research to assess an individual's capability beliefs in communicating his/her informational characteristics that are pertinent to the task performance of others. The construct is also shown to have value in team-building exercises.

Patient Engagement: The Quebec Path.

The issue on "The Patient Experience in Ontario 2020: What is Possible?" taught us how Ontario is trying to shift to a consistent culture of patient engagement at all levels of its healthcare system, from clinical to organizational and political. In this commentary, the authors share some of the avenues that have been taken in Quebec to structure patient engagement in a comprehensive way within and across stakeholder and patient populations. The model selected in Quebec is based on partnership of care and services, which includes not only patient involvement, but also interprofessional collaboration among professionals (Pomey et al. 2015b, 2015c).

[Experimentation of care partners program in psychiatry: the model Montreal]. / L'expérimentation du Programme partenaires de soins en psychiatrie : le modèle de Montréal.

UNLABELLED: The approach of the partnership of care and services developed by the direction collaboration dans patient partnership (DCPP) of the Faculty of medicine of the University of Montreal, considers the patient as a full care actor, in the same way as healthcare professionals, his experientiel knowledges are recognized and the patient develops gradually his self-determination. Since 2010, in order to allow cultural changes involved with this approach, the 'Program Partners of Care' (PPC) facilitated resource patient' integration and involvement into Continuous Improvement Committees (CIC), within 29 general and specialized health care teams in 19 health and social services facilities in Quebec, among wich four teams specialized in mental health. The purpose of the article is to describe briefly this approach, to demonstrate that it is successfully applicable to mental health clienteles, under certain conditions. METHOD: The evaluation of this approach arises from quantitative data of self-adminitered questionnaires by the participants of continuous Improvement Commettes, as well as a reflexive approach of the participants and the members of the DCPP to understand the processes and the implemented services. The results reveal that the objectives of transformation selected through the specialized mental health CIC refer to welcoming process in the facilities, to the period of transition from a facilities service to another one, to the patient involvement in their own Interdisciplinary Plan (IIP). Among the faciliting factors for patients' participation in thse CIC: the caregivers and managers' adaptability to adjust to a patient's pace; the identification to the best communication mechanisms to get in touch with them; faciliting discussion in small working group; an existing trust relationship with the members of the CIC; the support of the resource patients between them as well as support by coach patient of the DCPP. The members of the CIC develop a sense of pride, an energy, a new motivation and a group cohesion. The patient develop a sens of belonging to the team, they experience a higher self-esteem as well as developping a sens of usefulness, by contributing to the improvement of specialized mental health facilities. Giving back, as well as participing in the better quality of services fot the benefit of other patients make a whole lot of sense for them, this process even sometimes allows their full revovrey. In conclusion, the report reveals the applicicability of this approach in the field of the mental health. It il all the more attainable when the winning conditions as the closeness of the managers specialized in the domain, the choice of significant targets of continuous improvement for the patients are taken into account.

[The Montreal model: the challenges of a partnership relationship between patients and healthcare professionals]. / Le <> : enjeux du partenariat relationnel entre patients et professionnels de la santé.

A promising approach to improve the population's health and the quality of care and services provided by the health system consists of patient engagement at all levels of the health system together with training of health professionals. Since 2010, a new rational model based on the partnership between patients and healthcare professionals has been developed at the University of Montreal's Faculty of Medicine. This patient partnership model is based on the recognition of the patient's experiential knowledge gained from living with a disease, which is complementary to the healthcare professional's scientific knowledge. This partnership is part of a continuum of patient engagement and can be applied in healthcare, professional training, education and research settings. This article describes the theoretical basisfor patient partnerships and how this new model can be implemented in clinical, organizational and systemic levels, as well as the success factors in both patients and healthcare professionals. The Montreal Model provides relevant outlooks for chronic disease management by making patients essential partners in all decisions affecting them and by treating them as experts in the organisation of care. This model should have a significant impact on the population's health by improving physical, psychological health, as well as the patient's well-being. As part of this new framework, several research programs are currently underway to evaluate the impact of this model.

Implementation of interprofessional learning activities in a professional practicum: The emerging role of technology.

To prepare future healthcare professionals to collaborate effectively, many universities have developed interprofessional education programs (IPE). Till date, these programs have been mostly courses or clinical simulation experiences. Few attempts have been made to pursue IPE in healthcare clinical settings. This article presents the results of a pilot project in which interprofessional learning activities (ILAs) were implemented during students' professional practicum and discusses the actual and potential use of informatics in the ILA implementation. We conducted a pilot study in four healthcare settings. Our analysis is based on focus group interviews with trainees, clinical supervisors, ILA coordinators, and education managers. Overall, ILAs led to better clarification of roles and understanding of each professional's specific expertise. Informatics was helpful for developing a common language about IPE between trainees and healthcare professionals; opportunities for future application of informatics were noted. Our results support the relevance of ILAs and the value of promoting professional exchanges between students of different professions, both in academia and in the clinical setting. Informatics appears to offer opportunities for networking among students from different professions and for team members' professional development. The use of technology facilitated communication among the participants.

