Virtually-delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans with PTSD: A study protocol for a nation-wide effectiveness and implementation evaluation.

BACKGROUND: Post-traumatic stress disorder (PTSD) remains a significant treatment challenge among Canadian veterans. Currently accessible pharmacological and non-pharmacological interventions for PTSD often do not lead to resolution of PTSD as a categorical diagnosis and have significant non-response rates. Sudarshan Kriya Yoga (SKY), a complementary and integrative health (CIH) intervention, can improve symptoms of PTSD. In response to the COVID-19 pandemic, this intervention has pivoted to virtual delivery and may be reaching new sets of participants who face multiple barriers to care. OBJECTIVE: To evaluate the implementation and effectiveness of virtually delivered Sudarshan Kriya Yoga (SKY) on decreasing PTSD symptom severity, symptoms of depression, anxiety, and pain, and improving quality of life in Canadian veterans affected by PTSD. METHODS AND ANALYSIS: Using a mixed-methods approach guided by the RE-AIM framework, we will conduct a hybrid type II effectiveness and implementation study of virtually delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans. Effectiveness will be evaluated by comparing virtually delivered SKY to a waitlist control in a single-blinded (investigator and data analyst) randomized controlled trial (RCT). Change in PTSD symptoms (PCL-5) is the primary outcome and quality of life (SF-36), symptoms of depression (PHQ-9), anxiety (GAD-7), and pain (BPI) are secondary outcomes. The SKY intervention will be conducted over a 6-week period with assessments at baseline, 6-weeks, 12-weeks, and 30 weeks. The reach, effectiveness, adoption, implementation, and maintenance of the intervention will be evaluated through one-on-one semi-structured interviews with RCT participants, SKY instructors, health professionals, and administrators that work with veterans. DISCUSSION: This is the first investigation of the virtual delivery of SKY for PTSD in veterans and aims to determine if the intervention is effective and implementable at scale.

Achieving holistic, quality-of-life focused care: description of a Compassion Care Community initiative in Canada.

The compassionate community movement as both a public health approach and a social model of care for various life stages is gaining traction in Canada and elsewhere. One example is the Windsor-Essex Compassion Care Community (WECCC), an evidence-based model and set of tools to improve the quality of life, health and wellness of vulnerable and aging populations by identifying and addressing upstream and downstream social and other risks to physical and mental health. This paper presents findings from the WECCC pilot evaluation. The WECCC initiative provided one-on-one volunteer-supported quality of life assessment, resource navigation and goals support program (Catalyzing Community Connections). This was augmented with public education sessions on social connection and loneliness (Importance of Being Connected) for the broader population. The RE-AIM framework was used to frame evaluation of WECCC through the first 4 years. Questionnaires were used to evaluate participant outcomes related to implementation and effectiveness. Interviews and focus groups were completed to understand impacts. From 2017 to 2020, WECCC has engaged over 2,500 individuals, 65 organizations and 400 volunteers combined in both programs. Nearly all (82% to 95%) participants reported positive changes to health, quality of life and/or social connections. This developmental phase of a compassionate community initiative has allowed piloting of an evaluation framework focusing on reach, adoption, implementation and early signals of effectiveness and maintenance. This demonstration provides information on feasibility, acceptability and potential impacts of this type of over-arching community initiative.

The compassionate communities movement is a social and holistic approach to care that engages community members in caring for others. The movement is growing around the world. The philosophy is that all citizens benefit from participating in care for others who are aging, disabled, nearing end-of-life or struggling with determinants of health. The Windsor-Essex Compassion Care Community (WECCC) is a Canadian example of this model. WECCC seeks to improve the health of people at any stage of life by helping them to identify their life needs and goals and providing them support to meet them. The program has two core components: one-on-one volunteer-support for person-directed goals and navigation (Catalyzing Community Connections) and public education sessions about loneliness and social connection (Importance of Being Connected). Evaluation is a routine part of program delivery with questionnaires, interviews and focus groups used to understand the program's outcomes. From 2017 to 2020, WECCC has worked with over 2,500 individuals, 65 organizations and 400 volunteers. Satisfaction with the program is very high (95%). Nearly all participants reported positive changes to their quality of life (82%) and social connections (95%). Although pilot results are favorable, continued evaluation and stronger research designs are needed to comprehensively evaluate the WECCC program over time and to support growth and spread of the model.

