Lessons Learned from the Implementation of Youth Wellness Hubs Ontario, an Integrated Youth Services Network: Perspectives from Network Leads.

Introduction: Mental health and substance use services for youth in Canada continue to be fragmented. In response, Integrated Youth Services (IYS) has been proposed to address gaps in youth mental health services that can lead to improved youth outcomes. Youth Wellness Hubs Ontario (YWHO) was launched in 2017 as Ontario's IYS Network for youth ages 12-25, prioritizing continuous improvement through evaluation. Description: At the end of the first three years of the YWHO initiative, an evaluation was carried out to identify the barriers and facilitators to the initial implementation of YWHO and service delivery modifications resulting from the COVID-19 pandemic across ten sites. Reporting on these is the focus of this article. Key informant interviews were conducted in early 2021 with Network Leads from all ten initial YWHO sites. Reflexive thematic analysis was used to analyze all interview data. Discussion: Facilitators to the implementation of the YWHO model included diversified funding models, YWHO Provincial Office implementation supports, clear hub processes, robust community partnerships, organizational support and dedicated staff. Common barriers included certain challenges related to staffing and finances, implementation of the shared data collection platform, implementation of measurement-based care, partnerships, integrated service delivery, and branding and communications. Conclusion: Implementation of IYS is highly collaborative and quite complex. As interest in such models increase, so does the need for knowledge related to optimal implementation. Learnings have informed developments and improvements made to the YWHO model. Insights will also inform how stakeholders support youth in their communities in designing and implementing services that improve youth mental health and overall well-being.

Youth Wellness Hubs Ontario: Development and initial implementation of integrated youth services in Ontario, Canada.

AIM: The need for youth-friendly early intervention services to meet the mental health, substance use, primary care, and other social needs of adolescents and young adults is well-documented. This article describes Youth Wellness Hubs Ontario, a province-wide initiative in Ontario, Canada to build and implement a one-stop-shop model of integrated youth services. METHODS: We describe the development of Youth Wellness Hubs Ontario, in the context of global youth mental health system transformation, as well as pan-Canadian youth mental health system change. We also describe Youth Wellness Hubs Ontario's values and services. RESULTS: The demonstration phase of Youth Wellness Hubs Ontario was initiated in 2017-2018. Youth Wellness Hubs Ontario is co-created with youth for youth aged 12-25 years old across diverse community contexts. Youth Wellness Hubs Ontario centres engagement and equity, and offers developmentally-appropriate services in an integrated, community-based walk-in format. As an initiative committed to continuous learning and quality improvement, Youth Wellness Hubs Ontario offers evidence-based and evidence-generating services, and measurement-based care. Youth Wellness Hubs Ontario is supported by backbone resources with expertise in implementation science, health equity, Indigenous practices, youth and family engagement, evaluation, and knowledge translation. In 2020 Youth Wellness Hubs Ontario secured sustainable funding for the first 10 locations and scale-up began in 2021, with 10 additional locations in development. CONCLUSIONS: Youth Wellness Hubs Ontario demonstrates the feasibility of integrated mental health and substance use early intervention services, offered in the context of a broad range of health and social services.

Polypharmacy and use of potentially inappropriate medications in long-term care facilities: does coordinated primary care make a difference?

OBJECTIVES: Polypharmacy is both common and harmful for frail residents of long-term care facilities (LTCF). We aimed to study rates of polypharmacy and potentially inappropriate medications (PIMs) before and after the implementation of a new model of coordinated primary care in LTCF, 'Care by Design (CBD)'. METHODS: This was an observational before/after study in 10 LTCFs in Halifax, NS, Canada. Chart reviews were conducted for 529 LTCF residents for whom medication use was available. Both regularly scheduled and PRN medications were included but topical, inhaled and other non-systemic agents were excluded. Polypharmacy was defined as the concomitant use of more than 10 medications. PIMs were identified using Beers Criteria. KEY FINDINGS: Mean age of LTCF residents was older pre- versus post-CBD (85.7 versus 82.1 years; P = 0.0015). The burden of polypharmacy was high, but decreased significantly from 86.8% pre-CBD to 79.5% post-CBD (P = 0.046). The mean number of medications per resident decreased from 16.7 (SD 5.6) pre- to 15.5 (SD 6.2) post-CBD (P = 0.037). Residents with dementia were taking fewer medications both overall and following the implementation of CBD (mean 15.9, SD 0.6 pre-CBD versus 14.4, SD 0.4 post-CBD; P = 0.04). PIM rates were high and showed no change with CBD (86.2% versus 81.1%, P = 0.16). CONCLUSIONS: Polypharmacy was the norm of this sample of LTCF residents. Implementation of coordinated care through the CBD model was associated with a small decrease in polypharmacy but not overall use of PIMs. Further targeted efforts are required to substantially reduce both polypharmacy and PIMs in clinical practice.

Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents.

