Understanding collaborative implementation between community and academic partners in a complex intervention: a qualitative descriptive study.

BACKGROUND: Community-academic partnerships (CAPs) can improve the relevance, sustainability, and uptake of new innovations within the community. However, little is known about what topics CAPs focus on and how their discussions and decisions impact implementation at ground level. The objectives of this study were to better understand the activities and learnings from implementation of a complex health intervention by a CAP at the planner/decision-maker level, and how that compared to experiences implementing the program at local sites. METHODS: The intervention, Health TAPESTRY, was implemented by a nine-partner CAP including academic, charitable organizations, and primary care practices. Meeting minutes were analyzed using qualitative description, latent content analysis, and a member check with key implementors. An open-answer survey about the best and worst elements of the program was completed by clients and health care providers and analyzed using thematic analysis. RESULTS: In total, 128 meeting minutes were analyzed, 278 providers and clients completed the survey, and six people participated in the member check. Prominent topics of discussion categories from the meeting minutes were: primary care sites, volunteer coordination, volunteer experience, internal and external connections, and sustainability and scalability. Clients liked that they learned new things and gained awareness of community programs, but did not like the volunteer visit length. Clinicians liked the regular interprofessional team meetings but found the program time-consuming. CONCLUSIONS: An important learning was about who had "voice" at the planner/decision-maker level: many of the topics discussed in meeting minutes were not identified as issues or lasting impacts by clients or providers; this may be due to differing roles and needs, but may also identify a gap. Overall, we identified three phases that could serve as a guide for other CAPs: Phase (1) recruitment, financial support, and data ownership; Phase (2) considerations for modifications and adaptations; Phase (3) active input and reflection.

Health TAPESTRY Ontario: A Multi-Site Randomized Controlled Trial Testing Implementation and Reproducibility.

PURPOSE: Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a complex primary care program aimed at assisting older adults to stay healthier for longer. This study evaluated the feasibility of implementation across multiple sites, and the reproducibility of the effects found in the previous randomized controlled trial. METHODS: This was a pragmatic, unblinded, 6-month parallel group randomized controlled trial. Participants were randomized (intervention or control) using a computer-generated system. Eligible patients, aged 70 years and older, were rostered to 1 of 6 participating interprofessional primary care practices (urban and rural). In total, 599 (301 intervention, 298 control) patients were recruited from March 2018 through August 2019. Intervention participants received a home visit from volunteers to collect information on physical and mental health, and social context. An interprofessional care team created and implemented a plan of care. The primary outcomes were physical activity and number of hospitalizations. RESULTS: Based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, Health TAPESTRY had widespread reach and adoption. In the intention-to-treat analysis (257 intervention, 255 control), there were no statistically significant between-group differences for hospitalizations (incidence rate ratio = 0.79; 95% CI, 0.48-1.30; P = .35) or total physical activity (mean difference = -0.26; 95% CI, -1.18 to 0.67; P = .58). There were 37 non-study related serious adverse events (19 intervention, 18 control). CONCLUSIONS: We found Health TAPESTRY was successfully implemented for patients in diverse primary care practices; however, implementation did not reproduce the effect on hospitalizations and physical activity found in the initial randomized controlled trial.

Lessons Learned Through Two Phases of Developing and Implementing a Technology Supporting Integrated Care: Case Study.

