WHO, WHEN, HOW: a scoping review on flexible at-home respite for informal caregivers of older adults.

BACKGROUND: As the world population is aging, considerable efforts need to be put towards developing and maintaining evidenced-based care for older adults. Respite services are part of the selection of homecare offered to informal caregivers. Although current best practices around respite are rooted in person centeredness, there is no integrated synthesis of its flexible components. Such a synthesis could offer a better understanding of key characteristics of flexible respite and, as such, support its implementation and use. METHODS: To map the literature around the characteristics of flexible at-home respite for informal caregivers of older adults, a scoping study was conducted. Qualitative data from the review was analyzed using content analysis. The characterization of flexible at-home respite was built on three dimensions: WHO, WHEN and HOW. To triangulate the scoping results, an online questionnaire was distributed to homecare providers and informal caregivers of older adults. RESULTS: A total of 42 documents were included in the review. The questionnaire was completed by 105 participants. The results summarize the characteristics of flexible at-home respite found in the literature. Flexibility in respite can be understood through three dimensions: (1) WHO is tendering it, (2) WHEN it is tendered and (3) HOW it is tendered. Firstly, human resources (WHO) must be compatible with the homecare sector as well as being trained and qualified to offer respite to informal caregivers of older adults. Secondly, flexible respite includes considerations of time, duration, frequency, and predictability (WHEN). Lastly, flexible at-home respite exhibits approachability, appropriateness, affordability, availability, and acceptability (HOW). Overall, flexible at-home respite adjusts to the needs of the informal caregiver and care recipient in terms of WHO, WHEN, and HOW. CONCLUSION: This review is a step towards a more precise definition of flexible at-home respite. Flexibility of homecare, in particular respite, must be considered when designing, implementing and evaluating services.

Tensions experienced by case managers working in home care for older adults in Quebec: first level analysis of an institutional ethnography.

BACKGROUND: Case managers play a vital role in integrating the necessary services to optimise health-related goals and outcomes. Studies suggest that in home care, case managers encounter tensions in their day-to-day work, that is, disjuncture between what they should do, in theory, and what they actually do, in practice. However, direct exploration of these tensions is lacking. As such, this study aimed to describe the tensions encountered by case managers in public home care for older adults in Quebec and their influence on day-to-day work. METHODS: An institutional ethnography was conducted through observations of work, interviews and a survey with case managers working in home care in Quebec. Data were analysed using institutional ethnography first-level analysis procedures. This included mapping the work sequences as well as identifying the tensions experienced by case managers through the words they used. RESULTS: Three main tensions were identified. First, case managers perceive that, despite working to return hospitalised older adults at home safely, their work also aims to help free up hospital beds. Thus, they often find themselves needing to respond quickly to hospital-related inquiries or expedite requests for home care services. Second, they are supposed to delegate the care to "partners" (e.g., private organisations). However, they feel that they are in effect managing the quality of the services provided by the "partners." Consequently, they go to great lengths to ensure that good care will be provided. Finally, they must choose between meeting organisational requirements (e.g., reporting statistics about the work, documenting information in the older adults' file, doing mandatory assessments) and spending time providing direct care. This often leads to prioritising direct care provision over administrative tasks, resulting in minimal reporting of essential information. CONCLUSION: The results are discussed using the three lenses of professional practice context analyses (i.e., accountability, ethics, and professional-as-worker) to formulate recommendations for practice and research. They suggest that, despite their important role, case managers have limited power in home care (e.g., with partners, with the hospital).

Fear of Reprisal and Change Agency in the Public Health and Social Service System: Protocol for a Sequential Mixed Methods Study.

