A longitudinal multi-site evaluation of community-based partnerships: implications for researchers, funders, and communities.

BACKGROUND: Innovative Models Promoting Access to Care Transformation (IMPACT) was a five-year (2013-2018), Canadian-Australian research program that aimed to use a community-based partnership approach to transform primary health care (PHC) organizational structures to improve access to appropriate care for vulnerable populations. Local Innovation Partnerships (LIPs) were developed to support the IMPACT research program, and to be ongoing structures that would continue to drive local improvements to PHC. METHODS: A longitudinal development-focused evaluation explored the overall approach to governance, relationships and processes of the LIPs in the IMPACT program. Semi-structured interviews were conducted with purposively selected participants including researchers with implementation roles and non-researchers who were members of LIPs at four time points: early in the development of the LIPs in 2014; during intervention development in 2015/2016; at the intervention implementation phase in 2017; and nearing completion of the research program in 2018.  A hybrid deductive-inductive thematic analysis approach was used. A Guide developed to support the program was used as the framework for designing questions and analysing data using a qualitative descriptive method initially. A visual representation was developed and refined after each round of data collection to illustrate emerging themes around governance, processes and relationship building that were demonstrated by IMPACT LIPs. After all rounds of data collection, an overarching cross-case analysis of narrative summaries of each site was conducted. RESULTS: Common components of the LIPs identified across all rounds of data collection related to governance structures, stakeholder relationships, collaborative processes, and contextual barriers.  LIPs were seen primarily as a structure to support implementation of a research project rather than an ongoing multisectoral community-based partnership.  LIPs had relationships with many and varied stakeholders although not necessarily in ways that reflected the intended purpose. Collaboration was valued, but multiple barriers impeded the ability of LIPs to enact real collaboration in daily operations over time. We learned that experience, history, and time matter, especially with respect to community-oriented collaborative skills, structures, and relationships. CONCLUSIONS: This longitudinal multiple case study offers lessons and implications for researchers, funders, and potential stakeholders in community-based participatory research.

Defining community health services in Australia: a qualitative exploration.

BACKGROUND: The Community Health Program of the 1970s was an attempt to introduce a national community health model. However, although community-based health care is an important element of the health systems of all Australian states and territories, the definition of what constitutes a 'community health service' in Australia today is not clear. METHODS: A search of government websites failed to provide information about the types and characteristics of services that would be included in the term. Therefore, semi-structured interviews were conducted with 13 key informants in roles with responsibility for primary and community health services from health departments in all Australian states and territories. Questions explored their understanding of community health services as they operated in their jurisdiction. The study adopted a blended inductive and deductive orientation within a qualitative descriptive method. RESULTS: There was little consistency in the way community health services were described across jurisdictions. The defining attributes of a 'community health centre' described by an international peak body did not apply to services in the majority of jurisdictions in Australia. Victoria was more aligned with the description than other jurisdictions, with organisations defined through legislation and a separate funding stream to support aspects of service delivery. CONCLUSIONS: Those designing and implementing national health system programs and reforms need to be aware that terms, such as 'community health', do not mean the same thing across jurisdictions; attempts to create consistency have to recognise differences that will affect new initiatives, as well as the spread of successful policies and programs from one jurisdiction to another. Without a consistent description, it is difficult to explore the current role of community-based health care across Australia in improving access to health care.

Responding to foot health needs of people experiencing homelessness: the role of a publicly funded community-based podiatry service.

BACKGROUND: People experiencing homelessness are known to suffer from poor health and can be reluctant to seek healthcare except in crisis. Foot and ankle problems are a concern; as well as causing discomfort and pain, they may escalate from a minor problem to a very serious one without timely and appropriate treatment. Little is known about the foot and ankle problems of people experiencing homelessness. This paper describes a podiatric service specifically for people experiencing homelessness, which includes a fixed site as well as outreach services. The service operates as part of the Homelessness Team program at Cohealth, a large community health service in Melbourne. METHODS: The study used routinely collected data. Every person who was seen by the podiatrist in the Cohealth Homelessness Team in 2019, whether on site or on outreach, was included in the study (n = 295). Of these, 156 were attending for the first time and 139 were returning clients. People who used the service were predominantly rough sleeping (45.2%), with 32.2% in unstable or insecure housing and 22.6% recently housed. RESULTS: Skin and nail pathologies (68.1%), inadequate footwear (51.9%) and biomechanical issues (44.1%) were the most common presentations. People sleeping rough were particularly likely to present with biomechanical issues (50.8%), acute wound care needs (17.4%) or traumatic injury (10.6%). Most people presented with more than one issue (mean = 2.4), and new clients (mean = 2.53) and those rough sleeping (mean = 2.69) had more issues than others. Outreach was the most effective way to reach clients in the most difficult circumstances (48.9% of those in unstable housing, 34.8% of rough sleepers). Most of the clients (81.4%) had connections with other services offered by Cohealth, such as social work or physiotherapy. CONCLUSIONS: This study demonstrated that reaching and intervening on foot and ankle problems of people experiencing homelessness who may not seek care on their own could be achieved through a publicly funded health service, using simplified pathways to care including outreach. In addition to the long- and short- term benefits of the immediate podiatric treatment, building trust and connections through footcare may provide an entry point into accepting other health and welfare services.

