Exploring Patient Advisors' Perceptions of Virtual Care Across Canada: Qualitative Phenomenological Study.

BACKGROUND: While virtual care services existed prior to the emergence of COVID-19, the pandemic catalyzed a rapid transition from in-person to virtual care service delivery across the Canadian health care system. Virtual care includes synchronous or asynchronous delivery of health care services through video visits, telephone visits, or secure messaging. Patient advisors are people with patient and caregiving experiences who collaborate within the health care system to share insights and experiences in order to improve health care. OBJECTIVE: This study aimed to understand patient advisors' perceptions related to virtual care and potential impacts on health care quality. METHODS: We adopted a phenomenological approach, whereby we interviewed 20 participants who were patient advisors across Canada using a semistructured interview protocol. The protocol was developed by content experts and medical education researchers. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data collection stopped once thematic saturation was reached. The study was conducted at Queen's University, Kingston, Ontario. We recruited 20 participants from 5 Canadian provinces (17 female participants and 3 male participants). RESULTS: Six themes were identified: (1) characteristics of effective health care, (2) experiences with virtual care, (3) modality preferences, (4) involvement of others, (5) risks associated with virtual care encounters, and (6) vulnerable populations. Participants reported that high-quality health care included building relationships and treating patients holistically. In general, participants described positive experiences with virtual care during the pandemic, including greater efficiency, increased accessibility, and that virtual care was less stressful and more patient centered. Participants comparing virtual care with in-person care reported that time, scheduling, and content of interactions were similar across modalities. However, participants also shared the perception that certain modalities were more appropriate for specific clinical encounters (eg, prescription renewals and follow-up appointments). Perspectives related to the involvement of family members and medical trainees were positive. Potential risks included miscommunication, privacy concerns, and inaccurate patient assessments. All participants agreed that stakeholders should be proactive in applying strategies to support vulnerable patients. Participants also recommended education for patients and providers to improve virtual care delivery. CONCLUSIONS: Participant-reported experiences of virtual care encounters were relatively positive. Future work could focus on delivering training and resources for providers and patients. While initial experiences are positive, there is a need for ongoing stakeholder engagement and evaluation to improve patient and caregiver experiences with virtual care.

Exploring the Determinants and Experiences of Senior Stroke Patients with Virtual Care.

OBJECTIVE: The study sought to explore the experiences of participants affected by stroke with home video visit (HVV) for follow-up visits in order to understand the determinants, barriers, and benefits associated with HVVs. METHODS: Semi-structured interviews were conducted with (n = 23) participants to gather insight and descriptive information about patients' experiences with HVV. Specifically, we sought to collect descriptions about the (1) costs and time associated with in-person visits, (2) facilitators and barriers to in-person and virtual visits, and (3) their values attached to traditional and virtual forms of patient care. RESULTS: HVVs were perceived to be a mode of healthcare that is time-saving and convenient for both participants and physicians. However, our study also found some participants felt uncomfortable using technology to conduct medical visits while others still supported a positive view of traditional forms of in-person visits because they valued the in-person interactions and safe environment of the hospital. CONCLUSION: While HVVs were considered to be useful in addressing geographical barriers to health care, technological and digital health literacy may serve to impede seniors from using the service, with some of them opting to go to the hospital despite geographical barriers. Resultantly, HVVs may serve both to alleviate and exacerbate certain determinants to health care.

An Observational Study of a Digital Substance Use and Recovery Program.

