Towards developing an intervention to support periodic health checks for adults with intellectual and developmental disabilities: Striving for health equity.

BACKGROUND: Although the Canadian Consensus Guidelines for Primary Care of Adults with Intellectual and Developmental Disabilities recommends conducting periodic health checks in primary care, uptake is lacking. This study seeks to understand factors influencing the conduct of periodic health checks and identify what needs to change to increase them. METHOD: Qualitative data from five stakeholder groups (adults with intellectual and developmental disabilities, primary care providers, administrative staff, family, disability support workers) was guided by the Behaviour Change Wheel and the Theoretical Domains Framework to identify barriers and 'what needs to change' to support periodic health checks. RESULTS: Stakeholders (n = 41) voiced multiple barriers. A total of 31 common and 2 unique themes were identified plus 33 items 'needing to change'. CONCLUSION: Despite barriers, stakeholders saw merit in periodic health checks as a preventative and equitable healthcare offering for adults with intellectual and developmental disabilities. Results will inform future intervention development steps.

Clinical approach to driving and the older person.

BACKGROUND: Austroads has recently introduced a new set of guidelines for driving assessment in Australia. It is therefore timely to review the clinical approach to driving assessments, which is often seen as one of the most difficult areas of general practice. OBJECTIVE: This article reviews the difficulties of driving assessment, including what measures there are to guide general practitioners (GPs), and proposes a practical approach to this issue for general practice. DISCUSSION: There is as yet no widely agreed toolkit for office-based driving assessment in general practice. On-road assessment by a trained assessor, such as an occupational therapist, remains the gold standard. GPs should consider a stepped approach to driving cessation by raising this issue well in advance of the need for licence termination, working with the patient and the family through the driving cessation itself and providing follow-up support for the patient afterwards.

Driving assessments for older adult patients: Interviews with general practitioners to gauge current strategies and future directions.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) in New South Wales are required to perform annual medical assessments of driving fitness in patients aged 75 years or older. The objective of this study was to understand GPs' attitudes towards driving assessments and to highlight guideline limitations and possible solutions. METHOD: Semi-structured interviews with a sample of 10 GPs were audio-recorded, transcribed and thematically analysed. RESULTS: The key themes that emerged were challenges GPs face with the current driving fitness assessment, techniques used to overcome these challenges, and the process of negotiating with patients. DISCUSSION: The findings highlighted the need for further support of GPs and for more statistical evidence of driving risks. Key areas of uncertainty were applying licence restrictions, calculating the sum of effects of comorbidities and assessment of new patients. This study might prompt consideration of a range of supports to assist GP decision making, as well as contribute to a decision aid for older drivers.

Utilization of health services among adults with autism spectrum disorders: Stakeholders' experiences.

BACKGROUND: Autism spectrum disorder (ASD) is a lifelong disorder, beginning in early childhood, which often accompanies with several healthcare challenges. There is a need for consistent and continued healthcare services throughout the life of an individual with ASD. The majority of previous studies have examined healthcare services in children with ASD and there is limited evidence about healthcare needs of adults with ASD. OBJECTIVE: The aim of this project was to capture the experiences of stakeholders including adults with ASD in receiving healthcare services. METHOD: We interviewed 22 stakeholders, including adults with ASD (n = 13), parents of adults with ASD (n = 5), and service providers (n = 4). Open-ended questions were used to explore their experiences with the healthcare system. We analysed the data thematically to develop the overarching themes. RESULTS: Three themes emerged from interviews including a) availability and accessibility of healthcare services, b) provision of quality healthcare and service delivery, and c) striving for better health outcomes. CONCLUSION: This study found that many adults with ASD can experience a continued lack of access to services and the care they receive is often of limited quality. The unmet healthcare needs lead stakeholders to feel stress, frustration, exhaustion, and possible burnout. The detrimental cost of limited services not only impacts adults with ASD but also their caregivers.

Health check guidelines and billing for family physicians caring for adults with intellectual and developmental disabilities: Incentives to improve care.

