User-Centered Design and Evaluation of a Web-Based Decision Aid for Older Adults Living With Mild Cognitive Impairment and Their Health Care Providers: Mixed Methods Study.

BACKGROUND: Mild cognitive impairment (MCI) is often considered a transitional state between normal and pathologic (eg, dementia) cognitive aging. Although its prognosis varies largely, the diagnosis carries the risk of causing uncertainty and overtreatment of older adults with MCI who may never progress to dementia. Decision aids help people become better informed and more involved in decision making by providing evidence-based information about options and possible outcomes and by assisting them in clarifying their personal values in relation to the decision to be made. OBJECTIVE: This study aimed to incorporate features that best support values clarification and adjust the level of detail of a web-based decision aid for individuals with MCI. METHODS: We conducted a rapid review to identify options to maintain or improve cognitive functions in individuals with MCI. The evidence was structured into a novel web-based decision aid designed in collaboration with digital specialists and graphic designers. Qualitative and user-centered evaluations were used to draw on users' knowledge, clarify values, and inform potential adoption in routine clinical practice. We invited clinicians, older adults with MCI, and their caregivers to evaluate the decision aid in 6 consecutive rounds, with new participants in each round. Quantitative data were collected using the Values Clarity and Informed subscales of the Decisional Conflict Scale, the System Usability Scale, the Ottawa Acceptability questionnaire, and a 5-point satisfaction rating scale. We verified their comprehension using a teach-back method and recorded usability issues. We recorded the audio and computer screen during the session. An inductive thematic qualitative analysis approach was used to identify and describe the issues that arose. After each round, an expert panel met to prioritize and find solutions to mitigate the issues. An integrated analysis was conducted to confirm our choices. RESULTS: A total of 7 clinicians (social workers, nurses, family physicians, psychologists) and 12 older (≥60 years) community-dwelling individuals with MCI, half of them women, with education levels going from none to university diploma, were recruited and completed testing. The thematic analysis revealed 3 major issues. First, the user should be guided through the decision-making process by tailoring the presentation of options to users' priorities using the values clarification exercise. Second, its content should be simple, but not simplistic, notably by using information layering, plain language, and pictograms. Third, the interface should be intuitive and user friendly, utilize pop-up windows and information tips, avoid drop-down menus, and limit the need to scroll down. The quantitative assessments corroborated the qualitative findings. CONCLUSIONS: This project resulted in a promising web-based decision aid that can support decision making for MCI intervention, based on the personal values and preferences of the users. Further ongoing research will allow its implementation to be tested in clinical settings.

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact.

BACKGROUND AND AIM: Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness. METHOD: A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis. RESULTS: Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions. CONCLUSION: Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level.

Key stakeholders' views on the quality of care and services available to frail seniors in Canada.

BACKGROUND: Frail seniors often receive ineffective care, which does not meet their needs. It is still unclear how healthcare systems should be redesigned to be more sensitive to the needs and values of frail seniors and their caregivers. We thus aimed to describe key stakeholders' perspectives on the current healthcare and services available to frail seniors. METHODS: In this qualitative descriptive study, we conducted semi-structured interviews with a convenience sample of 42 frail seniors, caregivers, clinicians, or healthcare administrators/decision makers involved in frail senior care from five Canadian provinces. We explored participants' perspectives on the quality of care and services for frail seniors. We used an inductive/deductive thematic data analysis approach based on the Square-of-Care model, including emerging themes using the constant comparison method. RESULTS: We grouped participants' perspectives into strengths, weaknesses and opportunities for improvement, and then into nine themes: care processes, continuity of care, social frailty, access to healthcare and services, models of healthcare delivery, cost of care, healthcare staff management and professional development of healthcare providers, material resources and environmental design of healthcare facilities, and coordination of care. Our findings suggest redesigning assessment, communication with frail seniors and their caregivers, targeting care and services to the needs, and integrating care better across settings and in time. CONCLUSIONS: A systematic identification of frail older people is the first step to adapt healthcare systems to this population's needs. Participation of frail older people and their caregivers to decision making would also allow choosing care plans meeting their care goals. The integration of care and services across settings, over time, and with various providers, is also needed to meet frail senior needs.