BACKGROUND: As health care becomes more fragmented, it is even more important to focus on the provision of integrated, coordinated care between health and social care systems. With the aging population, this coordination is even more vital. Information and communication technology (ICT) can support integrated care if the form of technology follows and supports functional integration. Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a program centered on the health of older adults, supported by volunteers, primary care teams, community engagement and connections, and an ICT known as the Health TAPESTRY application (TAP-App), a web-based application that supports volunteers in completing client surveys, volunteer coordinators in managing the volunteer program, and primary care teams in requesting and receiving information. OBJECTIVE: This paper describes the development, evolution, and implementation of the TAP-App ICT to share the lessons learned. METHODS: A case study was conducted with the TAP-App as the case and the perspectives of end users and stakeholders as the units of analysis. The data consisted of researchers' perspectives on the TAP-App from their own experiences, as well as feedback from other stakeholders and end user groups. Data were collected through written retrospective reflection with the program manager, a specific interview with the technology lead, key emailed questions to the TAP-App developer, and viewpoints and feedback during paper drafting from other research team members. There were 2 iterations of Health TAPESTRY and the TAP-App and we focused on learnings from the second implementation (2018-2020) which was a pragmatic implementation scale-up trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework at 6 primary care sites across Ontario, Canada. RESULTS: TAP-App (version 1.0), which was iteratively developed, was introduced as a tool to schedule volunteer and client visits and collect survey data using a tablet computer. TAP-App (version 2.0) was developed based on this initial experience and a desire for a program management tool that focused more on dual flow among users and provided better support for research. The themes of the lessons learned were as follows: iterative feedback is valuable; if ICT will be used for research, develop it with research in mind; prepare for challenges in the integration of ICT into the existing workflow; ask whether interoperability should be a goal; and know that technology cannot do it alone yet-the importance of human touch points. CONCLUSIONS: Health TAPESTRY is human-centered. The TAP-App does not replace these elements but rather helps enable them. Despite this shift in supporting integrated care, barriers remained to the uptake of the TAP-App that would have allowed a full flow of information between health and social settings in supporting patient care. This indicates the need for an ongoing focus on the human use of ICT in similar programs.

Community Volunteers and Primary Care Providers Supporting Older Adults in System Navigation: A Mixed Methods Study.

Introduction: Primary care providers and community volunteers have important roles in supporting patient system navigation and utilization of community-based health and social services (CBHSS). This study aimed to explore the experiences and impacts of system navigation in a complex intervention supporting older adults. Methods: We used a convergent mixed methods design. Participants included primary care team members (n = 67), community volunteers (n = 38), and programme clients (n = 128) across six communities in Ontario, Canada. Data sources included focus groups, interviews, system navigation function survey for volunteers, CBHSS use survey for clients, and implementation data on CBHSS recommended by providers and volunteers and used by clients. Results: Results showed the different patterns of how CBHSS categories were recommended and ultimately used. Exercise-related CBHSS were both recommended and used, independence-related CBHSS were mostly only recommended with less uptake, and chronic health condition and diet/nutrition CBHSS were most often used by clients. Discussion: Primary care teams' practice of system navigation was impacted by programme participation, including through learning about local CBHSS. However, volunteers felt more confident in tasks that did not include connecting to CBHSS. The programme did seem to result in many referrals, though the actual client uptake tended to be to more clinical rather than healthy lifestyle resources.

Understanding volunteer retention in a complex, community-centred intervention: A mixed methods study in Ontario, Canada.

Volunteers are critical to supporting health care systems worldwide. For organisations that rely on volunteers, service to clients can be disrupted when volunteers leave their roles. Volunteer retention is a multi-layered phenomenon. In this mixed methods case-control study, we compared two naturally-occurring volunteer groups supporting a complex primary care-based programme for older adults in the community: volunteers retained by the programme, and volunteers that left. Our objectives were to describe differences between the groups and also understand how compassion changed over time for those that stayed. We collected quantitative data on demographics, the UCLA Geriatric Attitudes Scale, the Professional Quality of Life Index, the Basic Empathy Scale, the Reasons for Volunteering subscale of the Volunteerism Questionnaire and the 5-level EQ-5D. Qualitative data were collected through focus groups/interviews. Overall, 78 volunteers completed surveys and 23 participated in focus groups/interviews. Volunteers that stayed were more likely to be a little older and were a slightly higher proportion male than those who left. They also had significantly less positive attitudes towards older adults, descriptively lower Cognitive Empathy and descriptively higher Secondary Traumatic Stress. Compared to volunteers who left, volunteers retained were more likely to have said they were volunteering for Enhancement or Social purposes; however, these differences were non-significant. Over time, Compassion Satisfaction decreased with a medium effect size for those that stayed, and Burnout decreased with a small effect size. Volunteers that stayed described more logistical and client-related aspects of the programme were working well. We recommend that volunteer programmes communicate positive programme impacts that could enhance volunteers' development, communicate any client impacts to volunteers to reinforce volunteers' purposes for volunteering (thus reinforcing that their work is meaningful), and ensure logistical aspects of volunteer role work well.