BACKGROUND:  Since they are key witnesses to the systemic difficulties and social inequities experienced by vulnerable patients, health and social service (HSS) professionals and clinical managers must act as change agents. Using their expertise to achieve greater social justice, change agents employ a wide range of actions that span a continuum from the clinical (microsystem) to the societal (macrosystem) sphere and involve actors inside and outside the HSS system. Typically, however, clinical professionals and managers act in a circumscribed manner, that is, within the clinical sphere and with patients and colleagues. Among the hypotheses explaining this reduced scope of action is the fear of reprisal. Little is known about the prevalence of this fear and its complex dynamics. OBJECTIVE:  The overall aim is to gain a better understanding of the complex dynamic process leading to clinical professionals' and managers' fear of reprisal in their change agent actions and senior administrators' and managers' determination of wrongdoing. The objectives are (1) to estimate the prevalence of fear of reprisal among clinical professionals and managers; (2) to identify the factors involved in (a) the emergence of this fear among clinical professionals and managers, and (b) the determination of wrongdoing by senior administrators and managers; (3) to describe the process of emergence of (a) the fear of reprisal among clinical professionals and managers, and (b) the determination of wrongdoing by senior administrators and managers; and (4) to document the legal and ethical issues associated with the factors identified (objective 2) and the processes described (objective 3). METHODS:  Based on the Exit, Voice, Loyalty, Neglect model, a 3-part sequential mixed methods design will include (1) a web-based survey (objective 1), (2) a qualitative grounded theory design (objectives 2 and 3), and (3) legal and ethical analysis (objective 4). Survey: 77,794 clinical professionals or clinical managers working in the Québec public HSS system will be contacted via email. Data will be analyzed using descriptive statistics. Grounded theory design: for each of the 3 types of participants (clinical professionals, clinical managers, and senior administrators and managers), a theoretical sample of 15 to 30 people will be selected via various strategies. Data will be independently analyzed using constant comparison process. Legal and ethical analysis: situations described by participants will be analyzed using, respectively, applicable legislation and jurisprudence and 2 ethical models. RESULTS:  This ongoing study began in June 2022 and is scheduled for completion by March 2027. CONCLUSIONS:  Instead of acting, fear of reprisal could induce clinical professionals to tolerate situations that run counter to their social justice values. To ensure they use their capacities for serving a population that is or could become vulnerable, it is important to know the prevalence of the fear of reprisal and gain a better understanding of its complex dynamics. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/48400.

"What Services?": Stakeholders' Perceived Unmet Support Needs for Parents With Neurological Disorders.

Background. Knowledge about the needs of parents with neurological disorders who take care of young children is limited. Purpose. The overall aim of this qualitative study was to explore the perceived unmet parent needs, current supports, and potential solutions to optimize supports of parents with neurological disorders in early childhood in a Canadian setting. Method. Focus groups and individual interviews with parents (n = 8), spouses (n = 5), rehabilitation clinicians (n = 8), community partners (n = 7), and researchers (n = 7) were conducted with a total of 35 participants recruited using convenience sampling. Inductive iterative thematic analysis was performed. Findings. The participants identified the need for society to officially recognize parenting with disabilities, adjust public policies, increase the scope of public programs, consider child development and family well-being, and have barrier-free communities. Conclusion. Providing customized solutions that will adequately fill perceived service gaps is of utmost importance to address these families' needs.

Which interventions with youths counter ageism toward older adults? Results from a realist review.

Age-related social biases - ageism - are developed at an early age. Interventions to counter ageism have been identified but little is known about their mechanisms, particularly in children. This study aimed to provide a comprehensive understanding of which interventions in youths are most effective, under which circumstances, how, and with what outcomes. Using 46 keywords in 6 databases, a realist review identified 24 studies published between 2000 and 2022 targeting youths under 18. A content analysis of these studies led to the construction of a Context-Mechanisms-Outcomes explanatory model. Contextual facilitators triggering mechanisms for changing stereotypes, prejudices and discrimination were: 1) enhancing knowledge about aging and older adults by providing nuanced information, 2) improving the quality of intergenerational contacts, 3) increasing opportunities to apply previously acquired knowledge in intergenerational interactions, and 4) promoting reflective thinking about experiences with older adults. However, stereotypes and prejudices appeared to be resistant and changes difficult to generalize. Insufficiently advanced cognitive development in children or viewing healthy and socially engaged older adults as unrepresentative of their age group were obstacles that reduced intervention effectiveness. Future studies should explore how advancing age influences interventions as well as the characteristics of older adults involved.

Occupational Therapy Practice in Palliative and End-of-Life Care in Québec.

Background. There is an emerging evidence base about the scope of occupational therapy in palliative and end-of-life care, but little is known about this practice in Québec or barriers impeding it. Purpose. To describe Québec occupational therapists' practice in palliative and end-of-life care and barriers they encounter. Method. Using the Québec regulatory board members list, we invited occupational therapists working in palliative and end-of-life care to answer an online survey comprising 24 closed- and 5 open-ended questions. We analyzed data using descriptive statistics and content analysis. Findings. The 67 survey participants mainly optimized comfort and safety in meaningful occupations such as mobility, transfers, and hygiene. Barriers to their practice included organizational obstacles and unfamiliarity with their role. Implications. Findings highlight the need to improve education and awareness among occupational therapists and other healthcare professionals about the scope of what occupational therapists can do in palliative and end-of-life care.

