Addressing quadruple aims through primary care and public health collaboration: ten Canadian case studies.

BACKGROUND: Health systems in Canada and elsewhere are at a crossroads of reform in response to rising economic and societal pressures. The Quadruple Aim advocates for: improving patient experience, reducing cost, advancing population health and improving the provider experience. It is at the forefront of Canadian reform debates aimed to improve a complex and often-fragmented health care system. Concurrently, collaboration between primary care and public health has been the focus of current research, looking for integrated community-based primary health care models that best suit the health needs of communities and address health equity. This study aimed to explore the nature of Canadian primary care - public health collaborations, their aims, motivations, activities, collaboration barriers and enablers, and perceived outcomes. METHODS: Ten case studies were conducted in three provinces (Nova Scotia, Ontario, and British Columbia) to elucidate experiences of primary care and public health collaboration in different settings, contexts, populations and forms. Data sources included a survey using the Partnership Self-Assessment Tool, focus groups, and document analysis. This provided an opportunity to explore how primary care and public health collaboration could serve in transforming community-based primary health care with the potential to address the Quadruple Aims. RESULTS: Aims of collaborations included: provider capacity building, regional vaccine/immunization management, community-based health promotion programming, and, outreach to increase access to care. Common precipitators were having a shared vision and/or community concern. Barriers and enablers differed among cases. Perceived barriers included ineffective communication processes, inadequate time for collaboration, geographic challenges, lack of resources, and varying organizational goals and mandates. Enablers included clear goals, trusting and inclusive relationships, role clarity, strong leadership, strong coordination and communication, and optimal use of resources. Cases achieved outcomes addressing the Q-Aims such as improving access to services, addressing population health through outreach to at-risk populations, reducing costs through efficiencies, and improving provider experience through capacity building. CONCLUSIONS: Primary care and public health collaborations can strengthen community-based primary health care while addressing the Quadruple Aims with an emphasis on reducing health inequities but requires attention to collaboration barriers and enablers.

An evaluation study of caregiver perceptions of the Ontario's Health Links program.

INTRODUCTION: In 2012, the Ontario government launched Health Links (HL), which was designed to integrate care for patients with multimorbidity and complex needs who are high users of health services. This study evaluated perceptions of family and friend caregivers of patients enrolled in the HL program. Research questions included: What are (a) characteristics of caregivers of patients enrolled in HL (b) caregivers' perceptions of the program in relation to HL's guiding principles (patient and family-centred care, accessibility, coordination of services, and continuity of care and care provider) and (c) caregivers' perceptions of the impact of HL on themselves and their care recipient? METHODS: This study involved a survey and qualitative, semi-structured interviews. HL guiding principles (patient and family-centered care, accessibility, coordination of services, and continuity) guided the analysis. RESULTS: Twenty-seven surveys and 16 qualitative interviews were completed. Caregivers reported high levels of strain [Modified Caregiver Strain Index (MCSI) 15.5 (SD 7.03)], mild anxiety [Generalized Anxiety Disorder (GAD 7), 9.6 (SD 6.64)] and depression [Center for Epidemiological Studies Depression Scale (CES-D 10), 11.9 (SD 8.72)]. Regarding the guiding principles, most caregivers had a copy of the HL patient's care plan, although some caregivers noted that their needs were not included in the plan, nor were they asked for input. Caregivers found the program's home and phone visits accessible. Despite minimum wait times for community-based services, other access barriers persisted, (i.e., out-of-pocket costs). HL provided well-coordinated patient services, although some perceived that there was poor team communication. Caregiver perceptions varied on the quality of care provided. Provider continuity provided caregiver relief and patient support: A lack of continuity was related to changes in care coordinators and weekend staff and attrition. CONCLUSIONS: Caregivers of HL patients appreciated patient- and family-centred, accessible, consistent, coordinated and team-based approaches in care. Providers and decision-makers are urged to ensure that programs aimed at high system users address these core concepts while addressing caregivers' needs.