OBJECTIVE: To examine the degree to which Canadian consensus guideline recommendations for annual comprehensive preventive care assessments of adults with intellectual and developmental disabilities (IDD) are being taken up by Nova Scotia family physicians since the introduction of incentive billing codes; and to discuss the importance of complete physical examinations for this patient population, extra time needed in clinic encounters, and challenges for practitioners providing care. DESIGN: Analysis of family physicians' billing of codes 03.04C and 03.03E from April 2012 to December 2016. SETTING: Nova Scotia. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Number of billings through fee-for-service and alternative payment plans, and number of providers who used these fee codes. RESULTS: Analysis yielded 3 key results. Use of incentivized billing codes for adult IDD visits and complete examinations in Nova Scotia has steadily increased for patients since the introduction of the modified codes. There is measurable uptake of the IDD adult visit code in total numbers and numbers of providers billing the code. There is poor uptake of the complete examination code. CONCLUSION: Enhanced billing codes will provide Nova Scotia family physicians with an incentive to employ the newly revised 2018 Canadian consensus guidelines in the care of adults with IDDs. With continued discussion and promotion of annual physical examinations for patients with IDD, more patients and caregivers might make this proactive care item a priority.

Mobile memory clinic: implementing a nurse practitioner-led, collaborative dementia model of care within general practice.

The limited capacity of secondary health services to address the increasing prevalence of dementia within the community draws attention to the need for an enhanced role for nurses working collaboratively with GPs in diagnosing and coordinating post-diagnostic care for patients with dementia. This study investigated the feasibility and acceptability of a nurse practitioner-led mobile memory clinic that was embedded within general practice and targeted to caring for patients and their carers in areas of socioeconomic disadvantage with poor access to specialist health services. Over the period from mid-2013 to mid-2014, 40 GPs referred 102 patients, with the nurse practitioner conducting assessments with 77 of these patients in their homes. Overall, there was a strong interest in this model of care by general practice staff, with the assessment and care provided by the nurse practitioner evaluated as highly acceptable by both patients and their carers. Nonetheless, there are financial and structural impediments to this model of care being implemented within the current Australian health service framework, necessitating further research investigating its cost-effectiveness and efficacy.

Workplace stress and resilience in the Australian nursing workforce: A comprehensive integrative review.

This integrative review aimed to identify and synthesize evidence on workplace stress and resilience in the Australian nursing workforce. A search of the published literature was conducted using EMBASE, MEDLINE, CINAHL (EBSCO), PsycINFO, Web of Science, and Scopus. The search was limited to papers published in English from January 2008 to December 2018. The review integrated both qualitative and quantitative data into a single synthesis. Of the 41 papers that met the inclusion criteria, 65.85% (27/41) used quantitative data, 29.26% (12/41) used qualitative data, and 4.87% (2/41) used mixed methods. About 48.78% (20/41) of the papers addressed resilience issues, 46.34% (19/41) addressed workplace stress, and 4.87% (2/41) addressed both workplace stress and resilience. The synthesis indicated that nurses experience moderate to high levels of stress. Several individual attributes and organizational resources are employed by nurses to manage workplace adversity. The individual attributes include the use of work-life balance and organizing work as a mindful strategy, as well as self-reliance, passion and interest, positive thinking, and emotional intelligence as self-efficacy mechanisms. The organizational resources used to build resilience are support services (both formal and informal), leadership, and role modelling. The empirical studies on resilience largely address individual attributes and organizational resources used to build resilience, with relatively few studies focusing on workplace interventions. Our review recommends that research attention be devoted to educational interventions to achieve sustainable improvements in the mental health and wellbeing of nurses.

A study of macro-, meso- and micro-barriers and enablers affecting extended scopes of practice: the case of rural nurse practitioners in Australia.

BACKGROUND: Shortages of skills needed to deliver optimal health care in rural and remote locations raises questions about using extended scopes of practice or advanced practice models in a range of health professions. The nurse practitioner (NP) model was introduced to address health service gaps; however, its sustainability has been questioned, while other extended scope of practice roles have not progressed in Australia. This study aimed to explore the experiences and perceptions of NPs and their colleagues about barriers to and enablers of extended scope of practice and consider the relevance of the findings to other health professions. METHODS: Semi-structured, in-depth interviews were conducted with primary, nurse practitioner informants, who were also invited to nominate up to two colleagues, as secondary informants. Data analysis was guided by a multi-level, socio-institutional lens of macro-, meso- and micro-perspectives. RESULTS: Fifteen primary informants and five colleagues were interviewed from various rural and remote locations. There was a fairly even distribution of informants across primary, aged, chronic and emergency or critical care roles. Key barriers and enablers at each level of analysis were identified. At the macro-level were legal, regulatory, and economic barriers and enablers, as well as job availability. The meso-level concerned local health service and community factors, such as attitudes and support from managers and patients. The micro-level relates to day-to-day practice. Role clarity was of considerable importance, along with embedded professional hierarchies and traditional role expectations influencing interactions with individual colleagues. Given a lack of understanding of NP scope of practice, NPs often had to expend effort promoting and advocating for their roles. CONCLUSIONS: For communities to benefit from extended scope of practice models of health service delivery, energy needs to be directed towards addressing legislative and regulatory barriers. To be successful, extended scope of practice roles must be promoted with managers and decision-makers, who may have limited understanding of the clinical importance. Support is also important from other members of the interprofessional health care team.