The patient-as-partner approach in health care: a conceptual framework for a necessary transition.

The prevalence of chronic diseases today calls for new ways of working with patients to manage their care. Although patient-centered approaches have contributed to significant advances in care and to treatments that more fully respect patients' preferences, values, and personal experiences, the reality is that health care professionals still hold a monopoly on the role of healer. Patients live with their conditions every day and are experts when it comes to their own experiences of illness; this expertise should be welcomed, valued, and fostered by other members of the care team. The patient-as-partner approach embodies the ideal of making the patient a bona fide member of the health care team, a true partner in his or her care. Since 2010, the University of Montreal, through the Direction of Collaboration and Patient Partnership, has embraced this approach. Patients are not only active members of their own health care team but also are involved in research and provide valuable training to health sciences students. Including patients as full partners in the health care team entails a significant shift in both the medical practice and medical education cultures. In this perspective, the authors describe this innovative approach to patient care, including the conceptual framework used in its development and the main achievements of patient partners in education, health care, and research.

Innovating in teaching collaborative practice with a large student cohort at Université de Montréal.

Université de Montréal implemented an interprofessional education (IPE) curriculum on collaborative practice in a large cohort of students (>1,100) from 10 health sciences and psychosocial sciences training programs. It is made up of three one-credit undergraduate courses (CSS1900, CSS2900, CSS3900) spanning the first 3 years of training. The course content and activities aim for development of the six competency domains identified by the Canadian Interprofessional Health Collaborative. This paper describes the IPE curriculum and highlights the features contributing to its success and originality. Among main success key factors were: administrative cooperation among participating faculties, educators eager to develop innovative approaches, extensive use of clinical situations conducive to knowledge and skill application, strong logistic support, close cooperation with health care delivery organizations, and partnership between clinicians and patients. A distinguishing feature of this IPE curriculum is the concept of partnership in care between the patient and caregivers. Patients' representatives were involved in course planning, and patients were trained to become patients-as-trainers and cofacilitate interprofessional discussion workshops. They give feedback to students regarding integration and application of the patient partnership concept from a patient's point of view.

Educational needs of health care providers working in long-term care facilities with regard to pain management.

BACKGROUND: The prevalence of chronic pain ranges from 40% to 80% in long-term care facilities (LTCF), with the highest proportion being found among older adults and residents with dementia. Unfortunately, pain in older adults is underdiagnosed, undertreated, inadequately treated or not treated at all. A solution to this problem would be to provide effective and innovative interdisciplinary continuing education to health care providers (HCPs). OBJECTIVE: To identify the educational needs of HCPs working in LTCF with regard to pain management. METHODS: A qualitative research design using the nominal group technique was undertaken. Seventy-two HCPs (21 physicians/pharmacists, 15 occupational/physical therapists, 24 nurses and 21 orderlies) were recruited from three LTCF in Quebec. Each participant was asked to provide and prioritize a list of the most important topics to be addressed within a continuing education program on chronic pain management in LTCF. RESULTS: Forty topics were generated across all groups, and six specific topics were common to at least three out of the four HCP groups. Educational need in pain assessment was ranked the highest by all groups. Other highly rated topics included pharmacological treatment of pain, pain neurophysiology, nonpharmacological treatments and how to distinguish pain expression from other behaviours. CONCLUSION: The present study showed that despite an average of more than 10 years of work experience in LTCF, HCPs have significant educational needs in pain management, especially pain assessment. These results will help in the development of a comprehensive pain management educational program for HCPs in LTCF.

Predictors of quality-of-care processes in geriatric assessment units: toward a better organizational framework.

OBJECTIVES: To identify the structural and patient characteristics associated with better care processes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-four Geriatric Assessment Units (GAU). PARTICIPANTS: Patients aged 65 and older who were admitted to a GAU for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, completion of advance health care directives) assessed through chart audit; 14 patient- and 23 GAU-related characteristics obtained from hospitalization records, national databases, and GAU managers. RESULTS: A total of 877 hospitalization records were included. Final models were based on multilevel modeling using stepwise variable selection. Strongest predictors of better comprehensiveness were longer hospital length of stay (LOS), higher clinical complexity (eg, higher mortality risk), and having a geriatrician as attending physician. Comprehensiveness score increased sharply up to 3 weeks LOS and then tended to plateau. Better informational continuity was associated with more comprehensive care, higher risk of mortality, acute rather than rehabilitation care, communication with community health care professionals within 48 hours after admission, and a target LOS of 3 weeks or longer. The completion of advance directives was more likely in the presence of advanced age, higher risk of mortality, cognitive impairment, discharge to another care facility, longer LOS, university-affiliated institution, and nonurban location. CONCLUSION: In GAUs, quality-of-care processes are related to both structural and patient characteristics. Our results pointed toward an organizational framework that may help to streamline the geriatric units and better use resources, notably by narrowing the admission criteria, targeting a proper LOS, improving communication with community organizations, and making systematic completion of advance directives.