Success Strategies for Linguistically Competent Healthcare: The Magic Bullets and Cautionary Tales of the Active Offer of French-Language Health Services in Ontario.

An active offer of French-language health services (FLHS) was introduced in several Canadian provinces to help create an environment that will anticipate the needs of Francophones in their community and will stimulate the demand for services in French. For the active offer to be implemented, changes in how health services are organized and managed at both organizational and system levels must be introduced. In this perspective paper, we identify several success strategies and potential pitfalls with regards to the implementation of the active offer of FLHS primarily at the level of healthcare organization. Our recommendations are based on a recent health services research study exploring reorganization and management strategies for the delivery of the active offer of FLHS in Ontario and insights from a focus group with healthcare administrators conducted as part of this research. We propose a ";wrap-around strategy" called organizational health literacy to help reorient organizational culture and improve management and sustainability of the active offer of FLHS. These strategies have relevance for advocates and professionals working to promote an active offer of FLHS, including healthcare administrators, human resource professionals, quality-improvement specialists and others.

Organizational Health Literacy: Review of Theories, Frameworks, Guides, and Implementation Issues.

Organizational health literacy is described as an organization-wide effort to transform organization and delivery of care and services to make it easier for people to navigate, understand, and use information and services to take care of their health. Several health literacy guides have been developed to assist healthcare organizations with this effort, but their content has not been systematically reviewed to understand the scope and practical implications of this transformation. The objective of this study was to review (1) theories and frameworks that inform the concept of organizational health literacy, (2) the attributes of organizational health literacy as described in the guides, (3) the evidence for the effectiveness of the guides, and (4) the barriers and facilitators to implementing organizational health literacy. Drawing on a metanarrative review method, 48 publications were reviewed, of which 15 dealt with the theories and operational frameworks, 20 presented health literacy guides, and 13 addressed guided implementation of organizational health literacy. Seven theories and 9 operational frameworks have been identified. Six health literacy dimensions and 9 quality-improvement characteristics were reviewed for each health literacy guide. Evidence about the effectiveness of health literacy guides is limited at this time, but experiences with the guides were positive. Thirteen key barriers (conceived also as facilitators) were identified. Further development of organizational health literacy requires a strong and a clear connection between its vision and operationalization as an implementation strategy to patient-centered care. For many organizations, becoming health literate will require multiple, simultaneous, and radical changes. Organizational health literacy has to make sense from clinical and financial perspectives in order for organizations to embark on such transformative journey.

Active offer of health services in French in Ontario: Analysis of reorganization and management strategies of health care organizations.

BACKGROUND: The availability of health services in French is not only weak but also inexistent in some regions in Canada. As a result, estimated 78% of more than a million of Francophones living in a minority situation in Canada experience difficulties accessing health care in French. To promote the delivery of health services in French, publicly funded organizations are encouraged to take measures to ensure that French-language services are clearly visible, available, easily accessible, and equivalent to the quality of services offered in English. OBJECTIVE: This study examines the reorganization and management strategies taken by health care organizations in Ontario that provide health services in French. METHODS: Review and analysis of designation plans of a sample of health care organizations. RESULTS: Few health care organizations providing services in French have concrete strategies to guarantee availability, visibility, and accessibility of French-language services. CONCLUSIONS: Implementation of the active offer of French-language services is likely to be difficult and slow. The Ontario government must strengthen collaboration with health care organizations, Francophone communities, and other key actors participating in the designation process to help health care organizations build capacities for the effective offer of French-language services.

Triple Aim in Canada: developing capacity to lead to better health, care and cost.