The student experience of clinical supervision across health disciplines - Perspectives and remedies to enhance clinical placement.

Effective clinical practice supervision for health students is essential prior to commencing their respective professions. Students require adequate preparation before their clinical practice event with an experienced clinical supervisor able to impart professional 'know how' and skills to students. The purpose of this study was to describe final year health students' perspectives and experiences of clinical supervision, and to develop an interprofessional model of clinical supervision. Focus groups and semi-structured interviews were conducted with undergraduate health students across a range of disciplines. Some students provided email comments. Qualitative data was analysed thematically using NVivo (V11). Six key themes and their various sub-themes (refer Table 1) were identified: (1) undergraduate learning valued by the CP provider; (2) effective connections (communications) between student, CS, CP provider and university; (3) undergraduate student learning not being valued; (4) ineffective connections; (5) mitigating factors for students; and (6) the impact of increasing student numbers. Undergraduate health student clinical placement requires careful educational preparation, structuring and adequate support for both the student undergoing the practice event and for the clinical supervisor stewarding the undergraduate health professional. A prospective plan to ensure an excellent experience is required (Fig. 1).

Men's Preconception Health: A Primary Health-Care Viewpoint.

The purpose of this article is to theoretically explore men's preconception health as a mechanism to enhance fertility, as well as the health and well-being of the subject and his descendants. Premorbid risk factors and behaviors associated with stress, environmental toxins, excessive alcohol consumption, smoking, lack of exercise/obesity, and the use of illicit drugs are all known to affect fecundity. While there are many health clinics available to women, where advice in areas such as postnatal care of the newborn, family planning, and couples fertility is provided, there are few, if any, equivalent health clinics available to men. Additionally, getting men to attend primary health-care services has also been continuously problematic, even in the context of there being a clearly discernible need for treatment. It is argued in this article that an impetus is required to encourage men to focus on and improve their preconception health and to utilize primary health-care services to take action. An assertive men's preconception health outlook can positively influence the conjugal relationship, fathering, male self-esteem, and continued good health. Using the sometimes complex concept of preconception health as a motivating factor for healthy lifestyle adaptation has the potential to improve male fertility outcomes and general health and well-being, as well as the health of future generations.

Primary care of adults with intellectual and developmental disabilities: 2018 Canadian consensus guidelines.

OBJECTIVE: To update the 2011 Canadian guidelines for primary care of adults with intellectual and developmental disabilities (IDD). METHODS: Family physicians and other health professionals experienced in the care of people with IDD reviewed and synthesized recent empirical, ecosystem, expert, and experiential knowledge. A system was developed to grade the strength of recommendations. RECOMMENDATIONS: Adults with IDD are a heterogeneous group of patients and have health conditions and factors affecting their health that can vary in kind, manifestation, severity, or complexity from those of others in the community. They require approaches to care and interventions that are adapted to their needs. These guidelines provide advice regarding standards of care. References to clinical tools and other practical resources are incorporated. The approaches to care that are outlined here can be applied to other groups of patients that have impairments in cognitive, communicative, or other adaptive functioning. CONCLUSION: As primary care providers, family physicians play a vital role in promoting the health and well-being of adults with IDD. These guidelines can aid their decision making with patients and caregivers.

Soins primaires aux adultes ayant des déficiences intellectuelles et développementales: Lignes directrices consensuelles canadiennes de 2018.