Understanding how context and culture in six communities can shape implementation of a complex intervention: a comparative case study.

BACKGROUND: Contextual factors can act as barriers or facilitators to scaling-up health care interventions, but there is limited understanding of how context and local culture can lead to differences in implementation of complex interventions with multiple stakeholder groups. This study aimed to explore and describe the nature of and differences between communities implementing Health TAPESTRY, a complex primary care intervention aiming to keep older adults healthier in their homes for longer, as it was scaled beyond its initial effectiveness trial. METHODS: We conducted a comparative case study with six communities in Ontario, Canada implementing Health TAPESTRY. We focused on differences between three key elements: interprofessional primary care teams, volunteer program coordination, and the client experience. Sources of data included semi-structured focus groups and interviews. Data were analyzed through the steps of thematic analysis. We then created matrices in NVivo by splitting the qualitative data by community and comparing across the key elements of the Health TAPESTRY intervention. RESULTS: Overall 135 people participated (39 clients, 8 clinical managers, 59 health providers, 6 volunteer coordinators, and 23 volunteers). The six communities had differences in size and composition of both their primary care practices and communities, and how the volunteer program and Health TAPESTRY were implemented. Distinctions between communities relating to the work of the interprofessional teams included characteristics of the huddle lead, involvement of physicians and the volunteer coordinator, and clarity of providers' role with Health TAPESTRY. Key differences between communities relating to volunteer program coordination included the relationship between the volunteers and primary care practices, volunteer coordinator characteristics, volunteer training, and connections with the community. Differences regarding the client experience between communities included differing approaches used in implementation, such as recruitment methods. CONCLUSIONS: Although all six communities had the same key program elements, implementation differed community-by-community. Key aspects that seemed to lead to differences across categories included the size and spread of communities, size of primary care practices, and linkages between program elements. We suggest future programs engaging stakeholders from the beginning and provide clear roles; target the most appropriate clients; and consider the size of communities and practices in implementation. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03397836 .

Impact of Integrated Care Pathways Within the Framework of Collaborative Care on Older Adults With Anxiety, Depression, or Mild Cognitive Impairment.

OBJECTIVES: To evaluate the impact of an Integrated Care Pathway (ICP) within a collaborative care framework for anxiety, depression and mild cognitive impairment (MCI) on clinical outcomes, quality of life, and time to treatment initiation. DESIGN: Prospective Cohort study. SETTING: Primary care practices in Toronto and Hamilton, Ontario, Canada. PARTICIPANTS: Patients of participating primary care practices born in the years 1950 to 1958. SAMPLE SIZE: Target 150 participants, 75 in ICP and 75 in Treatment-As-Usual (TAU) arm. INTERVENTION: ICP within a collaborative care framework and TAU. METHODS AND RESULTS: One hundred forty-five participants with anxiety, depression or MCI, from five primary care practices were enrolled: 69 were managed as per ICP and 76 as per TAU. All underwent outcome assessments at 6, 12, 18, and 24 months. Compared to TAU, ICP participants had a significantly higher rate of improvement in depression symptoms (ß = -0.620, F (1, 256) = 4.10, p = 0.044), anxiety symptoms (ß = -0.593, F (1, 223) = 4.00, p = 0.047), and quality of life (ß = 1.351, F(1, 358) = 6.58, p = 0.011). The ICP group had also a significantly higher "hazard" of treatment initiation (HR = 3.557; 95% CI: [2.228, 5.678]; p < 0.001) after controlling for age, gender and baseline severity of symptoms compared to TAU group. CONCLUSIONS: Use of an ICP within a collaborative care framework in primary care settings for anxiety, depression and MCI among older adults, results in faster reductions in clinical symptoms and improvement in quality of life compared to usual care, as well as faster access to recommended treatments.