Sahaj Samadhi Meditation versus a Health Enhancement Program for depression in chronic pain: protocol for a randomized controlled trial and implementation evaluation.

BACKGROUND: Despite the high prevalence of comorbid chronic pain and depression, this comorbidity remains understudied. Meditation has demonstrated efficacy for both chronic pain and depression independently, yet there have been few studies examining its effectiveness when both conditions are present concurrently. Furthermore, while meditation is generally accepted as a safe and effective health intervention, little is known about how to implement meditation programs within or alongside the health care system. METHODS: We will conduct a hybrid type 1 effectiveness-implementation evaluation. To measure effectiveness, we will conduct a randomized controlled trial comparing Sahaj Samadhi Meditation and the Health Enhancement Program in 160 people living with chronic pain, clinically significant depressive symptoms, and on long-term opioid therapy. Changes in depressive symptoms will be our primary outcome; pain severity, pain-related function, opioid use, and quality of life will be the secondary outcomes. The primary end point will be at 12 weeks with a secondary end point at 24 weeks to measure the sustainability of acute effects. Patients will be recruited from a community-based chronic pain clinic in a large urban center in Mississauga, Canada. The meditation program will be delivered in the clinical environment where patients normally receive their chronic pain care by certified meditation teachers who are not regulated health care providers. We will use a mixed-methods design using the multi-level framework to understand the implementation of this particular co-location model. DISCUSSION: Results of this hybrid evaluation will add important knowledge about the effectiveness of meditation for managing depressive symptoms in people with chronic pain. The implementation evaluation will inform both effectiveness outcomes and future program development, scalability, and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04039568. Registered on 31 July 2019.

A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration.

BACKGROUND: A population-based approach to healthcare goes beyond the traditional biomedical model and addresses the importance of cross-sectoral collaboration in promoting health of communities. By establishing partnerships across primary care (PC) and public health (PH) sectors in particular, healthcare organizations can address local health needs of populations and improve health outcomes. The purpose of this study was to map a series of interventions from the empirical literature that facilitate PC-PH collaboration and develop a resource for healthcare organizations to self-evaluate their clinical practices and identify opportunities for collaboration with PH. METHODS: A scoping review was designed and studies from relevant peer-reviewed literature and reports between 1990 and 2017 were included if they met the following criteria: empirical study methodology (quantitative, qualitative, or mixed methods), based in US, Canada, Western Europe, Australia or New Zealand, describing an intervention involving PC-PH collaboration, and reporting on structures, processes, outcomes or markers of a PC-PH collaboration intervention. RESULTS: Out of 2962 reviewed articles, 45 studies with interventions leading to collaboration were classified into the following four synergy groups developed by Lasker's Committee on Medicine and Public Health: Coordinating healthcare services (n = 13); Applying a population perspective to clinical practice (n = 21); Identifying and addressing community health problems (n = 19), and Strengthening health promotion and health protection (n = 21). Furthermore, select empirical examples of interventions and their key features were highlighted to illustrate various approaches to implementing collaboration interventions in the field. CONCLUSIONS: The findings of our review can be utilized by a range of organizations in healthcare settings across the included countries. Furthermore, we developed a self-evaluation tool that can serve as a resource for clinical practices to identify opportunities for cross-sectoral collaboration and develop a range of interventions to address unmet health needs in communities; however, the generalizability of the findings depends on the evaluations conducted in individual studies in our review. From a health equity perspective, our findings also highlight interventions from the empirical literature that address inequities in care by targeting underserved, high-risk populations groups. Further research is needed to develop outcome measures for successful collaboration and determine which interventions are sustainable in the long term.