A realist review of the home care literature and its blind spots.

RATIONALE, AIMS AND OBJECTIVES: There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature. METHOD: We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analysed according to a realist review approach. RESULTS: A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable. At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models' effectiveness. CONCLUSION: We conclude by providing advice for supporting the design and implementation of stronger home care delivery systems. Our analysis suggests that doing so implies a series of sequential steps: identify what system-level goals the model should achieve and which populations it should serve; identify what type of services are likely to achieve those goals in order to establish a basket of services; and finally, identify the best ways and specific means to effectively and efficiently provide those services. Those same steps can also support ex-post evaluations of existing home care systems.

A Scoping Review of the Implementation of Local Health and Social Services for Older Adults.

BACKGROUND: Implementing elder-dedicated local health and social services (LHSS) is primary for older Canadian adults to age in place. However, there is currently no synthesis of the factors (barriers and facilitators) involved in LHSS implementation. OBJECTIVE: This study aimed to synthesize current knowledge about the institutional factors involved in elder-dedicated LHSS implementation by describing them and their influence. METHODS: A scoping review was conducted using eight databases and the grey literature. Data were analyzed thematically. RESULTS: A total of 23 documents led to the identification of 15 inter-influencing factors (12 barriers and 11 facilitators). Indeed, 20 connections were noted among factors, mostly among barriers. DISCUSSION AND IMPLICATION: Although some barriers and facilitators also affect the implementation of services dedicated to the general population in Canada, the interplay between agism and power issues needs to be taken into consideration for a successful elder-dedicated LHSS implementation.

Occupational Therapists as Social Change Agents: Exploring Factors that Influence Their Actions.

BACKGROUND.: When acting effectively in their social change agent (SCA) role, occupational therapists can impact population health and occupational justice. However, empirical evidence of the influence of personal and environmental factors on their ability to act as SCAs is scarce. PURPOSE.: To explore personal and environmental factors that influence the ability of occupational therapists to act as effective SCAs. METHOD.: We conducted a descriptive interpretive qualitative study with 18 Québec occupational therapists recognized as successful SCAs. We collected data through semi-structured interviews with three focus groups and analyzed them thematically using a lexicon. FINDINGS.: We identified nine cross-cutting personal factors, including discovery, effective communication, and planning, that enable occupational therapists to act as successful SCAs. Six thematic groups of environmental factors facilitated or hindered their actions. IMPLICATIONS.: To act effectively as SCAs, occupational therapists need to consider personal and environmental factors involved in their change project.

Acting as Change Agents: Insight Into Québec Occupational Therapists' Current Practice: Actions menées à titre d'agents de changement : aperçu des pratiques actuelles parmi les ergothérapeutes du Québec.

BACKGROUND.: Change agents' actions have been studied mainly from a theoretical perspective. PURPOSE.: This study aimed to empirically identify occupational therapists' actual change agent actions. METHOD.: As part of a research partnership with the Canadian Association of Occupational Therapists-Québec chapter, we conducted this cross-sectional pilot study using an online survey. FINDINGS.: The change agent practices of our 103 participants involve many types of actions but show underinvestment in mass communication. Mass communication actions are more frequent when participants have greater experience, additional academic degrees, and training in change agency. Also, occupational therapists with additional academic degrees and change agency training tend to use a wider variety of actions. Finally, our participants' actions principally target actors in the clinical context, rarely political actors. IMPLICATIONS.: Our results suggest that occupational therapists can and will invest in the full range of change agent actions provided they can acquire the necessary knowledge and skills.

Levers for Change and Unexpected Outcomes of a Participatory Research Partnership: Toward Fostering Older adults' Social Participation to Promote Health Equity.

Promoting health equity in aging requires ensuring older adults' effective access to community-based services fostering their social participation. This study aimed to (a) identify levers for change in community-based services to foster older adults' social participation and (b) explore unexpected outcomes of stakeholder engagement. Based in a large Canadian city, a critical participatory research partnership was formed in a district experiencing considerable health disparities. Four focus groups and seven individual interviews were followed by a collaborative workshop with 28 community stakeholders. Participants identified mainly systemic and organizational levers for change. These levers comprised changing performance indicators and the institutional culture of homecare to value services fostering social participation opportunities. Other levers included supporting individual change agency through participatory research involving community members. Stakeholder engagement led to five unexpected outcomes: "Marking a new beginning," "Expressing ourselves," "Feeling better," "Working together," and "Influencing the community." Recognizing levers for change is essential to understand how to develop services fostering social participation to promote health equity, with whom and in which contexts.