OBJECTIVE: Digital substance use treatment programs present an opportunity to provide nonresidential care for people with problematic substance use. In June 2021, the provincial government in Ontario provided free access to Breaking Free Online (BFO), a digital behavioral change program for people with substance use disorders. METHODS: An observational study was conducted with retrospective data to characterize clients' use and engagement patterns in BFO and examine changes in self-reported outcomes. RESULTS: In total, 6,370 individuals registered for BFO between June 2021 and October 2022, of whom 3,650 completed the intake assessment. Most of these clients were self-referred (64%), with 37% having been referred by health service providers. More than one-half of the clients (52%) resided in Ontario West or East regions. Support for addressing problematic alcohol use was the most requested program (40%). By October 2022, about 44% of the clients had completed between one and four of 12 program strategies. Analysis revealed significant changes in pre-post scores across four validated scales (p<0.001), indicating a decrease in anxiety and depression, an increase in quality of life, an improvement in recovery progression, and a decrease in severity of symptoms associated with substance use disorders. CONCLUSIONS: BFO clients with higher completion rates had the most improvement across the scales used; however, clients with lower and medium completion rates also had improvements. Because of the shame and stigma associated with substance use, digital supports with low barriers to entry can help support the autonomy, privacy, and preferences of individuals seeking help for problematic substance use.

Patient and Therapist Perceptions of a Publicly Funded Internet-Based Cognitive Behavioral Therapy (iCBT) Program for Ontario Adults During the COVID-19 Pandemic: Qualitative Study.

BACKGROUND: To address the anticipated rise in mental health symptoms experienced at the population level during the COVID-19 pandemic, the Ontario government provided 2 therapist-assisted internet-delivered cognitive behavioral therapy (iCBT) programs to adults free of charge at the point of service. OBJECTIVE: The study aims to explore the facilitators of and barriers to implementing iCBT at the population level in Ontario, Canada, from the perspective of patients and therapists to better understand how therapist-assisted iCBT programs can be effectively implemented at the population level and inform strategies for enhancing service delivery and integration into the health care system. METHODS: Using a convenience sampling methodology, semistructured interviews were conducted with 10 therapists who delivered iCBT and 20 patients who received iCBT through either of the publicly funded programs to explore their perspectives of the program. Interview data were analyzed using inductive thematic analysis to generate themes. RESULTS: Six salient themes were identified. Facilitators included the therapist-assisted nature of the program; the ease of registration and the lack of cost; and the feasibility of completing the psychoeducational modules given the online and self-paced nature of the program. Barriers included challenges with the online remote modality for developing the therapeutic alliance; the program's generalized nature, which limited customization to individual needs; and a lack of formal integration between the iCBT program and the health care system. CONCLUSIONS: Although the program was generally well-received by patients and therapists due to its accessibility and feasibility, the digital format of the program presented both benefits and unique challenges. Strategies for improving the quality of service delivery include opportunities for synchronous communication between therapists and patients, options for increased customization, and the formal integration of iCBT into a broader stepped-care model that centralizes patient referrals between care providers and promotes continuity of care.

Efficacy of an Electronic Cognitive Behavioral Therapy Program Delivered via the Online Psychotherapy Tool for Depression and Anxiety Related to the COVID-19 Pandemic: Pre-Post Pilot Study.

BACKGROUND: Lockdowns and social distancing resulting from the COVID-19 pandemic have worsened the population's mental health and made it more difficult for individuals to receive care. Electronic cognitive behavioral therapy (e-CBT) is a cost-effective and evidence-based treatment for anxiety and depression and can be accessed remotely. OBJECTIVE: The objective of the study was to investigate the efficacy of online psychotherapy tailored to depression and anxiety symptoms during the pandemic. METHODS: The pilot study used a pre-post design to evaluate the efficacy of a 9-week e-CBT program designed for individuals with depression and anxiety affected by the pandemic. Participants were adults (N=59) diagnosed with major depressive disorder and generalized anxiety disorder, whose mental health symptoms initiated or worsened during the COVID-19 pandemic. The online psychotherapy program focused on teaching coping, mindfulness, and problem-solving skills. Symptoms of anxiety and depression, resilience, and quality of life were assessed. RESULTS: Participants demonstrated significant improvements in symptoms of anxiety (P=.02) and depression (P=.03) after the intervention. Similar trends were observed in the intention-to-treat analysis. No significant differences were observed in resilience and quality-of-life measures. The sample comprised mostly females, making it challenging to discern the benefits of the intervention in males. Although a pre-post design is less rigorous than a controlled trial, this design was selected to observe changes in scores during a critical period. CONCLUSIONS: e-CBT for COVID-19 is an effective and accessible treatment option. Improvements in clinical symptoms of anxiety and depression can be observed in individuals whose mental health is affected by the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/study/NCT04476667. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/24913.