"On the Margins and Not the Mainstream:" Case Selection for the Implementation of Community Based Primary Health Care in Canada and New Zealand.

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of aging populations and their carers. Across the world CBPHC is at varying stages of evolution and no standard model exists. In order to scale up and spread successful models of care it is important to study what works well and why to support broader efforts to implement, scale-up and spread promising innovations. The first step in this endevour is to select appropriate cases to study. In this paper we share our adaptation of case study methodology to iteratively select models of CBPHC in three jurisdictions: Ontario, Quebec (Canada) and New Zealand. A combination of literataure searches (of empirical and gray sources) and stakeholder engagement enabled the selection of cases to study, with the latter providing the most fruitful method. We conclude that it is possible to use personal networks and experts exclusively. It is not clear how much value formal searching adds over and above expert advice. However in a situation where there is no existing definitive list of potential cases, and no acknowledged "gold standard" way to create such a list, it seems appropriate to gather cases using multiple methods and to document those methods systematically.

Capturing the experiences of patients across multiple complex interventions: a meta-qualitative approach.

OBJECTIVES: The perspectives, needs and preferences of individuals with complex health and social needs can be overlooked in the design of healthcare interventions. This study was designed to provide new insights on patient perspectives drawing from the qualitative evaluation of 5 complex healthcare interventions. SETTING: Patients and their caregivers were recruited from 5 interventions based in primary, hospital and community care in Ontario, Canada. PARTICIPANTS: We included 62 interviews from 44 patients and 18 non-clinical caregivers. INTERVENTION: Our team analysed the transcripts from 5 distinct projects. This approach to qualitative meta-evaluation identifies common issues described by a diverse group of patients, therefore providing potential insights into systems issues. OUTCOME MEASURES: This study is a secondary analysis of qualitative data; therefore, no outcome measures were identified. RESULTS: We identified 5 broad themes that capture the patients' experience and highlight issues that might not be adequately addressed in complex interventions. In our study, we found that: (1) the emergency department is the unavoidable point of care; (2) patients and caregivers are part of complex and variable family systems; (3) non-medical issues mediate patients' experiences of health and healthcare delivery; (4) the unanticipated consequences of complex healthcare interventions are often the most valuable; and (5) patient experiences are shaped by the healthcare discourses on medically complex patients. CONCLUSIONS: Our findings suggest that key assumptions about patients that inform intervention design need to be made explicit in order to build capacity to better understand and support patients with multiple chronic diseases. Across many health systems internationally, multiple models are being implemented simultaneously that may have shared features and target similar patients, and a qualitative meta-evaluation approach, thus offers an opportunity for cumulative learning at a system level in addition to informing intervention design and modification.

A scoping review and thematic classification of patient complexity: offering a unifying framework.

The path to improving healthcare quality for individuals with complex health conditions is complicated by a lack of common understanding of complexity. Modern medicine, together with social and environmental factors, has extended life, leading to a growing population of patients with chronic conditions. In many cases, there are social and psychological factors that impact treatment, health outcomes, and quality of life. This is the face of complexity. Care challenges, burden, and cost have positioned complexity as an important health issue. Complex chronic conditions are now being discussed by clinicians, researchers, and policy-makers around such issues as quantification, payment schemes, transitions, management models, clinical practice, and improved patient experience. We conducted a scoping review of the literature for definitions and descriptions of complexity. We provide an overview of complex chronic conditions, and what is known about complexity, and describe variations in how it is understood. We developed a Complexity Framework from these findings to guide our approach to understanding patient complexity. It is critical to use common vernacular and conceptualization of complexity to improve service and outcomes for patients with complex chronic conditions. Many questions still persist about how to develop this work with a health and social care lens; our framework offers a foundation to structure thinking about complex patients. Further insight into patient complexity can inform treatment models and goals of care, and identify required services and barriers to the management of complexity. Journal of Comorbidity 2012;2:1-9.