Institutional context: What elements shape how community occupational therapists think about their clients' care?

Clinical reasoning (CR) is the cognitive process that therapists use to plan, direct, perform and reflect on client care. Linked to intervention efficiency and quality, CR is a core competency that occurs within an institutional context (legal, regulatory, administrative and organisational elements). Because this context can shape how community therapists think about their clients' care, its involvement in their CR could have a major impact on the interventions delivered. However, little is known about this involvement. Our study thus aimed to describe the elements of the institutional context involved in community therapists' CR. From March 2012 to June 2014, we conducted an institutional ethnography (IE) inquiry in three Health and Social Services Centres in Québec (Canada). We observed participants and conducted semi-structured interviews with 10 occupational therapists. We also interviewed 12 secondary key informants (colleagues and managers) and collected administrative documents (n = 50). We analysed data using the IE process. Of the 13 elements of the institutional context identified, we found that four are almost constantly involved in participants' CR. These four elements, that is, institutional procedures, organisation's basket of services, occupational therapists' mandate and wait times for their services, restrictively shape CR. Specifically, occupational therapists restrict their representation of the client's situation and exploration of potential solutions to what is possible within the bounds of these four elements. In light of such restrictions on the way they think about their clients' care, therapists should pay close attention to the elements of their own institutional context and how they are involved in their CR. Because of its potentially important impact on the future of professions (e.g. further restrictions on professionals' role, reduced contribution to population health and well-being), this involvement of the institutional context in CR concerns all professionals, be they clinicians, educators, researchers or regulatory college officers.

[Overview of the assessment practices of occupational therapists working in Quebec]. / Portrait des pratiques évaluatives des ergothérapeutes œuvrant au Québec.

BACKGROUND.: In occupational therapy practice, client assessments are essential for establishing treatment priorities and determining the effectiveness of interventions. However, occupational therapists' assessment practices are not well documented. PURPOSE.: This work aimed to provide an overview of the assessment practices of Quebec occupational therapists based on the person-environment-occupation components and clienteles. METHOD.: A cross-sectional survey was conducted using an online survey that was sent to occupational therapists in Quebec. FINDINGS.: In paediatrics, occupational therapists tend to use standardized tools to assess physical and neurological abilities. Adult assessment focuses mainly on physical abilities and productivity. For seniors, assessment focuses mainly on functional aspects (physical abilities, personal care, and home safety) and screening for cognitive difficulties. IMPLICATIONS.: Occupational therapy assessment mostly focuses on physicial abilities. To ensure a holistic approach, more occupational and environmental components should be included in the assessment practices.

DESCRIPTION.: L'évaluation du client est primordiale dans la pratique de l'ergothérapie, notamment pour établir les priorités de traitement et pour vérifier l'efficacité des interventions. Les pratiques évaluatives des ergothérapeutes sont cependant peu documentées. BUT.: Dresser un portrait des pratiques évaluatives des ergothérapeutes du Québec selon les dimensions personne-environnement-occupation et les clientèles. MÉTHODOLOGIE.: Une enquête transversale a été réalisée à l'aide d'un sondage en ligne envoyé aux ergothérapeutes du Québec. RÉSULTATS.: En pédiatrie, les ergothérapeutes utilisent majoritairement des outils standardisés des aptitudes physiques et neurologiques. L'évaluation d'adultes cible principalement les aptitudes physiques et la productivité. Auprès des aînés, l'évaluation repose surtout sur les aspects fonctionnels, particulièrement les aptitudes physiques, les soins personnels et la sécurité à domicile, et sur le dépistage des difficultés cognitives. IMPLICATIONS POUR LA PRATIQUE.: L'évaluation ergothérapique serait généralement axée sur les aptitudes physiques. Pour assurer une approche holistique, l'occupation et l'environnement devraient être davantage considérés dans l'évaluation.

Community-based participatory research remodelling occupational therapy to foster older adults' social participation.

