How Do Health Systems Address Patient Flow When Services Are Misaligned With Population Needs? A Qualitative Study.

BACKGROUND: Patient flow through health services is increasingly recognized as a system issue, yet the flow literature has focused overwhelmingly on localized interventions, with limited examination of system-level causes or remedies. Research suggests that intractable flow problems may reflect a basic misalignment between service offerings and population needs, requiring fundamental system redesign. However, little is known about health systems' approaches to population-capacity misalignment, and guidance for system redesign remains underdeveloped. METHODS: This qualitative study, part of a broader investigation of patient flow in urban Western Canada, explored health-system strategies to address or prevent population-capacity misalignment. We conducted in-depth interviews with a purposive sample of managers in 10 jurisdictions across 4 provinces (N = 300), spanning all healthcare sectors and levels of management. We used the constant comparative method to develop an understanding of relevant strategies and derive principles for system design. RESULTS: All regions showed evidence of pervasive population-capacity misalignment. The most superficial level of response - mutual accommodation (case-by-case problem solving) - was most prevalent; capacity (re)allocation occurred less frequently; population redefinition most rarely. Participants' insights yielded a general principle: Define populations on the basis of clusters of co-occurring need. However, defining such clusters demands a difficult balance between narrowness/rigidity and breadth/flexibility. Deeper analysis suggested a further principle: Populations that can be divided into homogeneous subgroups experiencing similar needs (eg, surgical patients) are best served by narrow/ rigid models; heterogeneous populations featuring diverse constellations of need (eg, frail older adults) require broad/ flexible models. CONCLUSION: To remedy population-capacity misalignment, health system planners should determine whether clusters of population need are separable vs. fused, select an appropriate service model for each population, allocate sufficient capacity, and only then promote mutual accommodation to address exceptions. Overreliance on case-by-case solutions to systemic problems ensures the persistence of population-capacity misalignment.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention.

INTRODUCTION: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches. METHODS AND ANALYSIS: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation. ETHICS AND DISSEMINATION: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners. TRIAL REGISTRATION NUMBER: NCT03442426;Pre-results.

Users' experiences of an online intervention for bipolar disorder: important lessons for design and evaluation.

BACKGROUND: The evidence base for digital interventions for physical and mental health, including severe and enduring mental health difficulties, is increasing. In a feasibility trial, web-based Enhanced Relapse Prevention (ERPonline) for bipolar disorder demonstrated high recruitment and retention rates. Relative to participants in the waitlist control group, those who received ERPonline showed increased monitoring for early warning signs of relapse and had developed more positive illness models. OBJECTIVE: To understand users' motivations and barriers for taking part in an online/telephone-based trial, and for engagement with ERPonline. METHODS: Participants from the trial who had been allocated to receive ERPonline were purposively sampled to participate in telephone-based, in-depth qualitative interviews about their experiences. Interviews (n=19) were analysed using framework analysis to identify themes relevant to study aims. FINDINGS: Participants took part due to the convenient, flexible and rewarding aspects of the trial design, as well as a desire to improve the mental health of themselves and others. Barriers included extensive assessments, practical difficulties and mood. ERPonline was was generally considered to be accessible, relevant and straightforward, but there were individual preferences regarding design, content and who it was for. Several participants reported positive changes, but there was a sense that digital interventions should not replace routine care. CONCLUSIONS: There are a number of barriers and facilitators to consider when evaluating and implementing digital interventions. Individual preferences and human contact were key factors for both trial design and engagement with an online intervention. CLINICAL IMPLICATIONS: Digital interventions should be co-produced, personalised, interactive and embedded as one component in a broader package of care. TRIAL REGISTRATION NUMBER: ISRCTN56908625; Post-results.

Advancing team-based primary health care: a comparative analysis of policies in western Canada.

BACKGROUND: We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada. METHODS: We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives. RESULTS: The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics. CONCLUSIONS: Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care.

Accountability for coordinated/integrated health services delivery: working paper

Accountability is an essential governance tool defining relationships, roles and responsibilities pertaining to the actors involved, ensuring that the resources necessary to perform those roles are available and that performance is measured and evaluated. This document explores how accountability can support coordinated/integrated health services delivery.

Factors that dentists use to decide whether or not to render a patient edentulous. Part 1. A qualitative study of East Lancashire general dental practitioners' views.