'No-one has listened to anything I've got to say before': Co-design with people who are sleeping rough.

BACKGROUND: Despite policies and programmes aimed at housing people who are homeless, there are still people who live and sleep rough. This project used the skills and knowledge of people in this situation to identify a strategy to mitigate some of the risks. OBJECTIVE: To describe the development and conduct of a co-design project involving people who are homeless. SETTING/GROUP MEMBERS: A Working Group of 11 was formed following a careful recruitment process from people who had volunteered after consultation by the project team. The co-design approach was guided by a set of principles. METHODS: Eight members of the Working Group were interviewed by an external researcher (RM). The approach was primarily deductive, with the principles adopted by the project team used as a framework for data collection and analysis. The co-design process was captured by the project leaders (BK, PC) supplemented with documentation review and team discussions. RESULTS: The group met weekly for 12 weeks, with 8-10 members present on average. They reviewed information from the survey, contributed ideas for solutions and ultimately decided to provide information via print, a website and an event. Important factors in on-going involvement were carefully selecting group members and making participation rewarding for them. DISCUSSION/CONCLUSIONS: Vulnerable people such as those experiencing homelessness can be excluded from decision-making processes affecting them, as they can be perceived as hard to reach and unable to make a meaningful contribution. This project demonstrated that a carefully managed project, with sufficient resources and commitment, it was possible to involve people who are homeless and maintain involvement over an extended time period. PUBLIC CONTRIBUTION: The Working Group reviewed survey findings and developed an intervention to minimize the health, social and legal harms of sleeping rough. Several members reviewe this paper.

Addressing elder abuse through integrating law into health: What do allied health professionals at a Community Health Service in Melbourne, Australia, think?

This research looked at the attitudes of Community Health Service (CHS) staff regarding the integration of a lawyer into their CHS both before and after the integration occurred. It assessed their confidence in identifying and addressing elder abuse at each point. A written survey was distributed to staff before the lawyer commenced (n = 126), and approximately 12 months afterwards (n = 54). The preliminary survey demonstrated widespread agreement that legal issues can affect older people and supported having a lawyer in a CHS. Respondents were not confident about their capacity to identify abuse and provide referrals to a lawyer, but this improved in the follow-up survey. These CHS staff were aware of the potential impacts of elder abuse and supported embedding a lawyer in the health service. Information and training as part of this service model should focus on the skills needed for CHS staff to play their role in such a partnership.

Frontline barriers to effective paramedic and emergency nursing STEMI management: clinician perspectives.

BACKGROUND: Factors that hinder the pivotal role frontline clinicians play in STEMI management are under-reported. We aimed to explore perceived barriers to effective STEMI management by addressing the following questions: 1. What are the most commonly occurring barriers to timely STEMI management for paramedics and emergency nurses? 2. Are there differences in barriers experienced by paramedics and emergency nurses? 3. Are there differences in barriers experienced by frontline clinicians in rural and metropolitan settings? METHODS: A 79-item online survey was offered to paramedics and emergency nurses. Descriptive statistics and exploratory factor analysis identified the most frequently experienced types of barriers. Professional groups and geographical locations were compared. RESULTS: There were 333 respondents. Response rates for paramedics was 10% and 9% for members of an emergency nursing association. Most commonly occurring barriers across all respondents were: 'lack of skills development'; 'lack of feedback'; 'untimely support'; 'distance to scene/hospital facilities'; 'hospital-related delays'. Statistically significant differences were found by professional group and geographical location. CONCLUSION: Barriers to timely management were present, but not frequently experienced. Survey responses indicate a need for improved continuing professional development opportunity, clearer feedback mechanisms, streamlined facilitation of STEMI processes in hospitals, and enhanced access to expert advice/resources for all frontline clinicians.

Towards a national model for organ donation requests in Australia: evaluation of a pilot model.