A qualitative study of predelivery counselling for extreme prematurity.

OBJECTIVE: To ascertain from parents of neonates born before 27 weeks' gestational age how to improve predelivery counselling for delivery room resuscitation. METHODS: Qualitative ethnographic study using semistructured, face-to-face interviews of 10 families. Data were analyzed using a constant comparative method. RESULTS: Parents had no previous knowledge about prematurity. They would have preferred prioritized information during predelivery counselling focused on the immediate risks to their child. Resuscitation wishes were inconsistently sought. Opportunities for repeat discussions involving both parents were often missed. Parents agreed that the opportunity to explicitly state resuscitation wishes should be offered. Additional materials, such as pamphlets or videos, would improve counselling. CONCLUSIONS: Information about prematurity should be offered when the pregnancy is deemed high risk, with repeat counselling opportunities for both parents to discuss options. Once the decision is made to resuscitate, parents want the neonatal team to convey a message of hope and compassion.

OBJECTIF: Vérifier auprès des parents de nouveau-nés venus au monde avant 27 semaines d'âge gestationnel comment améliorer les conseils prodigués avant l'accouchement au sujet de la réanimation en salle d'accouchement. MÉTHODOLOGIE: Étude ethnographique qualitative faisant appel à des entrevues semi-structurées menées directement auprès de dix familles. Les chercheurs ont analysé les données au moyen d'une méthode comparative constante. RÉSULTATS: Les parents ne connaissaient rien de la prématurité. Dans le cadre des conseils prodigués avant l'accouchement au sujet de leur enfant, ils auraient aimé que l'information axée sur les risques immédiats soit priorisée. On ne leur a pas toujours demandé s'ils souhaitaient que leur enfant soit réanimé. On ratait souvent des occasions de reprendre les discussions auprès des deux parents. Les parents s'entendaient pour affirmer qu'il faudrait leur permettre d'exprimer de manière explicite leurs désirs en matière de réanimation. De la documentation supplémentaire, telle que des dépliants ou des vidéos, amélioreraient les conseils. CONCLUSIONS: Il faudrait fournir de l'information au sujet de la prématurité lorsque la grossesse est considérée comme à haut risque et saisir les occasions de répéter les conseils pour que les deux parents puissent discuter des possibilités qui s'offrent à eux. Lorsqu'ils prennent la décision de réanimer le bébé, les parents veulent que l'équipe néonatale transmette un message d'espoir et de compassion.

Patient and caregiver perspectives on virtual care: a patient-oriented qualitative study.

