Older adults' experiences and perceived impacts of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) for diabetes self-management in Canada: a qualitative descriptive study.

OBJECTIVES: To assess the experiences and perceived impacts of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) from the perspectives of older adults with diabetes and other chronic conditions. The ACHRU-CPP is a complex 6-month self-management evidence-based intervention for community-living older adults aged 65 years or older with type 1 or type 2 diabetes and at least one other chronic condition. It includes home and phone visits, care coordination, system navigation support, caregiver support and group wellness sessions delivered by a nurse, dietitian or nutritionist, and community programme coordinator. DESIGN: Qualitative descriptive design embedded within a randomised controlled trial was used. SETTING: Six trial sites offering primary care services from three Canadian provinces (ie, Ontario, Quebec and Prince Edward Island) were included. PARTICIPANTS: The sample was 45 community-living older adults aged 65 years or older with diabetes and at least one other chronic condition. METHODS: Participants completed semistructured postintervention interviews by phone in English or French. The analytical process followed Braun and Clarke's experiential thematic analysis framework. Patient partners informed study design and interpretation. RESULTS: The mean age of older adults was 71.7 years, and the mean length of time living with diabetes was 18.8 years. Older adults reported positive experiences with the ACHRU-CPP that supported diabetes self-management, such as improved knowledge in managing diabetes and other chronic conditions, enhanced physical activity and function, improved eating habits, and opportunities for socialisation. They reported being connected to community resources by the intervention team to address social determinants of health and support self-management. CONCLUSIONS: Older adults perceived that a 6-month person-centred intervention collaboratively delivered by a team of health and social care providers helped support chronic disease self-management. There is a need for providers to help older adults connect with available health and social services in the community. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov ID: NCT03664583; Results.

Enhancing Physical and Community MoBility in OLDEr Adults with Health Inequities Using CommuNity Co-Design (EMBOLDEN): Results of an Environmental Scan.

Background: Using the comparatively new environmental scan methodology, a protocol was developed and conducted to inform the co-design and implementation of a novel intervention to promote mobility among older adults in Hamilton, Ontario, Canada. The EMBOLDEN program seeks to promote physical and community mobility in adults 55 years and older who face barriers accessing community programs and who reside in areas of high inequity in Hamilton, and to address the following areas of focus: physical activity, nutrition, social participation, and system navigation supports. Methods: The environmental scan protocol was developed using existing models and drew insights from census data, a review of existing services, organizational representative interviews, windshield surveys of selected high-priority neighbourhoods, and Geographic Information System (GIS) mapping. Results: A total of 98 programs for older adults from 50 different organizations were identified, with the majority (92) supporting mobility, physical activity, nutrition, social participation, and system navigation. The analysis of census tract data identified eight high-priority neighbourhoods characterized by large shares of older adults, high material deprivation, low income, and high proportion of immigrants. These populations can be hard to reach and face multiple barriers to participation in community-based activities. The scan also revealed the nature and types of services geared toward older adults in each neighbourhood, with each priority neighbourhood having at least one school and park. Most areas had a range of services and supports (i.e., health care, housing, stores, religious options), although there was a lack of diverse ethnic community centres and income-diverse activities specific to older adults in most neighbourhoods. Neighbourhoods also differed in the geographic distribution number of services, along with the number of recreational services specific to older adults. Barriers included financial and physical accessibility, lack of ethnically diverse community centres, and food deserts. Conclusions: Scan results will inform the co-design and implementation of the Enhancing physical and community MoBility in OLDEr adults with health inequities using commuNity co-design intervention-EMBOLDEN.

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.

A Multiphase Mixed Methods Study on the Integration of a Population Health Approach in Sexual Health Programs and Services in Ontario Public Health Units.

PURPOSE: This study investigated the extent of and factors influencing implementation of a population health approach within sexual health programming in public health. METHOD: This sequential multi-phase mixed methods study combined findings from a quantitative survey assessing the extent that a population health approach was implemented in sexual health programs in Ontario public health units and qualitative interviews with sexual health managers and/or supervisors. Interviews explored factors influencing implementation and were analyzed using directed content analysis. RESULTS: Staff from fifteen of 34 public health units completed surveys and ten interviews were completed with sexual health managers/supervisors. From the 8 Population Health Key Elements Template, 6 elements were moderately implemented and 2 had low implementation. Qualitative findings focused on enablers and barriers to implementing a population health approach in sexual health programs and services and explained most of the quantitative results. However, some of the quantitative findings were not explained by qualitative data (e.g., low implementation of using the principles of social justice). CONCLUSION: Qualitative findings revealed factors influencing the implementation of a population health approach. A lack of resources available to health units, differing priorities between health units and community stakeholders, and access to evidence around population-level interventions influenced implementation.