Health TAPESTRY Ontario: protocol for a randomized controlled trial to test reproducibility and implementation.

BACKGROUND: Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening qualitY) aims to help people stay healthier for longer where they live by providing person-focused care through the integration of four key program components: (1) trained volunteers who visit clients in their homes, (2) an interprofessional primary health care team, (3) use of technology to collect and share information, and (4) improved connections to community health and social services. The initial randomized controlled trial of Health TAPESTRY found promising results in terms of health care use and patient outcomes, indicating a shift from reactive to preventive care. The trial was based on one clinical academic center, thus limiting generalizability. The study objectives are (1) to test reproducibility of the established effectiveness of Health TAPESTRY on physical activity and hospitalizations, (2) to test the feasibility of, and understand the contributing factors to, the implementation of Health TAPESTRY in six diverse communities across Ontario, Canada, and (3) to determine the value for money of implementing Health TAPESTRY. METHODS: This planned study is a pragmatic parallel randomized controlled trial with a delayed intervention for control participants at 6 months. This trial will simultaneously assess effectiveness and implementation in a real-world setting (type II hybrid) in six diverse communities across Ontario. Participants 70 years of age and older will be randomized into the Health TAPESTRY intervention or the control group (usual care). Intervention clients will receive an individualized plan of care from an interprofessional care team. The plan will be based on a client's goals and current health risks identified through volunteer visits. The study's outcomes are mapped onto the RE-AIM framework, with levels of physical activity and number of hospitalizations as the co-primary outcomes. The main analysis will be a comparison at 6 months. DISCUSSION: It is important to evaluate the effectiveness and implementation of Health TAPESTRY in multiple communities prior to scaling or widespread adoption. TRIAL REGISTRATION: ClinicalTrials.gov NCT03397836 . Registered on 12 January 2018.

Experiences of integrating community volunteers as extensions of the primary care team to help support older adults at home: a qualitative study.

BACKGROUND: Increasing the integration of community volunteers into primary health care delivery has the potential to improve person-focused, coordinated care, yet the use of volunteers in primary care is largely unexplored. Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a multi-component intervention involving trained community volunteers functioning as extensions of primary care teams, supporting care based on older adults' health goals and needs. This study aimed to gain an understanding of volunteer experiences within the program and client and health care provider perspectives on the volunteer role. METHODS: This study used a qualitative descriptive approach embedded in a pragmatic randomized controlled trial. Participants included Health TAPESTRY volunteers, health care providers, volunteer coordinator, and program clients, all connected to two primary care practice sites in a large urban setting in Ontario, Canada. Data collection included semi-structured focus groups and interviews with all participants, and the completion of a measure of attitudes toward older adults and self-efficacy for volunteers. Qualitative data were inductively coded and analyzed using a constant comparative approach. Quantitative data were summarized using descriptive statistics. RESULTS: Overall, 30 volunteers and 64 other participants (clients, providers, volunteer coordinator) were included. Themes included: 1. Volunteer training: "An investment in volunteers"; 2. Intergenerational volunteer pairing: "The best of both worlds"; 3. Understanding the volunteer role and its scope: "Lay people involved in care"; 4. Volunteers as extensions of primary care teams: "Being the eyes where they live"; 5. The disconnect between volunteers and the clinical team: "Is something being done?"; 6. "Learning… all the time": Impacts on volunteers; and 7. Clients' acceptance of volunteers. CONCLUSIONS: This study showed that it is possible to integrate community volunteers into the primary care setting, adding human connections to deepen the primary care team's understanding of their patients. Program implementation suggestions that emerged included: using role play in training, making volunteer role boundaries and specifications clear, and making efforts to connect volunteers and the primary care team they are supporting. This exploration of stakeholder voices has the potential to help improve volunteer program uptake and acceptability, as well as volunteer recruitment, retention, and training. TRIAL REGISTRATION: For RCT: https://clinicaltrials.gov/ct2/show/NCT02283723, November 5, 2014.

Disconnected relationships between primary care and community-based health and social services and system navigation for older adults: a qualitative descriptive study.