QUALITY PROBLEM: Many modern health systems strive for 'Triple Aim' (TA)-better health for populations, improved experience of care for patients and lower costs of the system, but note challenges in implementation. Outcomes of applying TA as a quality improvement framework (QI) have started to be realized with early lessons as to why some systems make progress while others do not. INITIAL ASSESSMENT: Limited evidence is available as to how organizations create the capacity and infrastructure required to design, implement, evaluate and sustain TA systems. CHOICE OF SOLUTION: To support embedding TA across Canada, the Canadian Foundation for Healthcare Improvement supported enrolment of nine Canadian teams to participate in the Institute for Healthcare Improvement's TA Improvement Community. IMPLEMENTATION: Structured support for TA design, implementation, evaluation and sustainability was addressed in a collaborative programme of webinars and action periods. Teams were coached to undertake and test small-scale improvements before attempting to scale. EVALUATION: A summative evaluation of the Canadian cohort was undertaken to assess site progress in building TA infrastructure across various healthcare settings. The evaluation explored the process of change, experiences and challenges and strategies for continuous QI. LESSONS LEARNED: Delivering TA requires a sustained and coordinated effort supported by strong leadership and governance, continuous QI, engaged interdisciplinary teams and partnering within and beyond the healthcare sector.

[The priorities for research on the health of Francophones in Ontario]. / Les priorités de recherche sur la santé des francophones en Ontario.

OBJECTIVES: Several studies have demonstrated the health inequity between Francophones in minority-language communities (FMLC) and their English counterparts. While Ontario has the largest number of FMLC in Canada, health research priorities for FMLC have not yet been determined in this province. This article aims to fill this gap. METHODS: An online 2-round Delphi consultation was conducted electronically with Francophone researchers, policy-makers, community members and health professionals working or living in Ontario. Themes and subthemes were identified based on the literature. In order to assess the differences in opinion between participants, a Kruskal-Wallis test was performed in the second round. RESULTS: There were 34 participants in the first round and 31 in the second round. The top three priorities that emerged were: health services in French, health human resources, and health services policy in French. Among the subthemes listed within these three priorities, education in French and planning services were ranked among the top three priorities in the four groups. CONCLUSION: The participatory approach used in this study relied on the opinion of all stakeholders. The results obtained can inform future research agenda and inform the development of health policies for the provision of health services in French with a higher probability of responding adequately to the needs of Francophone users.

Pilot testing of a questionnaire for the evaluation of mental health services in family health team clinics in Ontario.

Family health teams (FHTs), regarded today as a premier model of provision of primary care services in North America, were introduced in 2004 to improve traditionally fragmented primary healthcare in Ontario. Physicians and healthcare providers from various disciplines team up under the same roof in FHTs to provide and coordinate care and to ensure adequate access to and continuity of care. Because many Canadians with mental health problems consult family physicians in primary care, routine evaluation of the delivery of primary mental health care services in FHTs is becoming important. The authors' goal was to develop and test an evaluation tool (containing a questionnaire for patients and a questionnaire for providers) for mental health services provided in FHTs with a focus on accessibility, availability, quality, continuity of care and coordination of services. They developed and pilot tested an English-French tailored evaluation instrument in several FHTs in South East, Champlain and North East Local Health Integration Networks across Ontario. A convenience sample of English- and French-speaking healthcare providers and patients using mental health services was recruited. Provider and patient questionnaires were developed and pilot-tested with 12 providers and 10 clients. Patient reviewers rated the patient questionnaire consistently as "good" or "very good." Provider reviewers found the provider questionnaire to be important and timely and the questions to be adequate and interesting. This instrument evaluates, from both the patient and provider perspectives, whether mental health services are structured to meet expectations set for FHTs, and enables healthcare providers, administrators and policy makers to learn about the benefits and the deficiencies of mental health care delivered through these clinics. This instrument can also be used to enhance future research and evaluation of FHTs. Further validation effort will be required to establish its validity and reliability.