BACKGROUND: Since the onset of the COVID-19 pandemic, virtual care solutions have been rapidly adopted across the country to provide safe, quality care to diverse patient populations. The objective of this qualitative case study was to understand patient and caregiver experiences of virtual care to identify barriers and gather suggestions to address them. METHODS: In this patient-oriented project, we sought to understand gaps in virtual care experienced by patients and caregivers, using virtual focus groups. With the assistance of a patient research liaison, we engaged 2 patient partners as full partners; they participated in study conception, data collection, data analysis and knowledge translation. Recruitment was done through email by disseminating the study poster to 30 community organizations and health units in Ontario and British Columbia. We conducted a constructivist, qualitative study guided by grounded theory methodology. One researcher employed in-vivo coding, followed by axial coding with focus group participants, followed by selective coding with the study team. The study took place from November to December 2020. RESULTS: We conducted 6 focus groups with 13 patients and 5 caregivers. The analysis resulted in 6 major themes and 17 minor themes. Key findings showed that barriers related to access to technology and Internet, language and cultural differences were challenges to virtual care. Participants identified special considerations surrounding caregiver and family involvement; privacy, consent and confidentiality; and the patient-physician relationship. Participants suggested that technology and the Internet be universally accessible and that virtual care modalities be integrated (e.g., consolidated patient portal) to improve virtual care. INTERPRETATION: There are multiple patient-identified barriers to accessing virtual care in Canada; patients can provide insights into ways to address these barriers. Future research should include robust patient engagement to explore ways to address these challenges and barriers to ensure that virtual care can be equitable, accessible and safe for all users. PLAIN LANGUAGE SUMMARY: Although virtual care has been rapidly adopted and scaled up in health care institutions across the country, few improvements informed by patient and caregiver experiences have been made. Driven by concerns expressed by patient partners, our study team undertook a patient-partnered qualitative study to understand the barriers of virtual care from the perspectives and experiences of patients and caregivers. Our study team created the interview guide drawing from our previous patient-oriented qualitative studies and designed an orientation package to provide resources related to the focus groups and to introduce participants to the study team. Drawing from local health teams, clinics and patient advisory groups, the study team recruited 13 patients and 5 caregivers to participate in 6 focus group interviews. An analysis based on grounded theory was undertaken, with participation from both the study team and participants. Lack of access to technology or Internet and language barriers were determined to be the primary challenges in virtual care. Special considerations to caregiver and family involvement, privacy and confidentiality, as well as the patient-physician relationship were considered priorities to improving access to virtual care. Participants offered recommendations and potential solutions to address barriers and challenges in virtual care, which can serve to encourage large-scale policy and programmatic changes in patient-centred ways.

Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study.

INTRODUCTION: People with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI? METHODS AND ANALYSIS: We will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting. ETHICS AND DISSEMINATION: This study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.

Development and pilot testing of the collaborative practice assessment tool.

Collaborative practice is receiving increased attention as a model of healthcare delivery that positively influences the effectiveness and efficiency of patient care while improving the work environment of healthcare providers. The collaborative practice assessment tool (CPAT) was developed from the literature to enable interprofessional teams to assess their collaborative practice. The CPAT survey included 56 items across nine domains including: mission and goals; relationships; leadership; role responsibilities and autonomy; communication; decision-making and conflict management; community linkages and coordination; perceived effectiveness and patient involvement; in addition to three open-ended questions. The tool was developed for use in a variety of settings involving a diversity of healthcare providers with the aim of helping teams to identify professional development needs and corresponding educational interventions. The results of two pilot tests indicated that the CPAT is a valid and reliable tool for assessing levels of collaborative practice within teams. This article describes the development of the tool, the pilot testing and validation process, as well as limitations of the tool.

Using the Online Psychotherapy Tool to Address Mental Health Problems in the Context of the COVID-19 Pandemic: Protocol for an Electronically Delivered Cognitive Behavioral Therapy Program.

BACKGROUND: The considerable rise of mental health challenges during the COVID-19 pandemic has had detrimental effects on the public health sector and economy. To meet the overwhelming and growing demand for mental health care, innovative approaches must be employed to significantly expand mental health care delivery capacity. Although it is not feasible to increase the number of mental health care providers or hours they work in the short term, improving their time efficiency may be a viable solution. Virtually and digitally delivering psychotherapy, which has been shown to be efficient and clinically effective, might be a good method for addressing this growing demand. OBJECTIVE: This research protocol aims to evaluate the feasibility and efficacy of using an online, digital, asynchronous care model to treat mental health issues that are started or aggravated by stressors associated with the COVID-19 pandemic. METHODS: This nonrandomized controlled trial intervention will be delivered through the Online Psychotherapy Tool, a secure, cloud-based, digital mental health platform. Participants will be offered a 9-week electronically delivered cognitive behavioral therapy program that is tailored to address mental health problems in the context of the COVID-19 pandemic. This program will involve weekly self-guided educational material that provides an overview of behavioral skills and weekly homework. Participants (N=80) will receive personalized feedback from and weekly interaction with a therapist throughout the course of the program. The efficacy of the program will be evaluated using clinically validated symptomology questionnaires, which are to be completed by participants at baseline, week 5, and posttreatment. Inclusion criteria includes the capacity to consent; a primary diagnosis of generalized anxiety disorder or major depressive disorder, with symptoms that started or worsened during the COVID-19 pandemic; the ability to speak and read English; and consistent and reliable access to the internet. Exclusion criteria includes active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation. RESULTS: This study received funding in May 2020. Ethics approval was received in June 2020. The recruitment of participants began in June 2020. Participant recruitment is being conducted via social media, web-based communities, and physician referrals. To date, 58 participants have been recruited (intervention group: n=35; control group: n=23). Data collection is expected to conclude by the end of 2020. Analyses (ie, linear regression analysis for continuous outcomes and binomial regression analysis for categorical outcomes) are expected to be completed by February 2021. CONCLUSIONS: If proven feasible, this care delivery method could increase care capacity by up to fourfold. The findings from this study can potentially influence clinical practices and policies and increase accessibility to care during the COVID-19 pandemic, without sacrificing the quality of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/ct2/show/NCT04476667. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24913.