The assessment and treatment of a complex geriatric patient by an interprofessional primary care team.

Mr K is an 89-year-old married man with a number of comorbid conditions and multiple recent falls. He was referred to the IMPACT clinic (Interprofessional Model of Practice for Aging and Complex Treatments) as his primary care physician was concerned about his declining health and the growing care giver burden on his wife. Mr K's condition was deteriorating while the complexity of his case was increasing; therefore, an in-depth team assessment was sought to determine the best management plan and to assess his capacity to remain at home (his expressed preference). The IMPACT team met with Mr K and his wife for a 2 h interprofessional assessment. A comprehensive care plan was developed including specific recommendations for implementing change. After the visit to the IMPACT clinic, Mr K's care was returned to his regular family physician.

A population-based cohort study of ambulatory care service utilization among older adults.

RATIONALE, AIMS AND OBJECTIVES: Age-related effects on ambulatory care service utilization are not well understood. We aim to measure the utilization patterns of ambulatory health care services (i.e. family physician visits, specialist physician visits and emergency room visits) in the late life course (65 years and older). METHODS: A population-based retrospective cohort study was conducted for the period 1 April 2005 to 31 March 2006. All Ontario, Canada, residents aged 65+ and eligible for government health insurance were included in the analysis. RESULTS: This population-based cohort study demonstrates considerable increase in utilization rates and variability of ambulatory services as age increases. Variations in utilization were observed by gender as overall women were more likely to consult a family physician, and men more likely to visit specialists and the emergency room. A small group of high users, constituting 5.5% of the total population, accounted for 18.7% of total ambulatory visits. Finally, we report socio-economic status (SES) based disparity for specialist services in which high users were more likely to have higher SES. CONCLUSIONS: There is increasing utilization and variability in ambulatory service utilization with increase in age. Further research is required to explain the gender and SES differences reported in this study.

Oral vitamin B12 therapy in the primary care setting: a qualitative and quantitative study of patient perspectives.

BACKGROUND: Although oral replacement with high doses of vitamin B12 is both effective and safe for the treatment of B12 deficiency, little is known about patients' views concerning the acceptability and effectiveness of oral B12. We investigated patient perspectives on switching from injection to oral B12 therapy. METHODS: This study involved a quantitative arm using questionnaires and a qualitative arm using semi-structured interviews, both to assess patient views on injection and oral therapy. Patients were also offered a six-month trial of oral B12 therapy. One hundred and thirty-three patients who receive regular B12 injections were included from three family practice units (two hospital-based academic clinics and one community health centre clinic) in Toronto. RESULTS: Seventy-three percent (63/86) of respondents were willing to try oral B12. In a multivariate analysis, patient factors associated with a "willingness to switch" to oral B12 included being able to get to the clinic in less than 30 minutes (OR 9.3, 95% CI 2.2-40.0), and believing that frequent visits to the health care provider (OR 5.4, 95% CI 1.1-26.6) or the increased costs to the health care system (OR 16.7, 95% CI 1.5-184.2) were disadvantages of injection B12. Fifty-five patients attempted oral therapy and 52 patients returned the final questionnaire. Of those who tried oral therapy, 76% (39/51) were satisfied and 71% (39/55) wished to permanently switch. Factors associated with permanently switching to oral therapy included believing that the frequent visits to the health care provider (OR 35.4, 95% CI 2.9-432.7) and travel/parking costs (OR 8.7, 95% CI 1.2-65.3) were disadvantages of injection B12. Interview participants consistently cited convenience as an advantage of oral therapy. CONCLUSION: Switching patients from injection to oral B12 is both feasible and acceptable to patients. Oral B12 supplementation is well received largely due to increased convenience. Clinicians should offer oral B12 therapy to their patients who are currently receiving injections, and newly diagnosed B12-deficient patients who can tolerate and are compliant with oral medications should be offered oral supplementation.