OBJECTIF: Mettre à jour les Lignes directrices consensuelles canadiennes 2011 en matière de soins primaires aux adultes ayant une déficience développementale. MÉTHODES: Des médecins de famille et d'autres professionnels de la santé expérimentés dans les soins aux personnes ayant des DID ont examiné et synthétisé les récentes connaissances empiriques, d'écosystèmes, expertes et expérientielles. Un système a été conçu pour catégoriser la qualité des recommandations. RECOMMANDATIONS: Les adultes ayant des DID sont un groupe hétérogène de patients qui présentent des affections médicales et des facteurs qui influent sur leur santé, qui diffèrent de ceux qui touchent les autres membres de la communauté de par leur nature, leurs manifestations, leur gravité ou leur complexité. Ces personnes nécessitent une approche de soins et des interventions adaptées à leurs besoins. Les présentes lignes directrices offrent des conseils en matière de normes de soins. Nous avons incorporé des références à des outils cliniques et à d'autres ressources pratiques. Les approches de soins décrites ici s'appliquent aussi à d'autres groupes de patients ayant un déficit cognitif ou de la communication, ou d'autres déficits des fonctions adaptatives. CONCLUSION: À titre de fournisseurs de soins de première ligne, les médecins de famille jouent un rôle vital de promotion de la santé et de bien-être auprès des adultes ayant des DID. Ces lignes directrices peuvent les aider à prendre des décisions avec les patients et les aidants naturels.

HELP for behaviours that challenge in adults with intellectual and developmental disabilities.

OBJECTIVE: To provide primary care physicians with an understanding of the causes of behaviours that challenge (BTC) in adults with intellectual and developmental disabilities (IDD), as presented in the 2018 Canadian consensus guidelines for primary care of adults with IDD; to offer a systematic approach to the assessment and treatment of such behaviours; and to link to tools to support these assessments. SOURCES OF INFORMATION: This review elaborates upon guidelines 26 to 29 in the mental health section of the 2018 Canadian consensus guidelines. Several of the authors participated in the development of these guidelines, which were based on literature searches and interdisciplinary input. MAIN MESSAGE: Most adults with IDD are followed by primary care providers but they comprise a small proportion of primary care practices. Unique ways of communicating needs, diagnostic queries, and BTC are common in this population. This complexity can lead to missed diagnoses and inappropriate antipsychotic medication use with attendant risks. This article presents a systematic approach, HELP, to the assessment and treatment of factors of Health, Environment, Lived experience, and Psychiatric conditions that can lead to BTC and includes tools to support these assessments. CONCLUSION: A structured approach to the assessment and treatment of BTC in adults with IDD helps family physicians provide guideline-directed, individualized care to this population. This includes a systematic evaluation using the HELP framework that takes place over multiple visits. A team of health professionals might be needed for optimal care, but these resources are not routinely available across Canada.

Circles of care for people with intellectual and developmental disabilities: Communication, collaboration, and coordination.

OBJECTIVE: To review health information exchange (HIE) processes that affect the health of people with intellectual and developmental disabilities (IDD) and to suggest practical tips and strategies for communicating, collaborating, and coordinating in the primary care setting. SOURCES OF INFORMATION: The "Primary care of adults with intellectual and developmental disabilities. 2018 Canadian consensus guidelines" literature review and interdisciplinary input. MAIN MESSAGE: Disparities exist between the provision of health care for the general population and that for people with IDD. These disparities are due in part to gaps in HIE. Health information exchange involves documenting, collecting, and disseminating a patient's health information. In exploring ways to improve HIE for people with IDD, the communication skills of the family physician are considered in the context of the triad that includes the patient, his or her caregivers, and the family physician. The framework of the Patient's Medical Home is used in exploring these processes, and various strategies are offered for communicating, collaborating, and coordinating health care that can be implemented by family physicians in order to narrow the gaps in care that exist for people with IDD. CONCLUSION: Improvements in HIE by communicating, collaborating, and coordinating health care better will improve health outcomes for people with IDD.

New Fathers' Perinatal Depression and Anxiety-Treatment Options: An Integrative Review.

More than 10% of fathers experience depression and anxiety during the perinatal period, but paternal perinatal depression (PPND) and anxiety have received less attention than maternal perinatal mental health problems. Few mainstream treatment options are available for men with PPND and anxiety. The aim of this literature review was to summarize the current understanding of PPND and the treatment programs specifically designed for fathers with perinatal depression. Eight electronic databases were searched using a predefined strategy, and reference lists were also hand searched. PPND and anxiety were identified to have a negative impact on family relationships, as well as the health of mothers and children. Evidence suggests a lack of support and tailored treatment options for men having trouble adjusting to the transition to fatherhood. Of the limited options available, cognitive behavioral therapy, group work, and blended delivery programs, including e-support approaches appear to be most effective in helping fathers with perinatal depression and anxiety. The review findings have important implications for the understanding of PPND and anxiety. Future research is needed to address the adoption of father-inclusive and father-specific models of care to encourage fathers' help-seeking behavior. Inclusion of male-specific requirements into support and treatment options can improve the ability of services to engage new fathers. Psychotherapeutic intervention could assist to address the cognitive differences and dissonance for men adjusting to the role of father, including male identity and role expectations.