A new inter-professional course preparing learners for life in rural communities.

The 'Professionals in Rural Practice' course was developed with the aim of preparing students enrolled in professional programs in Canada to become better equipped for the possible eventuality of professional work in a rural setting. To match the reality of living and working in a rural community, which by nature is interprofessional, the course designers were an interprofessional teaching team. In order to promote group cohesiveness the course included the participation of an interprofessional group of students and instructors from the disciplines of medicine, nursing, occupational therapy, physical therapy, teacher education, and theology. The format of the course included three-hour classes over an eight-week period and a two-day field experience in a rural community. The course utilized various experiential and interactive teaching and learning methods, along with a variety of assessment methods. Data were collected from student participants over two iterations of the course using a mixed methods approach. Results demonstrate that students value the interprofessional and experiential approach to learning and viewed this course as indispensable for gaining knowledge of other professions and preparation for rural practice. The data reveal important organizational and pedagogical considerations specific to interprofessional education, community based action research, and the unique interprofessional nature of training for life and work in a rural community. This study also indicates the potential value of further longitudinal study of participants in this course. Key words: Canada, community based action research, education, interdisciplinary, interprofessional.

Developing empathy as a foundation of client-centred practice: evaluation of a university curriculum initiative.

BACKGROUND: The foundation of client-centred practice is the therapist's capacity to view the world through the client's eyes and to develop an understanding of the lived experience of disability. PURPOSE: This paper describes the evaluation of an educational initiative promoting student empathy to the lived experience of disability. METHODS: Pairs of first-year occupational therapy students visited adults with disabilities who shared their knowledge and experience of living with a disability. Students reflected on their visits in journals, which were later analyzed using pattern matching. FINDINGS: Students appeared to appreciate the co-existence of health and disorder and demonstrated a holistic understanding of living with a disability. Little attention was focused on cultural and institutional environments. Students struggled to define the nature of their relationship with their tutors. Practice Implications. The evaluation confirmed our belief that this educational initiative could facilitate student empathy, consistent with critical features of client-centred practice.

Clinical education in private practice: an interdisciplinary project.

Education of rehabilitation professionals traditionally has occurred in acute care hospitals, rehabilitation centres, and other publicly funded institutions, but increasing numbers of rehabilitation professionals are now working in the community in private agencies and clinics. These privately owned clinics and community agencies represent underutilized resources for the clinical training of students. Historically, private practitioners have been less likely to participate in clinical education because of concerns over patient satisfaction and quality of care, workload, costs, and liability. Through a program funded by the Ministry of Health of Ontario, we conducted a series of interviews and focus groups with private practitioners, which identified that several incentives could potentially increase the numbers of clinical placements in private practices, including participation in the development of student learning objectives related to private practice, professional recognition, and improved relationships with the university departments. Placement in private practices can afford students skills in administration, business management, marketing and promotion, resource development, research, consulting, networking, and medical-legal assessments and processes. This paper presents a discussion of clinical education issues from the perspective of private practitioners, based on the findings of a clinical education project undertaken at Queen's University, Kingston, Ontario, and previous literature.