Quality-of-care processes in geriatric assessment units: principles, practice, and outcomes.

OBJECTIVES: To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients. DESIGN: Retrospective study. SETTING: Forty-nine Geriatric Assessment Units. PARTICIPANTS: Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma. MEASUREMENTS: Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases. RESULTS: A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55-0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82-1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74-0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59-0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes. CONCLUSION: A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.

A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model.

BACKGROUND: Elderly patients admitted to Geriatric Assessment Units (GAU) typically have complex health problems that require multi-professional care. Considering the scope of human and technological resources solicited during hospitalization, as well as the many risks and discomforts incurred by the patient, it is important to ensure the communication of pertinent information for quality follow-up care in the community setting. Conventional discharge summaries do not adequately incorporate the elements specific to an aging clientele. OBJECTIVE: To develop a discharge summary adapted to the frail elderly patient (D-SAFE) in order to communicate relevant information from hospital to community services. METHODS: The items to be included in the D-SAFE have been determined by means of a modified Delphi method through consultation with clinical experts from GAUs (11 physicians and 5 pharmacists) and the community (10 physicians and 5 pharmacists). The consensus analysis and the level of agreement among the experts were reached using a modified version of the RAND®/University of California at Los Angeles appropriateness method. RESULTS: A consensus was reached after two rounds of consultation for all the items evaluated, where none was judged "inappropriate". Among the items proposed, four were judged to be "uncertain" and were eliminated from the final D-SAFE, which was divided into two sections: the medical discharge summary (22 main items) and the discharge prescription (14 main items). CONCLUSIONS: The D-SAFE was developed as a more comprehensive tool specifically designed for GAU inpatients. Additional research to validate its acceptability and practical impact on the continuity of care is needed before it can be recommended for use on a broader scale.

Short-term geriatric assessment units: 30 years later.

BACKGROUND: The increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them. METHODS: In 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their unit's operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile. RESULTS: Overall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAU's operation. CONCLUSIONS: The GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAU's primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

[Do the activities of day programs for the elderly correspond to their various needs?]. / Les activités de groupe des centres de jour pour personnes âgées correspondent-elles aux besoins des différents profils de participants ?

This study was carried out to explore the fit between health and functional characteristics of Day Program participants and the types of program activities they were offered in Day Programs. The subjects were 132 participants from 5 Day Programs in Montreal. Four different participant profile groups were identified using cluster analysis. A classification of program activities was created by a panel of experts. Participation in these activities was studied for each profile group, and compared to recommended activities for such client groups outlined through examination of the literature and consultation with our panel of experts. Results showed only partial correspondence between program activities and participants' needs. This correspondence seemed higher for individuals with physical health problems or mobility impairments and weaker for those presenting depressive symptoms or cognitive impairments. These results suggest a need to review activity program components and determine ways to match better these with client needs to optimise the benefits of Day Program participation.

Development of an individualized service plan tool and rules for case management in Québec.

From past experience with integrated service delivery, there appears to be a need for a clinical tool to help case managers plan, monitor, and coordinate services. In this context the Québec Ministry of Health and Social Services created a task force to suggest improvements to the Individualized Service Plan tool included in the Multiclientele Assessment Tool. This article reports the findings of this multidisciplinary task force working with various clienteles (older, with physical or mental disabilities, mental diseases). Based on a literature review and recent results from the Program of Research on the Integration of Services for the Maintenance of Autonomy, the task force proposed a dynamic, concise, user-friendly tool and a clear definition of how it should be used. The Individualized Service Plan must list the patient's needs, with an orientation regarding the action plan for each, and a list of services allocated in response to these needs that work in the defined direction. The tool must also contain a section for analyzing variations between the services needed and allocated. This tool was presented to case managers for validation and received an enthusiastic response. It should be implemented in the coming years in the provincial Multiclientele Assessment Tool.

Determinants of adult day center attendance among older adults with functional limitations.

OBJECTIVE: To examine factors related to regularity of adult day center (ADC) attendance among seniors with functional limitations. METHODS: Using data collected as part of a larger study, we identified the proportion of scheduled days attended among 101 ADC users in Montréal and identified determinants of this attendance. RESULTS: More regular attendance was associated with previous profession of ADC participant or spouse in a sector other than health care, receiving formal help for activities of daily living or instrumental activities of daily living on days of expected ADC participation, participating for the whole day rather than half a day, lower participation in prevention and health-promotion activities, and lower caregiver burden among persons with cognitive impairments and higher caregiver burden among persons without cognitive impairments. DISCUSSION: To enhance ADC intervention effects, levels of participation should be maximized. Study findings suggest ways to promote more regular attendance.