Implementation of the Community Assets Supporting Transitions (CAST) transitional care intervention for older adults with multimorbidity and depressive symptoms: A qualitative descriptive study.

BACKGROUND: Older adults with multimorbidity experience frequent care transitions, particularly from hospital to home, which are often poorly coordinated and fragmented. We conducted a pragmatic randomized controlled trial to test the implementation and effectiveness of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led intervention to support older adults with multimorbidity and depressive symptoms with the aim of improving health outcomes and enhancing transitions from hospital to home. This trial was conducted in three sites, representing suburban/rural and urban communities, within two health regions in Ontario, Canada. PURPOSE: This paper reports on facilitators and barriers to implementing CAST. METHODS: Data collection and analysis were guided by the Consolidated Framework for Implementation Research framework. Data were collected through study documents and individual and group interviews conducted with Care Transition Coordinators and members from local Community Advisory Boards. Study documents included minutes of meetings with research team members, study partners, Community Advisory Boards, and Care Transition Coordinators. Data were analyzed using content analysis. FINDINGS: Intervention implementation was facilitated by: (a) engaging the community to gain buy-in and adapt CAST to the local community contest; (b) planning, training, and research meetings; (c) facilitating engagement, building relationships, and collaborating with local partners; (d) ensuring availability of support and resources for Care Transition Coordinators; and (e) tailoring of the intervention to individual client (i.e., older adult) needs and preferences. Implementation barriers included: (a) difficulties recruiting and retaining intervention staff; (b) difficulties engaging older adults in the intervention; (c) balancing tailoring the intervention with delivering the core intervention components; and (c) Care Transition Coordinators' challenges in engaging providers within clients' circles of care. CONCLUSION: This research enhances our understanding of the importance of considering intervention characteristics, the context within which the intervention is being implemented, and the processes required for implementing transitional care intervention for complex older adults.

Preliminary instrument development to measure implementing a population health approach in sexual health.

OBJECTIVES: This study aims to describe the preliminary development and validation of an instrument to measure the extent that a population health approach was applied in sexual health by public health units in Ontario, Canada. DESIGN: Preliminary scale development and administration occurred in two phases that included item development and validity testing. MEASUREMENT AND SAMPLE: Two phases of development included: (1) using literature and expert input (n = 6) to develop items; and (2) validation of items by content experts (n = 5) and pre-testing (n = 3). RESULTS: The validated scale consisted of 69 items across the eight key elements of a population health approach. 15 out of 35 health units completed the survey, representing 43% of health units. Instrument administration revealed that Focus on the Health of Populations and Address the Determinants of Health and their Interactions were implemented more frequently compared to Collaborate Across Sectors and Levels and Employ Mechanisms for Public Involvement, which were infrequently implemented. CONCLUSION: This preliminary scale is a way for sexual health programs to measure the extent that a population health approach is implemented by their organization. Further testing with a broader sample is needed to strengthen generalizability and address reliability.

Influences on the uptake of a population health approach to sexual health programs in Ontario public health units: a qualitative descriptive study.

Aim: Population-level prevention initiatives are the cornerstone of public health practice. However, despite this normative practice, sexual health programming within public health has not utilized this approach to the same extent as other public health programs. Understanding requirements to put a population-level approach into practice is needed. The objective of this study was to explore the barriers and facilitators experienced by sexual health programs and services within public health when implementing a population health approach. Subject design and methods: The principles of qualitative description guided all sampling, data collection and analysis decisions. Data collection involved in-depth semi-structured interviews with 12 sexual health managers and/or supervisors from ten Ontario public health units. Directed content analysis was used to code and synthesize the data. Data collection and analysis was guided using constructs from the Consolidated Framework for Implementation Research. Results: Factors that served as either barriers and facilitators to implementing a population health approach, were mainly in the inner and outer setting domains of the Consolidated Framework for Implementation Research. Participants identified the presence of community partnerships, adequate staff training on population health, and access to data on population health served as facilitators. In comparison, barriers to implementation included a lack of resources (human, financial) and clinicians' value of and preferences for delivering services at the individual clinic level. Conclusion: Some clear barriers and facilitators influenced if staff in sexual health programs and services could implement a population health approach. Results indicate where public health resources need to be enhanced to move toward a population health approach and provide insight into what worked and should be considered by public health organizations.