BACKGROUND: There are gaps in knowledge and understanding about the relationships between primary care and community-based health and social services in the context of healthy aging at home and system navigation. This study examined provider perspectives on: a) older adults' health and social needs; b) barriers to accessing services; c) the nature of relationships between primary care and health and social services; and d) ways to facilitate primary care and health and social services navigation to optimize older adults' health. METHODS: Four focus groups were conducted involving providers (n = 21) in: urban primary care clinics and health and social services organizations serving older adults in Hamilton, Ontario, Canada. Purposive sampling was employed to recruit community health and social services managers, directors or supervisors and primary health care providers in a Family Health Team via email. RESULTS: Health and social services needs were exacerbated for community-dwelling older adults with multiple chronic conditions. Strong family/caregiver social support and advocacy was often lacking. Access barriers for older adults included: financial challenges; lack of accessible transportation; wait times and eligibility criteria; and lack of programs to address older adults' needs. Having multiple providers meant that assessments among providers and older adults resulted in contradictory care pathways. Primary care and health and social services linkages were deficient and complicated by poor communication with patients and health literacy barriers. Primary care had stronger links with other health services than with community-based health and social services; primary care providers were frustrated by the complex nature of health and social services navigation; and care coordination was problematic. Health and social services referred older adults to primary care for medical needs and gathered patient information to gauge program eligibility, but not without challenges. CONCLUSIONS: Results point to strategies to strengthen primary care and health and social services system navigation for older adults including: using a person-focused approach; employing effective primary care and health and social services communication strategies; applying effective system navigation; building trust between primary care and health and social services providers; advocating for improved program access; and adapting services/programs to address access barriers and meet older adults' needs.

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory.

BACKGROUND: Many countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers. METHODS: This study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4 months (June-July 2015) and 12 months (February-March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings. RESULTS: Overall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program's purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes. CONCLUSIONS: This study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered.

Exploration of volunteers as health connectors within a multicomponent primary care-based program supporting self-management of diabetes and hypertension.

Volunteers support health and social care worldwide, yet there is little research on integrating these unpaid community members into primary care. 'Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management' (Health TAPESTRY-HC-DM) integrates volunteer 'health connectors' into a community- and primary care-based program supporting client self-management in Hamilton, Canada. Volunteers supported clients through goal setting, motivation, education and connections to community resources and primary care. This study aimed to create and apply a volunteer program evaluation framework to explore: (a) volunteer training effectiveness (learning online content, in-person training, self-efficacy in role tasks, training overall); (b) feasibility of program implementation (process measures, reflections on client encounters, understanding of volunteer roles/responsibilities, client perspectives on volunteer program); and (c) effects of volunteering on volunteers (health outcomes, self-efficacy, value of volunteering). A concurrent triangulation, mixed-methods design was used. Data were collected in 2016, sources included: volunteer online training quizzes, focus groups, self-efficacy survey, Veterans RAND 12-Item (VR-12) survey, in-person training feedback forms and narratives of client visits; client interviews; and quantitative implementation data. Quantitative data analysis included descriptive statistics, paired samples t tests, and effect size (Cohen's d). Qualitative data used descriptive thematic analysis. Nineteen volunteers and 12 clients participated in this evaluation. Findings demonstrate the volunteer program evaluation framework in action. Online training increased knowledge. In-person training received largely positive evaluations. Self-efficacy was high post-training and higher after volunteering. VR-12 sub-scale means increased descriptively. Volunteers understood themselves as healthcare system connectors, feeling fulfilled with their contributions and learning new skills. They identified barriers including not having the resources and skills of healthcare professionals. Clients found volunteers were a major program strength, appreciating their company and regular goals follow-up. Using a volunteer program evaluation framework generated rich and comprehensive data demonstrating the feasibility of bringing volunteers into primary care.

Health TAPESTRY: Exploring the Potential of a Nursing Student Placement Within a Primary Care Intervention for Community-Dwelling Older Adults.