The paradoxical effects of workforce shortages on rural interprofessional practice.

RATIONALE AND AIM: While interprofessional practice has been promoted as a solution to the challenges besetting rural health services, current evidence does not offer a clear explanation as to why it is effective in some domains and yet is not successful in others. At the same time, rural clinicians are frequently faced with major workforce pressures and this has a significant influence on professional practice. The aim of this study was to explore how these pressures impact on rural interprofessional practice. METHOD: This study is part of a larger project investigating factors that enhance and detract from effective interprofessional working. We utilised a modified realistic evaluation approach to analyse the context, mechanisms and outcomes of rural interprofessional practice. Approval for this study was granted by an accredited research ethics committee. Semi-structured interviews were conducted with 22 rural clinicians who were purposively recruited from a range of settings, roles, locations and professions. FINDINGS AND DISCUSSION: We found that clinicians often invested in interprofessional practice because of the need to manage intense workloads and this necessitated sharing of responsibilities across disciplines and blurring of role boundaries. Paradoxically, participants noted that workload pressures hampered interprofessional working if there were long-term skill shortages. Sharing workload and responsibility is an important motivator for rural practitioners to engage in interprofessional practice; however, this driver is only effective under circumstances where there are sufficient resources to facilitate collaboration. In the context of intransient resource challenges, rural health service managers would be best to focus on enabling IPP through facilitating role understanding and respect between clinicians. This is most feasible via informal workplace learning and allowing time for teams to reflect on collaborative processes.

Implementing oral care practices and policy into long-term care: the Brushing up on Mouth Care project.

BACKGROUND: Optimal mouth care is integral to the health and quality of life of dependent older adults.Yet, a persistent lack of adequate oral care in long-term care (LTC) facilities exacerbates the burden of disease experienced by residents. The reasons for this are complex and create enormous challenges for care providers, clinicians, and administrators dedicated to comprehensive high quality care. OBJECTIVE: The aim of this study was to develop, implement, and evaluate a comprehensive program for daily mouth care for LTC. DESIGN: A case study design using a participatory and qualitative approach examined how individual, organizational (workplace practices and culture), and system factors (standards and policy) influenced the development and implementation of a comprehensive program to improve the delivery of daily oral care in LTC. SETTING AND PARTICIPANTS: The research was undertaken in 3 LTC residences administered under the same health authority and included personal care providers, nurse managers, and directors of care. INTERVENTION: A comprehensive program for care providers including, education, resources, and organizational guidelines, to improve the delivery of daily mouth care to LTC residents was created, rolled out, and refined over a 12-month period. MEASUREMENTS: Data was collected through diary studies, targeted interviews, field notes, oral care activities records, site team meetings, and direct feedback from members of the care team. RESULTS: The oral care intervention resulted in a heightened awareness, support and greater efficiency amongst care team. The presence of a "champion" was a key feature for sustaining processes. Management had a clear role to play to ensure support and accountability for the intervention. CONCLUSIONS: Optimizing oral care in long-term care can be achieved through an integrated approach that includes education, provision of resources, an oral care champion, support from managers and administrators, and appropriate organizational policy.

Adoption issues associated with a new periodontal screening tool: an online survey of Canadian dentists.

OBJECTIVE: To determine barriers and facilitators associated with the acceptance of a new diagnostic screening tool for periodontitis. METHODS: As part of a larger study to examine factors that affect the adoption of new technology by dentists, we piloted an online survey of Canadian dentists through an electronic newsletter produced by the Journal of the Canadian Dental Association. A new oral rinse that screens for the presence of periodontitis by estimating neutrophil abundance in saliva was used for illustrative purposes. The survey included questions about the types of patients for which the test would be beneficial, how the test might be incorporated into practice and how much the dentist would be willing to pay for the test. RESULTS: As the survey was delivered through a new communication tool, the response rate was low. Nonetheless there appeared to be interest in new periodontal screening tools to complement existing diagnostic tests for periodontitis. The test was seen as a valuable educational tool for patients; however, the cost to administer the test was determined to be an issue. CONCLUSIONS: Despite the low response rate, dentists were interested in new screening tests for periodontitis. A larger study with a more representative sample could provide valuable information for scientists who are interested in taking their research from the bench to chairside.