Evaluating Public Participation in a Deliberative Dialogue: A Single Case Study.

BACKGROUND: Deliberative dialogues (DDs) are used in policy-making and healthcare research to enhance knowledge exchange and research implementation strategies. They allow organized dissemination and integration of relevant research, contextual considerations, and input from diverse stakeholder perspectives. Despite recent interest in involving patient and public perspectives in the design and development of healthcare services, DDs typically involve only professional stakeholders. A DD took place in May 2019 that aimed to improve the social environment (eg, safety, social inclusion) and decrease social isolation in a rent-geared-to-income housing complex in a large urban community. Tenants of the housing complex, public health, primary care, and social service providers participated. This study aimed to determine how including community tenants impacted the planning and execution of a DD, including adjustments made to the traditional DD model to improve accessibility. METHODS: A Core Working Group (CWG) and Steering Committee coordinated with researchers to plan the DD, purposefully recruit participants, and determine appropriate accommodations for tenants. A single mixed-methods case study was used to evaluate the DD process. Meeting minutes, field notes, and researchers' observations were collected throughout all stages. Stakeholders' contributions to and perception of the DD were assessed using participant observation, survey responses, and focus groups (FGs). RESULTS: 34 participants attended the DD and 28 (82%) completed the survey. All stakeholder groups rated the overall DD experience positively and valued tenants' involvement. The tenants heavily influenced the planning and DD process, including decisions about key DD features. Suggestions to improve the experience for tenants were identified. CONCLUSION: These findings demonstrate the viability of and provide recommendations for DDs involving public participants. Like previous DDs, participants found the use of engaged facilitators, issue briefs, and off-the-record deliberations useful. Similarly, professional stakeholders did not highly value consensus as an output, although it was highly valued among tenants, as was actionability.

The Aging, Community and Health Research Unit Community Partnership Program (ACHRU-CPP) for older adults with diabetes and multiple chronic conditions: study protocol for a randomized controlled trial.

BACKGROUND: Older adults (≥65 years) with diabetes and multiple chronic conditions (MCC) (> 2 chronic conditions) experience reduced function and quality of life, increased health service use, and high mortality. Many community-based self-management interventions have been developed for this group, however the evidence for their effectiveness is limited. This paper presents the protocol for a randomized controlled trial (RCT) comparing the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) to usual care in older adults with diabetes and MCC and their caregivers. METHODS: We will conduct a cross-jurisdictional, multi-site implementation-effectiveness type II hybrid RCT. Eligibility criteria are: ≥65 years, diabetes diagnosis (Type 1 or 2) and at least one other chronic condition, and enrolled in a primary care or diabetes education program. Participants will be randomly assigned to the intervention (ACHRU-CPP) or control arm (1:1 ratio). The intervention arm consists of home/telephone visits, monthly group wellness sessions, multidisciplinary case conferences, and system navigation support. It will be delivered by registered nurses and registered dietitians/nutritionists from participating primary care or diabetes education programs and program coordinators from community-based organizations. The control arm consists of usual care provided by the primary care setting or diabetes education program. The primary outcome is the change from baseline to 6 months in mental functioning. Secondary outcomes will include, for example, the change from baseline to 6 months in physical functioning, diabetes self-management, depressive symptoms, and cost of use of healthcare services. Analysis of covariance (ANCOVA) models will be used to analyze all outcomes, with intention-to-treat analysis using multiple imputation to address missing data. Descriptive and qualitative data from older adults, caregivers and intervention teams will be used to examine intervention implementation, site-specific adaptations, and scalability potential. DISCUSSION: An interprofessional intervention supporting self-management may be effective in improving health outcomes and client/caregiver experience and reducing service use and costs in this complex population. This pragmatic trial includes a scalability assessment which considers a range of effectiveness and implementation criteria to inform the future scale-up of the ACHRU-CPP. TRIAL REGISTRATION: Clinical Trials.gov Identifier NCT03664583 . Registration date: September 10, 2018.

The Role of the Indigenous Patient Navigator: A Scoping Review.