The increasing prevalence of chronic diseases in aging places demands on primary care. Nurses are the major nonphysician primary care workforce. Baccalaureate nursing programs should expose students to primary care and older adults to support these demands and help recruit new graduates to this setting. However, many baccalaureate nursing programs focus on acute care and placements aimed at older adults are viewed negatively. To address these curriculum challenges, third-year Canadian baccalaureate nursing students were placed in an innovative primary care program-Health TAPESTRY-for community-dwelling older adults. Health TAPESTRY involves an interprofessional primary care team, trained lay volunteers conducting home visits, system navigation, and an online software application. The goal of this study was to explore third-year baccalaureate nursing students' perceptions of this unique clinical primary care placement. This qualitative descriptive study explored students' perceptions of this placement's strengths, weaknesses, opportunities, threats (SWOT), and outcomes. Nursing students participated in focus groups (n = 14) or an interview (n = 1) and five completed narrative summaries following visits. Qualitative content analysis was supported by NVivo 10. Strengths of the clinical placement included training for the intervention; new insights about older adults; and experience with home visiting, interprofessional team functions, and community resources. Weaknesses included limited exposure to older adult clients, lack of role clarity, lack of registered nurse role models, and technology challenges. Opportunities included more exposure to primary care, interprofessional teams, and community resources. No threats were described. Nursing students' clinical experiences can be enhanced through engagement in innovative primary care programs. Adequate exposure to clients, including older adults; interprofessional teams; mentoring by registered nurses or advanced practice nurse preceptors; and role clarity for students in the primary care team should be considered in supporting baccalaureate nursing students in primary care clinical placements.

Health TAPESTRY: co-designing interprofessional primary care programs for older adults using the persona-scenario method.

BACKGROUND: Working with patients and health care providers to co-design health interventions is gaining global prominence. While co-design of interventions is important for all patients, it is particularly important for older adults who often experience multiple and complex chronic conditions. Persona-scenarios have been used by designers of technology applications. The purpose of this paper is to explore how a modified approach to the persona-scenario method was used to co-design a complex primary health care intervention (Health TAPESTRY) by and for older adults and providers and the value added of this approach. METHODS: The persona-scenario method involved patient and clinician participants from two academically-linked primary care practices. Local prospective volunteers and community service providers (e.g., home care services, support services) were also recruited. Persona-scenario workshops were facilitated by researchers experienced in qualitative methods. Working mostly in homogenous pairs, participants created a fictitious but authentic persona that represented people like themselves. Core components of the Health TAPESTRY intervention were described. Then, participants created a story (scenario) involving their persona and an aspect of the proposed Health TAPESTRY program (e.g., volunteer roles). Two stages of analysis involved descriptive identification of themes, followed by an interpretive phase to extract possible actions and products related to ideas in each theme. RESULTS: Fourteen persona-scenario workshops were held involving patients (n = 15), healthcare providers/community care providers (n = 29), community service providers (n = 12), and volunteers (n = 14). Fifty themes emerged under four Health TAPESTRY components and a fifth category - patient. Eight cross cutting themes highlighted areas integral to the intervention. In total, 414 actions were identified and 406 products were extracted under the themes, of which 44.8% of the products (n = 182) were novel. The remaining 224 had been considered by the research team. CONCLUSIONS: The persona-scenario method drew out feasible novel ideas from stakeholders, which expanded on the research team's original ideas and highlighted interactions among components and stakeholder groups. Many ideas were integrated into the Health TAPESTRY program's design and implementation. Persona-scenario method added significant value worthy of the added time it required. This method presents a promising alternative to active engagement of multiple stakeholders in the co-design of complex interventions.

Perceptions of older adults in Ontario, Canada on the implementation and impact of a primary care programme, Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY): a descriptive qualitative study.