OBJECTIVE: To evaluate whether structural elements of a collaborative requesting model were observed in practice, and explore the impact of specialised communications training and elements of the model on consent rates. DESIGN: A national observational study captured staff observations of the organ donation requesting process. SETTING: DonateLife staff in 15 hospitals collected data from medical, nursing and allied health professionals who participated in the donation requesting process over a 12-month period. PARTICIPANTS: Data were collected from 201 family donation conversations (FDCs). MAIN OUTCOME MEASURES: Whether structural elements of the model were observed in practice, and rates of consent to donate. RESULTS: For most cases, there was a team planning meeting (87.0%); a gap in time between the meeting at which family understands brain death or the inevitability of death and the FDC for most cases (72.0%); and at least one trained requester present at the FDC (80.7%). Consent rates were significantly different according to who led the FDC: an untrained treating clinical specialist (45.2%); a trained treating clinical specialist (54.8%); or a trained requester who was not part of the treating clinical team (74.5%) (χ2=11.92, P=0.003). Logistic regression showed that the odds ratio (OR) for consent was significantly greater when the patient was on the Australian Organ Donor Register (OR, 9.3; CI, 3.5-24.5) and when the FDC was led by an FDC-trained requester who was not part of the treating clinical team (OR, 6.8; CI, 2.3-19.9). CONCLUSIONS: Structural elements of the model were observed in most cases, indicating that the model is feasible and acceptable. We showed that the highest consent rates were achieved when FDCs were led by professionals who had completed the specialised communications training and were not part of the treating clinical team for that patient.

Development and evaluation of an aged care specific Advance Care Plan.

OBJECTIVES: To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. DESIGN: An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. PARTICIPANTS AND SETTING: 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. RESULTS: Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents' values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. CONCLUSIONS: Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

Evaluating the feasibility of Goal Attainment Scaling as a rehabilitation outcome measure for veterans.

OBJECTIVE: The increasing number of veterans with complex health conditions accessing rehabilitation leads to the need for an outcome measure that identifies success in areas beyond return to work. The current study was designed to assess the feasibility of goal attainment scaling as a routine measure of outcomes of rehabilitation. METHODS: Fifteen organisations contracted by the Australian Department of Veterans' Affairs to work with veterans were invited to trial goal attainment scaling. Training was provided to rehabilitation professionals, and existing documentation was modified by the Australian Department of Veterans Affairs to introduce the goal attainment scaling approach. RESULTS: Analysis of the use of goal attainment scaling supported the feasibility and potential usefulness of the tool in a veteran population. Rehabilitation providers set goals across a range of domains including medical, psychological, social, as well as return to work. The quality of the goals and the outcome measures was generally good. CONCLUSIONS: The goal attainment scaling approach was seen to support a client-focussed approach to rehabilitation. Data obtained through the use of goal attainment scaling can be summarised at different levels to be useful for clients, providers, rehabilitation coordinators, and senior executives to monitor and report on the overall success of the different types of rehabilitation provided to veteran clients.

Quality of advance care planning policy and practice in residential aged care facilities in Australia.

OBJECTIVES: To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. DESIGN: Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. SETTING: 19 selected RACFs in Victoria. PARTICIPANTS: 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. RESULTS: Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. CONCLUSIONS: Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.

Successful aging: development and testing of a multidimensional model using data from a large sample of older australians.

OBJECTIVES: To develop a multidimensional statistical model that could assess the contribution of, and interrelationships between, measures likely to contribute to an individual's successful aging, defined as aging well across a number of dimensions. DESIGN: Cross-sectional. SETTING: Data collected from 8,841 Australians aged 16 to 85 during the 2007 National Survey of Mental Health and Well-Being conducted by the Australian Bureau of Statistics. PARTICIPANTS: Two thousand two hundred eighty-six survey participants aged 61 to 85. MEASUREMENTS: Self-assessed physical and mental health, quality of life, and cognition constitute the outcome factor: successful aging. Attributes measuring past and current mental and physical health, social measures, and health behaviors were considered for inclusion as predictor measures. Results of the final model allowed calculation of individual weighted successful aging scores. RESULTS: The final model closely fitted responses from participants and men and women separately. Factors measuring mental and physical health and social support contributed significantly and independently to successful aging. Health behaviors, measuring extent of physical exercise and not smoking, contributed to successful aging in addition to their association with physical health. On average, those scoring in the highest decile of the successful aging measure reported having two chronic health conditions, indicating that such conditions do not necessarily preclude high levels of well-being in older individuals. CONCLUSION: This model developed from a large sample of older individuals identified factors worth targeting in future social and health policy initiatives for this age group. It also indicates that chronic illness is not necessarily a barrier to successful aging.