BACKGROUND: Healthcare systems are complex and as a result patients may experience fragmentation of services. Indigenous populations experience increasingly disproportionate health disparities compared to non-Indigenous populations. Patient navigation is known as a patient-centered approach to empower individuals to connect with appropriate services. Literature surrounding the Indigenous Patient Navigator (IPN) remains sparse necessitating this scoping review. Purpose: To map the current state of the role of the IPN internationally within Canada, United States, Australia and New Zealand. METHODS: Estalished methodological framework by Arksey and O'Malley and the PRISMA extension for scoping reviews was used. RESULTS: A total of 820 articles were reviewed from four databases, yielding sixteen articles. CONCLUSIONS: The absence of published literature surrounding the IPN role in Australia and New Zealand was surprising considering similar histories of colonization. The term navigator was used most often and was typically used when describing lay/peer roles. Professional roles were described using specific role descriptions. Six IPN roles were identified including: (1) social service navigation, (2) wholistic support of Indigenous people, (3) advocacy/building capacity, (4) health assessment, (5) administrative navigation, and (6) outreach. Additionally, barriers and enablers IPNs address are identified. This scoping review will assist to promote and reinforce the IPN role.

Knowledge translation strategies for sharing evidence-based health information with older adults and their caregivers: findings from a persona-scenario method.

BACKGROUND: By understanding the information seeking behaviors of older adults, we can better develop or iterate effective information technologies, such as the McMaster Optimal Aging Portal, that provide evidence-based health information to the public. This paper reports health-related information seeking and searching behaviours and provides strategies for effective knowledge translation (KT) to increase awareness and use of reliable health information. METHODS: We conducted a qualitative study with eighteen older adults using the persona-scenario method, whereby participants created personas and scenarios describing older adults seeking health information. Scenarios were analyzed using a two-phase inductive qualitative approach, with the personas as context. From the findings related to pathways of engaging with health information, we identified targeted KT strategies to raise awareness and uptake of evidence-based information resources. RESULTS: Twelve women and six men, 60 to 81 years of age, participated. In pairs, they created twelve personas that captured rural and urban, male and female, and immigrant perspectives. Some scenarios described older adults who did not engage directly with technology, but rather accessed information indirectly through other sources or preferred nondigital modes of delivery. Two major themes regarding KT considerations were identified: connecting to information via other people and personal venues (people included healthcare professionals, librarians, and personal networks; personal venues included clinics, libraries, pharmacies, and community gatherings); and health information delivery formats, (e.g., printed and multimedia formats for web-based resources). For each theme, and any identified subthemes, corresponding sets of suggested KT strategies are presented. CONCLUSIONS: Our findings underline the importance of people, venues, and formats in the actions of older adults seeking trusted health information and highlight the need for enhanced KT strategies to share information across personal and professional networks of older adults. KT strategies that could be employed by organizations or communities sharing evidence-based, reliable health information include combinations of educational outreach and materials, decision support tools, small group sessions, publicity campaigns, champions/opinion leaders, and conferences.

A Web-Based Social Network Tool (GENIE) for Supporting Self-management Among High Users of the Health Care System: Feasibility and Usability Study.

BACKGROUND: Primary care providers are well positioned to foster self-management through linking patients to community-based health and social services (HSSs). This study evaluated a web-based tool-GENIE (Generating Engagement in Network Involvement)-to support the self-management of adults. GENIE empowers patients to leverage their personal social networks and increase their access to HSSs. GENIE maps patients' personal social networks, elicits preferences, and filters local HSSs from a community service directory based on patient's interests. Trained volunteers (an extension of the primary care team) conducted home visits and conducted surveys related to life and health goals in the context of the Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) program, in which the GENIE tool was implemented. GENIE reports were uploaded to an electronic medical record for care planning by the team. OBJECTIVE: This study aims to explore patients', volunteers', and clinicians' perceptions of the feasibility, usability, and perceived outcomes of GENIE-a tool for community-dwelling adults who are high users of the health care system. METHODS: This study involved 2 primary care clinician focus groups and 1 clinician interview (n=15), 1 volunteer focus group (n=3), patient telephone interviews (n=8), field observations that captured goal-action sequences to complete GENIE, and GENIE utilization statistics. The patients were enrolled in a primary care program-Health TAPESTRY-and Ontario's Health Links Program, which coordinates care for the highest users of the health care system. NVivo 11 (QSR International) was used to support qualitative data analyses related to feasibility and perceived outcomes, and descriptive statistics were used for quantitative data. RESULTS: Most participants reported positive overall perceptions of GENIE. However, feasibility testing showed that participants had a partial understanding of the tool; volunteer facilitation was critical to support the implementation of GENIE; clinicians perceived their navigation ability as superior to that of GENIE supported by volunteers; and tool completion took 39 minutes, which made the home visit too long for some. Usability challenges included difficulties completing some sections of the tool related to medical terminology and unclear instructions, limitations in the quality and quantity of HSSs results, and minor technological challenges. Almost all patients identified a community program or activity of interest. Half of the patients (4/8, 50%) followed up on HSSs and added new members to their network, whereas 1 participant lost a member. Clinicians' strengthened their understanding of patients' personal social networks and needs, and patients felt less social isolation. CONCLUSIONS: This study demonstrated the potential of GENIE, when supported by volunteers, to expand patients' social networks and link them to relevant HSSs. Volunteers require training to implement GENIE for self-management support, which may help overcome the time limitations faced by primary care clinicians. Refining the filtering capability of GENIE to address adults' needs may improve primary care providers' confidence in using such tools.