BACKGROUND.: Occupational therapists who provide community-based services are well positioned to foster older adults' social participation. However, community occupational therapists rarely address social participation and require support to change their practice. PURPOSE.: This study initiated a remodelling of community occupational therapy services by (a) selecting practices fostering older adults' social participation and (b) identifying factors that could affect their integration. METHOD.: A community-based participatory research study was conducted in a large Canadian city. Four focus group meetings and seven individual interviews were held with 28 key informants. FINDINGS.: A continuum of emerging practices was identified, including personalized, group-based, and community-based interventions. Potential enablers of these practices included clinical support, better communication, and user involvement. Organizational and systemic barriers were related to the institutional culture and performance indicators. IMPLICATIONS.: These results point to innovative ways to foster older adults' social participation and identify potential enablers and barriers affecting their integration.

Social change agent training program tailored to occupational therapists' needs: a design-based study protocol.

BACKGROUND: As social change agents (SCAs), occupational therapists (OTs) are expected to defend the rights of their clients, advocate for and with them, and try to influence organizational and political decision-makers. However, OTs do not generally feel equipped to take effective action. The overall goal of this research partnership is to support practising OTs in acquiring the knowledge and skills required to act as SCAs through a specific SCA training program and a toolkit that summarizes the key training points. METHODS: The study will include three iterative phases (conceptualization, implementation and evaluation) and use a participatory process. The design of the training program and toolkit will draw on the expertise of the researchers (theoretical knowledge), a professional provincial partner and study participants (experiential knowledge). To evaluate the training program and toolkit, a self-administered evaluation questionnaire, facilitator observation grid and semi-structured guide designed to facilitate focus group discussions will be used. The quantitative and qualitative data will be analyzed using descriptive statistics and thematic analysis, respectively. The results of the initial implementation and evaluation phases will inform improvement of the training program and toolkit before starting the cycle with the following groups. DISCUSSION: In addition to training about 100 OTs, this study will produce three main benefits: 1) development of two products, namely the SCA training program and toolkit, that are easy to reuse and potentially transferable to other professionals; 2) ownership of these products by the partner through its close involvement in all stages of the study; and 3) development of a sustainable partnership between a team of researchers and a recognized organization with networks across Canada and internationally. These three spin-offs will provide a solid basis for an increasing number of permanent implementation initiatives, in Québec and elsewhere in Canada, not just in occupational therapy but also in other professions.

Structural analysis of health-relevant policy-making information exchange networks in Canada.

BACKGROUND: Health systems worldwide struggle to identify, adopt, and implement in a timely and system-wide manner the best-evidence-informed-policy-level practices. Yet, there is still only limited evidence about individual and institutional best practices for fostering the use of scientific evidence in policy-making processes The present project is the first national-level attempt to (1) map and structurally analyze-quantitatively-health-relevant policy-making networks that connect evidence production, synthesis, interpretation, and use; (2) qualitatively investigate the interaction patterns of a subsample of actors with high centrality metrics within these networks to develop an in-depth understanding of evidence circulation processes; and (3) combine these findings in order to assess a policy network's "absorptive capacity" regarding scientific evidence and integrate them into a conceptually sound and empirically grounded framework. METHODS: The project is divided into two research components. The first component is based on quantitative analysis of ties (relationships) that link nodes (participants) in a network. Network data will be collected through a multi-step snowball sampling strategy. Data will be analyzed structurally using social network mapping and analysis methods. The second component is based on qualitative interviews with a subsample of the Web survey participants having central, bridging, or atypical positions in the network. Interviews will focus on the process through which evidence circulates and enters practice. Results from both components will then be integrated through an assessment of the network's and subnetwork's effectiveness in identifying, capturing, interpreting, sharing, reframing, and recodifying scientific evidence in policy-making processes. DISCUSSION: Knowledge developed from this project has the potential both to strengthen the scientific understanding of how policy-level knowledge transfer and exchange functions and to provide significantly improved advice on how to ensure evidence plays a more prominent role in public policies.

How to Find Lessons from the Public Health Literature: Example of a Scoping Study Protocol on the Neighborhood Environment.