OBJECTIVES: The aim of the study was to explore the perceptions of older adults on the implementation and impact of Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY), a multicomponent primary care programme that seeks to improve care coordination for individuals through health-related goal-setting supported by trained lay volunteers who are an extension of an interprofessional team, and the use of technology to support communication among the team. DESIGN: This study used a qualitative descriptive design. SETTING: The setting for this study was two primary care practice sites located in a large urban area in Ontario, Canada. PARTICIPANTS: The sample consisted of community-dwelling older adults aged 70 years and older. Participants were recruited from a convenience sample obtained from 360 clients who participated in the 12-month Health TAPESTRY randomised controlled trial. METHODS: Semistructured interviews were conducted with 32 older adults either face-to-face or by telephone. Interviews were transcribed verbatim. Data were analysed using a constant comparative approach to develop themes. RESULTS: Older adults' perceptions about the Health TAPESTRY programme included (1) the lack of a clear purpose and understanding of how information was shared among providers, (2) mixed positive and negative perceptions of goal-setting and provider follow-up after inhome visits by volunteers, (3) positive impacts such as satisfaction with the primary care team, and (4) the potential for the programme to become a regular programme and applied to other communities and groups. CONCLUSIONS: Older adults living in the community may benefit from greater primary care support provided through enhanced team-based approaches. Programmes such as Health TAPESTRY facilitate opportunities for older adults to work with primary care providers to meet their self-identified needs. By exploring perceptions of clients, primary care programmes can be further refined and expanded for various populations.

Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial.

BACKGROUND: The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes. METHODS: We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. RESULTS: There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation [SD] 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). INTERPRETATION: Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723.

Patient trade-offs between continuity and access in primary care interprofessional teaching clinics in Canada: a cross-sectional survey using discrete choice experiment.

OBJECTIVE: Timely access to care and continuity with a specific provider are important determinants of patient satisfaction when booking appointments in primary care settings. Advanced access booking systems restrict the majority of providers' appointment spots for same-day appointments and keep the number of prebooked appointments to a minimum. In the teaching clinic environment, continuity with the same provider can be a challenge. This study examines trade-offs that patients may consider during appointment bookings for six different clinical scenarios across a number of key access and continuity attributes using a discrete choice experiment (DCE) method. DESIGN: Cross-sectional survey. SETTING: Two urban family medicine teaching clinics in Canada. PARTICIPANTS: Convenience sample of 430 patients of family medicine clinics aged 18 and older. INTERVENTION: Discrete choice conjoint experiment survey. PRIMARY OUTCOME MEASURES: Patient preferences on six attributes: appointment booking method, appointment wait time, time spent in the waiting room, appointment time convenience, familiarity with healthcare provider and position of healthcare provider. Data were analysed by hierarchical Bayes analysis to determine estimates of part-worth utilities for each respondent. RESULTS: Patients rated appointment wait time as the most highly valued attribute, followed by position of provider, then familiarity with the provider. Patients showed a significant preference (p<0.02) for their own physician for booking of routine annual check-ups and other logical preferences across attributes overall and by clinical scenario. CONCLUSIONS: Patients preferred timely access to their primary care team over other attributes in the majority of health state scenarios tested, especially urgent issues, however they were willing to wait for a check-up. These results support the notion that advanced access booking systems which leave the majority of appointment spots for same day access and still leave a few for continuity (check-up) bookings, align well with trends in patient preferences.

Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach.