Engagement of older adults with multimorbidity as patient research partners: Lessons from a patient-oriented research program.

BACKGROUND: Patient "engagement" in health research broadly refers to including people with lived experience in the research process. Although previous reviews have systematically summarized approaches to engaging older adults and their caregivers in health research, there is currently little guidance on how to meaningfully engage older adults with multimorbidity as research partners. OBJECTIVES: This paper describes the lessons learned from a patient-oriented research program, the Aging, Community and Health Research Unit (ACHRU), on how to engage older adults with multimorbidity as research partners. Over the past 7-years, over 40 older adults from across Canada have been involved in 17 ACHRU projects as patient research partners. METHODS: We developed this list of lessons learned through iterative consensus building with ACHRU researchers and patient partners. We then met to collectively identify and summarize the reported successes, challenges and lessons learned from the experience of engaging older adults with multimorbidity as research partners. RESULTS: ACHRU researchers reported engaging older adult partners across many phases of the research process. Five challenges and lessons learned were identified: 1) actively finding patient partners who reflect the diversity of older adults with multimorbidity, 2) developing strong working relationships with patient partners, 3) providing education and support for both patient partners and researchers, 4) using flexible approaches for engaging patients, and 5) securing adequate resources to enable meaningful engagement. CONCLUSION: The lessons learned through this work may provide guidance to researchers on how to facilitate meaningful engagement of this vulnerable and understudied subgroup in the patient engagement literature.

Optimizing the Meaningful Engagement of Older Adults With Multimorbidity and Their Caregivers as Research Partners: A Qualitative Study.

It is widely recognized that the engagement of older adults with multimorbidity and their caregivers as partners in health care research is important and invaluable. The objective of this study was to examine how researchers can best engage and support older adults with multimorbidity and informal friend or family caregivers of older adults with multimorbidity as research partners in health care research teams. The persona-scenario method was used for participants to create fictional stories. These stories were analyzed to shed light on specific strategies that can support older adults and caregivers as partners on health care research teams, such as a patient-centered approach, identifying and addressing barriers to engagement, and clarifying roles and responsibilities on the research team. The results from this study can be used to inform research, policy, and education on supporting older adults with multimorbidity and caregivers of older adults with multimorbidity as research partners.

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.

Study protocol for a hospital-to-home transitional care intervention for older adults with multiple chronic conditions and depressive symptoms: a pragmatic effectiveness-implementation trial.

BACKGROUND: Older adults (> 65 years) with multiple chronic conditions (MCC) and depressive symptoms experience frequent transitions between hospital and home. Care transitions for this population are often poorly coordinated and fragmented, resulting in increased readmission rates, adverse medical events, decreased patient satisfaction and safety, and increased caregiver burden. There is a dearth of evidence on best practices in the provision of transitional care for older adults with MCC and depressive symptoms transitioning from hospital-to-home. This paper presents a protocol for a two-armed, multi-site pragmatic effectiveness-implementation trial of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led six-month intervention that supports older adults with MCC and depressive symptoms transitioning from hospital-to-home. The Collaborative Intervention Planning Framework is being used to engage patients and other key stakeholders in the implementation and evaluation of the intervention and planning for intervention scale-up to other communities. METHODS: Participants will be considered eligible if they are > 65 years, planned for discharged from hospital to the community in three Ontario locations, self-report at least two chronic conditions, and screen positive for depressive symptoms. A total of 216 eligible and consenting participants will be randomly assigned to the control (usual care) or intervention (CAST) arm. The intervention consists of tailored care delivery comprising in-home visits, telephone follow-up and system navigation support. The primary measure of effectiveness is mental health functioning of the older adult participant. Secondary outcomes include changes in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health and social service use and cost, from baseline to 6- and 12-months. Caregivers will be assessed for caregiver strain, depressive symptoms, anxiety, health-related quality of life, and health and social service use and costs. Descriptive and qualitative data from older adult and caregiver participants, and the nurse interventionists will be used to examine implementation of the intervention, how the intervention is adapted within each study region, and its potential for sustainability and scalability to other jurisdictions. DISCUSSION: A nurse-led transitional care strategy may provide a feasible and effective means for improving health outcomes and patient/caregiver experience and reduce service use and costs in this vulnerable population. TRIAL REGISTRATION: # NCT03157999 . Registration Date: April 4, 2017.