BACKGROUND: As key determinants of many favorable health and quality of life outcomes, it is important to identify factors associated with mobility and social participation. Although several investigations have been carried out on mobility, social participation and neighborhood environment, there is no clear integration of these results. This paper presents a scoping study protocol that aims to provide a comprehensive understanding of how the physical and social neighborhood environment is associated with or influences mobility and social participation in older adults. METHODS: The rigorous methodological framework for scoping studies is used to synthesize and disseminate current knowledge on the associations or influence of the neighborhood environment on mobility and social participation in aging. Nine databases from public health and other fields are searched with 51 predetermined keywords. Using content analysis, all data are exhaustively analyzed, organized, and synthesized independently by two research assistants. DISCUSSION: A comprehensive synthesis of empirical studies provides decision-makers, clinicians and researchers with current knowledge and best practices regarding neighborhood environments with a view to enhancing mobility and social participation. Such a synthesis represents an original contribution and can ultimately support decisions and development of innovative interventions and clear guidelines for the creation of age-supportive environments. Improvements in public health and clinical interventions might be the new innovation needed to foster health and quality of life for aging population. Finally, the aspects of the associations or influence of the neighborhood environment on mobility and social participation not covered by previous research are identified. CONCLUSIONS: Among factors that impact mobility and social participation, the neighborhood environment is important since interventions targeting it may have a greater impact on an individual's mobility and social participation than those targeting individual factors. Although investigations from various domains have been carried out on this topic, no clear integration of these results is available yet.

[Impact of accountability and performance optimization on the choice of occupational therapy interventions]. / Reddition de compte et optimisation de la performance : impacts sur le choix des interventions ergothérapiques.

The restricted range of OT interventions is incompatible with their holistic and patient-centred profession. Accountability and optimization may compromise the quality of their services, the scope of services offered, including prevention and health promotion activities, and, consequently, the achievement of the healthcare system objectives..

Participation needs of older adults having disabilities and receiving home care: met needs mainly concern daily activities, while unmet needs mostly involve social activities.

BACKGROUND: Participation is a key determinant of successful aging and enables older adults to stay in their homes and be integrated into the community. Assessing participation needs involves identifying restrictions in the accomplishment of daily and social activities. Although meeting participation needs involves older adults, their caregivers and healthcare providers, little is known about their respective viewpoints. This study thus explored the participation needs of older adults having disabilities as perceived by the older adults themselves, their caregivers and healthcare providers. METHODS: A qualitative multiple case study consisted of conducting 33 semi-structured interviews in eleven triads, each composed of an older adult, his/her caregiver and a healthcare provider recruited in a Health and Social Services Centre (HSSC) in Québec, Canada. Interview transcripts and reviews of clinical records were analyzed using content analysis and descriptive statistics based on thematic saliency analysis methods. RESULTS: Aged 66 to 88 years, five older adults had physical disabilities, five had mild cognitive impairment and one had psychological problems, leading to moderate to severe functional decline. Caregivers and healthcare providers were mainly women, respectively retired spouses and various professionals with four to 32 years of clinical experience. Participation needs reported by each triad included all domains of participation. Needs related to daily activities, such as personal care, nutrition, and housing, were generally met. Regarding social activities, few needs were met by various resources in the community and were generally limited to personal responsibilities, including making decisions and managing budgets, and some community life activities, such as going shopping. Unmet needs were mainly related to social activities, involving leisure, other community life activities and interpersonal relationships, and some daily activities, including fitness and mobility. CONCLUSIONS: This study highlights the complexity of older adults' participation needs, involving daily as well as social activities. Properly assessing and addressing these needs is thus necessary to improve older adults' health and well-being. Discrepancies in the various actors' perceptions of participation needs must be further explored. Additional research would help better understand how to optimize the contribution of community organizations and caregivers.

Standardized referral form: Restricting client-centered practice?

BACKGROUND: To increase homecare efficiency, the Ministry of Health and Social Services in Québec, Canada, encourages standardization of practices, including those of community occupational therapists (COTs). The impact of standardization is not known and might reduce client-centeredness. Aim/objectives. To explore the content and use of a referral form to standardize COTs' practice. MATERIAL/METHODS: An institutional ethnography inquiry was conducted through observations of work and interviews with 10 COTs working in three homecare programs. Secondary informants were also interviewed and documents collected. Data were analyzed using institutional ethnography procedures. FINDINGS: The referral form, completed by the COTs' colleagues, includes categories primarily related to safety or autonomy in personal care and mobility. The form organizes COTs' work, including information collection and interactions with clients and caregivers. Seen as consultants, COTs assess needs and make recommendations to keep clients at home safely for as long as possible, an important element of the homecare discourse. CONCLUSION/SIGNIFICANCE: The impact on COTs' potential to be truly client-centered revealed by these findings merits serious consideration by other health professionals. Concerted efforts by professionals to question and act upon contextual barriers to client-centeredness are needed.