AIMS: To identify the factors that dentists use to decide whether to render a patient edentulous, prior to developing a questionnaire to investigate the factors that dentists use when making this decision. METHOD: This was a qualitative study involving two groups of seven dentists practising in primary care in East Lancashire who were given scenarios involving patients of different types to facilitate discussion and identify all factors. Audio recordings were used during the focus groups and were subsequently fully transcribed. Two members of the research team independently coded the transcripts and then used thematic analysis to identify key themes. RESULTS: Analysis of the results identified 12 factors that the dentists considered when making a patient edentulous. These were caries, periodontal disease, position of the teeth, aesthetics, bone support, the transition from partial dentures, patient motivation, medicolegal issues, age of the patient, patient choice, cost of treatment, and the dentist's attitude and skills. CONCLUSION: The dentists identified a large number of factors that they might consider before making a patient edentulous. There was a consensus that the change should be made gradually, if possible.

Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part I: the GP perspective.

OBJECTIVES: This study aimed to describe social problems presented to general practitioners (GPs) in UK inner cities and GPs' responses; describe patients' help-seeking pathways; and consider how these pathways can be improved. METHODS: The study involved a pilot survey and follow-up qualitative interviews with patients in two inner city areas in London and Salford in 2001-2. The pilot survey involved five practices in each locality. GPs completed questionnaires on 57 people presenting with social problems. A diversity sample of 12 patients were followed up for interview. RESULTS: Study results are presented in two parts. This paper focuses on the GP survey results. People were presenting with a wide range of social problems, and multiple problems were also common. Problems with welfare benefits and housing were the most common, but GPs were most likely to refer to counselling services and to a lesser extent to generic advice services. Some GPs would have preferred to refer patients to more problem-specific services but did not believe these were available. CONCLUSIONS: The study highlights the role GPs play in helping people deal with social problems but also identifies limitations in their response to these problems. It points to the need for more integrated pathways to help and advice for social problems. Primary care can make existing pathways more visible and accessible, and create new pathways through, for example, the new commissioning role and extending the scope of social prescribing.

Social problems, primary care and pathways to help and support: addressing health inequalities at the individual level. Part II: lay perspectives.

OBJECTIVES: This study aimed to describe social problems presented to general practitioners (GPs) in UK inner cities and GPs' responses; describe patients help-seeking pathways; and consider how these pathways can be improved. METHODS: The study involved a pilot survey and follow-up qualitative interviews with patients in two inner city areas in London and Salford in 2001-2. The pilot survey involved five practices in each locality. GPs completed questionnaires on 57 people presenting with social problems. A diversity sample of 12 patients was followed up for interview. RESULTS: Study results are presented in two parts. Here (Part II) qualitative research results are reported highlighting four themes: the complex and enduring nature of social problems; the persistence people display seeking help; the fragmented and problematic pathways available; and the roles GPs play as: primary medical adviser; formal gateway to another service; advocates or facilitators to another service; and sources of support and advice during a process of recovery. Commonly, GPs occupied more than one role. CONCLUSIONS: GPs do help people deal with social problems, but their responses are limited. More integrated pathways to help and advice for social problems are needed. Existing pathways could be more visible and accessible, and new pathways developed through commissioning and extending social prescribing. More partnerships across sectors may create more co-ordinated provision, but these are notoriously difficult, and other trends such as the focus on lifestyle issues and long-standing conditions may make it more difficult for people with social needs to access support.

Listening to respondents: a qualitative assessment of the Short-Form 36 Health Status Questionnaire.

Standardised health status questionnaires are widely used to obtain subjective assessments of health. However, little research has investigated the meaning of the data they produce. Statistical tests will highlight some problems with the structure and wording of a questionnaire but they cannot shed any light on the way in which respondents interpret questions or their intended meaning when they select a response. Various qualitative techniques are being used within disciplines such as sociology and psychology to test both the language of survey instruments and the cognitive bases of surveys. This paper outlines some of these methods and reports findings from a qualitative research study in the UK with a widely used questionnaire--the Short-Form 36 Health Status Questionnaire. The value of including in-depth, qualitative validation techniques in the development and testing of surveys used to collect subjective assessments of health is clearly demonstrated by the findings of the study.