BACKGROUND: In keeping with the changing needs of the Canadian population, primary care systems need to become more person-focused in providing quality care to older adults. As part of Health TAPESTRY, a complex intervention to strengthen primary care for older adults, a goal setting exercise was developed and tested in an initial feasibility study, intended to foster collaboration between patients and providers. METHODS: Participants-clinic clients-were recruited from the McMaster Family Health Team in Hamilton, Ontario. Five participants took part in the goal setting feasibility study phase I, which tested the functionality of a technology-enabled goal setting exercise between older adults and volunteers. Based on observations and feedback from volunteers, interprofessional team members, and older adults, the exercise was refined to include a guided survey and goals report. The goal setting survey is a list of probing questions designed based on SMART (specific, measurable, attainable, relevant, timely) goal setting strategies and goal attainment scaling (GAS). This was used in phase II, carried out with 16 participants, where the feasibility of goal setting and goal attainment with support from volunteers and interprofessional teams was tested. Volunteers carried out the goal setting survey via a tablet computer, a report of client goals was generated and sent to interprofessional teams, and client goals were discussed during clinic huddles. At 6 months of follow-up, clients self-evaluated their progress using GAS. RESULTS AND DISCUSSION: The goal setting exercise in phase I took an average of 24:45 (SD 11:42) minutes and yielded a diverse set of life and health goals. Goals identified by older adults were primarily focused on the maintenance of a certain level of activity or health state. Phase I work resulted in important changes to the goal setting process (e.g., asking about goal setting later in conversation, changing wording of questions) and development of a summary report of goals sent to the interprofessional team. In phase II, 44 goals were set by 16 participants during an average 7:23 (SD 4:26) minute discussion. Of these goals, 43.9% were characterized as health goals while 63.4% were characterized as life goals. Under the umbrella of Life goals, productivity featured most prominently at 22.9% of all goals. Goal attainment was not measured in phase I. In phase II, clients had an average weighted goal attainment score of 51.5. Considering client preferences for one goal over another, 68.8% of clients, on average, at least partially achieved the goals they had set. CONCLUSION: Goal setting as part of the Health TAPESTRY approach was feasible and provided interprofessional teams with client narratives that helped improve care management for older adults. The overall intervention-including the refined goal setting component-is being scaled and evaluated in a pragmatic randomized controlled trial.

Protocol for a Delphi consensus exercise to identify a core set of criteria for selecting health related outcome measures (HROM) to be used in primary health care.

BACKGROUND: Promoting the collection and use of health related outcome measures (HROM) in daily practice has long been a goal for improving and assessing the effectiveness of care provided to patients. However, there has been a lack of consensus on what criteria to use to select outcomes or instruments, particularly in the context of primary health care settings where patients present with multiple concurrent health conditions and interventions are whole-health and person-focused. The purpose of this proposed study is to undertake a formal consensus exercise to establish criteria for selecting HROM (including patient-reported (PRO or PROM), observer-reported (ObsR)), clinician-reported (ClinRO) and performance related outcomes (PerfO) for use in shared decision-making, or in assessing, screening or monitoring health status in primary health care settings. METHODS: A Delphi consensus online survey will be developed. Criteria for the Delphi panel participants to consider were selected from a targeted literature search. These initial criteria (n = 35) were grouped into four categories within which items will be presented in the Delphi survey, with the option to suggest additional items. Panel members invited to participate will include primary health care practitioners and administrators, policy-makers, researchers, and experts in HROM development; patients will be excluded. Standard Delphi methodology will be employed with an expectation of at least 3 rounds to achieve consensus (75% agreement). As the final list of criteria for selecting HROM emerges, panel members will be asked to provide opinions about potential weighting of items. The Delphi survey was approved by the Ethics Committee in the Faculty of Health Sciences at McMaster University. DISCUSSION: Previous literature establishing criteria for selecting HROM were developed with a focus on patient reported outcomes, psychological/ behavioural outcomes or outcomes for minimum core outcome sets in clinical trials. Although helpful, these criteria may not be applicable and feasible for application in a primary health care context where patients with multi-morbidity and complex interventions are typical and the constraints of providing health services differ from those in research studies. The findings from this Delphi consensus study will address a gap for establishing consensus on criteria for selecting HROM for use across primary health care settings.

A Volunteer Program to Connect Primary Care and the Home to Support the Health of Older Adults: A Community Case Study.

Primary care providers are critical in providing and optimizing health care to an aging population. This paper describes the volunteer component of a program (Health TAPESTRY) which aims to encourage the delivery of effective primary health care in novel and proactive ways. As part of the program, volunteers visited older adults in their homes and entered information regarding health risks, needs, and goals into an electronic application on a tablet computer. A total of 657 home visits were conducted by 98 volunteers, with 22.45% of volunteers completing at least 20 home visits over the course of the program. Information was summarized in a report and electronically sent to the health care team via clients' electronic medical records. The report was reviewed by the interprofessional team who then plan ongoing care. Volunteer recruitment, screening, training, retention, and roles are described. This paper highlights the potential role of a volunteer in a unique connection between primary care providers and older adult patients in their homes.