Integrating Care from Home to Hospital to Home: Using Participatory Design to Develop a Provincial Transitions in Care Guideline.

Introduction: Patients worldwide experience fragmented and uncoordinated care as they transition between primary and acute care. To improve system integration and outcomes for patients, in 2017/2018 Alberta Health Services (largest health services delivery organization in Canada) called for a coordinated approach to improve transitions in care (TiC). Healthcare leadership responded by initiating the development of a province-wide guideline outlining core components of effective transitions in care. This case study highlights the extensive design process used to develop this guideline, with a focus on the participatory design (PD) approach used throughout. Methods: An iterative, mixed methods PD approach was used to engage over 750 stakeholders through the following activities to establish Guideline content: i) learning collaborative; ii) design-team; iii) targeted online surveys; iv) primary care stakeholder consultation; v) modified Delphi panel; and vi) patient advisory committee. Results: The result was Alberta's first guideline for supporting patients through TiC: "Alberta's Home to Hospital to Home Transitions Guideline". Conclusion: The extensive design process used to create the Guideline was instrumental in establishing content, encouraging system integration, and creating conditions to support provincial implementation. While intended to improve and standardize patient care in Alberta, the methods used and lessons learned throughout the development of the Guideline are applicable internationally.

Association between continuity and access in primary care: a retrospective cohort study.

BACKGROUND: Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care. METHODS: We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department. RESULTS: We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access. INTERPRETATION: Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.

Return on Investment of the Primary Health Care Integrated Geriatric Services Initiative Implementation.

BACKGROUND: Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities. AIM OF THE STUDY: We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread. METHODS: We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 \sim = USD 0.75) using the Canadian Consumer Price Index. RESULTS: The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The PHC IGSI is cost-effective in Alberta. IMPLICATIONS FOR HEALTH POLICY: The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted. IMPLICATIONS FOR FURTHER RESEARCH: Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.

Patient-Physician Relational Continuity and Health System Utilization among Patients in Alberta.

In Alberta, no standardized processes exist to identify patients with chronic diseases (CDs) who do not have a family physician. This study examined the association between relational continuity (continuity of care) and healthcare utilization patterns in this population. Relational continuity was assessed using health administrative data to calculate a Usual Provider Continuity (UPC) Index. The majority of patients with no or a low UPC Index were male, did not have CD and were healthy or non-users of healthcare. When grouped by UPC Index, regression modelling revealed that emergency department visits and unplanned hospitalization declined with increased continuity of care. Advanced state of disease(s) and location of residence increased the likelihood of utilization of these services in the low- and moderate-continuity groups.

Septohippocampal properties of N-methyl-D-aspartate-induced theta-band oscillation and synchrony.

Microinfusion of N-methyl-D-aspartate (NMDA) into apical dendrites of hippocampal CA1 pyramidal cells of urethane-anesthetized rats resulted in long lasting (20-30 min) induction of hippocampal synchrony at the field and cellular level. Power but not frequency of NMDA-induced theta was significantly greater than tail pinch-induced theta activity. This effect was antagonized by intrahippocampal infusion of AP5, but unaffected by i.v. atropine sulfate. During AP5 blockade tail pinch theta frequency and power were significantly reduced. Microinfusion of NMDA into the medial septum also resulted in long lasting induction of hippocampal theta field activity. Contrary to the results of hippocampal NMDA microinfusions, frequency but not power of NMDA-induced theta was significantly greater than tail pinch- induced theta activity. Microinfusion of AP5 into the medial septum significantly lowered power of tail pinch-induced theta but did not affect frequency. Wheel running behavior of rats induced by low levels of electrical stimulation of the posterior hypothalamic nucleus (PH) was completely abolished by microinfusion of AP5 into the medial septum, accompanied by a significant reduction in theta power and frequency. Wheel running and theta were maintained at control levels with high intensity PH stimulation. We propose that: (1) the glutamatergic septohippocampal projection represents a third pathway capable of generating hippocampal field and cellular synchrony, independent of that generated by the septohippocampal cholinergic and GABAergic projections, and (2) the septohippocampal glutamatergic projection serves to function as an interface between cholinergic and GABAergic modulated sensory processing Type 2 theta and movement related Type 1 theta.

Impaired dodging in food-conflict following fimbria-fornix transection in rats: a novel hippocampal formation deficit.

It is well known that damage to the hippocampal formation (Ammon's horn, dentate gyrus, fimbria-fornix, and other pathways) produces impairments in spatial navigation and in certain forms of learning. Lesions within these structures have also been reported to produce some motor impairments, but the nature of these impairments is less understood. The present study examined the effects of fimbria-fornix lesions on food wrenching and dodging, social interactions that occur when one rat attempts to steal food from a conspecific, who in turn attempts to protect the food by an evasive movement. Lesion effectiveness was confirmed histologically and electrophysiologically, by the loss of hippocampal rhythmical slow-wave activity (RSA or theta), and by changes in open field behavior (increased open field behavior, less thigmotaxis and more defecation). Analysis of the social interaction indicated when an eating control rat was approached by a conspecific that was attempting to steal its food, it prevented the theft by dodging, a rapid lateral maneuver involving forequarter turning and stepping with the rear limbs. Rats with fimbria-fornix lesions were significantly impaired in dodging and so were more likely to lose their food to the robber. This novel deficit in motor behavior is discussed in relation to contemporary theories of hippocampal function and it is suggested that the deficit may be caused by an inability of the fimbria-fornix damaged animals to disengage attention from eating in order to initiate an evasive movement to protect food. The finding of this novel deficit underscores the importance of considering both loss as well as release phenomena in the analysis of hippocampal formation function.