INTRODUCTION: Care by Design™ (CBD) (Canada), a model of coordinated team-based primary care, was implemented in long-term care facilities (LTCFs) in Halifax, Nova Scotia, Canada, to improve access to and continuity of primary care and to reduce high rates of transfers to emergency departments (EDs). METHODS: This was an observational time series before and after the implementation of CBD (Canada). Participants are LTCF residents with 911 Emergency Health Services calls from 10 LTCFs, representing 1424 beds. Data were abstracted from LTCF charts and Emergency Health Services databases. The primary outcome was ambulance transports from LTCFs to EDs. Secondary outcomes included access (primary care physician notes in charts) and continuity (physician numbers and contacts). RESULTS: After implementation of CBD (Canada), transports from LTCFs to EDs were reduced by 36%, from 68 to 44 per month (P = .01). Relational and informational continuity of care improved with resident charts with ≥10 physician notes, increasing 38% before CBD to 55% after CBD (P = .003), and the median number of chart notes increased from 7 to 10 (P = .0026). Physicians contacted before 911 calls and onsite assessment increased from 38% to 54% (P = .01) and 3.7% to 9.2% (P = .03), respectively, before CBD to after CBD. CONCLUSION: A 34% reduction in overall transports from LTCFs to EDs is likely attributable to improved onsite primary care, with consistent physician and team engagement and improvements in continuity of care.

A Long-Term Care-Comprehensive Geriatric Assessment (LTC-CGA) Tool: Improving Care for Frail Older Adults?

BACKGROUND: Most older adults living in long-term care facilities (LTCF) are frail and have complex care needs. Holistic understanding of residents' health status is key to providing good care. Comprehensive Geriatric Assessment (CGA) is a valid assessment method which aims to embrace complexity. Here we aimed to study a CGA that has been modified for use in long-term care (the LTC-CGA) and to investigate its acceptability and usefulness to stakeholders and users. METHODS: This mixed methods study, conducted in 10 LTCFs in Halifax, Nova Scotia, reviewed 598 resident charts from pre- and post-implementation of the LTC-CGA. Qualitative methods explored stakeholder perspectives (physicians, nurses, paramedics, administrators, residents and families) though focus groups. RESULTS: The LTC-CGA was present in 78% of LTCF charts in the post -implementation, period though it did not appear in acute care charts of transferred residents, despite the intention that it accompany residents between care sites. Some items had suboptimal completion rates (e.g., Advance Directives at 56.4%), though these were located in other sections of the LTCF chart (98.2%). Nevertheless, qualitative findings suggest the LTC-CGA describes a clinical baseline health status which enabled timely and informed clinical decision-making. CONCLUSIONS: The LTC-CGA is a useful resource whose full capacity may not yet have been realized.

Arthritis extended-role practitioners: impact on community practice (an exploratory study).

PURPOSE: We compared practice of extended role practitioners and experienced therapists without extended practice training to determine differences in assessment and management of clients with inflammatory arthritis, in preparation for a randomized controlled trial. METHODS: Retrospective review of randomly selected charts of extended-role trained occupational therapists or physiotherapists and from experienced therapists matched on therapist discipline, geographical location, and time of referral. Three trained reviewers used standardized forms to extract data independently. RESULTS: We reviewed 58 charts of adult clients with inflammatory arthritis. Compared with experienced therapists, extended-role practitioners were more likely to receive referrals specifically for assessments (52% vs. 14%); to treat clients with undifferentiated arthritis (48% vs. 10%); to document comorbidities (90% vs. 66%); to advocate on behalf of the client with the client's family, physician, or specialist (52% vs. 21%); to recommend or provide exercise or physical activity (86% vs. 62%); to educate clients about pain management (41% vs. 28%), energy conservation (24% vs. 14%), and posture (21% vs. 7%); to recommend splints (41% vs. 31%); and to refer for or recommend radiologic or laboratory assessments (14% vs. 3%). Experienced therapists were more likely to provide education about joint protection (41% vs. 31%), community resources (31% vs. 7%), and assistive devices (45% vs. 21%). CONCLUSIONS: We identified possible differences in practice between extended-role practitioners and experienced therapists without training for extended practice. Capturing these details in future studies evaluating the efficacy of extended role practitioner interventions will be important.

Taste bud development and patterning in sighted and blind morphs of Astyanax mexicanus.

In the blind cave-dwelling morph of A. mexicanus, the eye degenerates while other sensory systems, such as gustation, are expanded compared to their sighted (surface-dwelling) ancestor. This study compares the development of taste buds along the jaws of each morph. To determine whether cavefish have an altered onset or rate of taste bud development, we fluorescently labeled basal and receptor cells within taste buds over a developmental series. Our results show that taste bud number increases during development in both morphs. The rate of development is, however, accelerated in cavefish; a small difference in taste bud number exists at 5 dpf reaching threefold by 22 dpf. The expansion of taste buds in cavefish is, therefore, detectable after the onset of eye degeneration. This study provides important insights into the timing of taste bud expansion in cavefish as well as enhances our understanding of taste bud development in teleosts in general.