Models of Care and Team Activities in the Delivery of Transgender Primary Care: An Ontario Case Study.

Purpose: Transgender individuals experience barriers accessing primary care. In Ontario, primary care is delivered through a variety of delivery models. Literature supports team delivery of primary care for transgender individuals, yet little is known about care delivery in Ontario and the role of primary care teams. We intend to explore how primary care for transgender individuals is delivered within the different primary care models in Ontario and the roles primary care team members enact in care delivery, barriers, enablers, and clinical competence of practitioners in delivering transgender care. Methods: Case study methodology was used to compare transgender care across three Ontario primary care models. Key informants identified cases known to provide transgender care for case selection. Qualitative interviews were conducted. Documentary evidence and field notes were collected. Results: Practitioners clearly articulated their role and activities they were responsible for in providing care, however, they tended to work independently. In cases with an interdisciplinary team there was limited collaboration. Nurse practitioners, physicians, and counselors contributed most to the delivery of care. Key challenges included lack of service coordination within organizations, and the need for practitioner education. Continuing educational sessions, guidelines, and mentorship aided capacity building. Conclusions: Providing primary care to transgender individuals is within the scope of practice for primary care practitioners and can be part of routine care delivered in different models of care. Primary care team collaboration can be strengthened by regular team meetings. Professional training needs to include transgender education and continuing education opportunities need development.

National Competencies for Registered Nurses in Primary Care: A Delphi Study.

A Delphi (consensus) process was used to obtain national agreement on competencies for registered nurses (RNs) in primary care. A draft of competencies was developed by key informants. Following this, nurses with primary care experience/expertise completed a Delphi survey to rate the importance of competency statements on a six-point Likert scale. Statements not reaching consensus (agreement ≥80%) were modified and included in a second (final) round. The first survey was completed by 63% (n = 86/137) of participants and 84% (n = 72/86) of these participants completed the second survey. Most statements (n = 45) achieved agreement after the first survey; one statement was dropped and two were combined following the second round. The final list of competencies consists of 47 statements across six domains (professionalism; clinical practice; communication; collaboration and partnership; quality assurance, evaluation, and research; leadership). National competencies will help strengthen the RN workforce within primary care, improve team functioning, and support role integration/optimization.

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.

An integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A feasibility study.

BACKGROUND: Stroke is the leading cause of death and adult disability in Canada. Eighty percent of older adults (≥65 years) who have suffered a stroke will return to their homes, and 60% will require ongoing rehabilitation. The transition between hospital and home is often fragmented, leading to adverse health outcomes, hospital readmissions, and increased health-care costs. This study examined the feasibility of a 6-month integrated transitional care stroke intervention (TCSI), and explored its effects on health outcomes, patient and provider experience, and cost in 30 community-living older adults (≥55 years) with stroke and multimorbidity (≥2 chronic conditions) using outpatient stroke rehabilitation services. METHODS: The TCSI is a 6-month intervention delivered by an interprofessional (IP) team (occupational therapist, physiotherapist, speech language pathologist, registered nurse, social worker). It involved care coordination, home visiting, and IP case conferences, supported by a web-based application. A qualitative descriptive approach was used to explore the feasibility of implementing the intervention. A prospective one-group pretest/posttest was used to evaluate the effects of the intervention on health outcomes and use and costs of health services, from baseline to 6 months. RESULTS: Participants had an average of eight comorbid conditions. The intervention was feasible and acceptable to both older adults and providers. From baseline to 6 months, there was no statistically significant difference in health outcomes. However, there was a significant reduction in the total per person use and costs of health services. CONCLUSIONS: This study established the feasibility of conducting a larger randomized controlled trial of this intervention.