Strengthening primary health care through primary care and public health collaboration: the influence of intrapersonal and interpersonal factors.

AimThe aim of this paper is to examine Canadian key informants' perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration. BACKGROUND: Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context. METHODS: This interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor - effective communication - interacted with all of them. Results support and extend our understanding of what influences successful primary care and public health collaboration at these levels and are important considerations in building and sustaining primary care and public health collaborations.

Navigation delivery models and roles of navigators in primary care: a scoping literature review.

BACKGROUND: Systems navigation provided by individuals or teams is emerging as a strategy to reduce barriers to care. Complex clients with health and social support needs in primary care experience fragmentation and gaps in service delivery. There is great diversity in the design of navigation and a lack of consensus on navigation roles and models in primary care. METHODS: We conducted a scoping literature review following established methods to explore the existing evidence on system navigation in primary care. To be included, studies had to be published in English between 1990 and 2013, and include a navigator or navigation process in a primary care setting that involves the community- based social services beyond the health care system. RESULTS: We included 34 papers in our review, most of which were descriptive papers, and the majority originated in the US. Most of the studies involved studies of individual navigators (lay person or nurse) and were developed to meet the needs of specific patient populations. We make an important contribution to the literature by highlighting navigation models that address both health and social service navigation. The emergence and development of system navigation signals an important shift in the recognition that health care and social care are inextricably linked especially to address the social determinants of health. CONCLUSIONS: There is a high degree of variance in the literature, but descriptive studies can inform further innovation and development of navigation interventions in primary care.

What systemic factors contribute to collaboration between primary care and public health sectors? An interpretive descriptive study.

BACKGROUND: Purposefully building stronger collaborations between primary care (PC) and public health (PH) is one approach to strengthening primary health care. The purpose of this paper is to report: 1) what systemic factors influence collaborations between PC and PH; and 2) how systemic factors interact and could influence collaboration. METHODS: This interpretive descriptive study used purposive and snowball sampling to recruit and conduct interviews with PC and PH key informants in British Columbia (n = 20), Ontario (n = 19), and Nova Scotia (n = 21), Canada. Other participants (n = 14) were knowledgeable about collaborations and were located in various Canadian provinces or working at a national level. Data were organized into codes and thematic analysis was completed using NVivo. The frequency of "sources" (individual transcripts), "references" (quotes), and matrix queries were used to identify potential relationships between factors. RESULTS: We conducted a total of 70 in-depth interviews with 74 participants working in either PC (n = 33) or PH (n = 32), both PC and PH (n = 7), or neither sector (n = 2). Participant roles included direct service providers (n = 17), senior program managers (n = 14), executive officers (n = 11), and middle managers (n = 10). Seven systemic factors for collaboration were identified: 1) health service structures that promote collaboration; 2) funding models and financial incentives supporting collaboration; 3) governmental and regulatory policies and mandates for collaboration; 4) power relations; 5) harmonized information and communication infrastructure; 6) targeted professional education; and 7) formal systems leaders as collaborative champions. CONCLUSIONS: Most themes were discussed with equal frequency between PC and PH. An assessment of the system level context (i.e., provincial and regional organization and funding of PC and PH, history of government in successful implementation of health care reform, etc) along with these seven system level factors could assist other jurisdictions in moving towards increased PC and PH collaboration. There was some variation in the importance of the themes across provinces. British Columbia participants more frequently discussed system structures that could promote collaboration, power relations, harmonized information and communication structures, formal systems leaders as collaboration champions and targeted professional education. Ontario participants most frequently discussed governmental and regulatory policies and mandates for collaboration.

Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review.

BACKGROUND: Since the early 90s, patient navigation programs were introduced in the United States to address inequitable access to cancer care. Programs have since expanded internationally and in scope. The goals of patient navigation programs are to: a) link patients and families to primary care services, specialist care, and community-based health and social services (CBHSS); b) provide more holistic patient-centred care; and, c) identify and resolve patient barriers to care. This paper fills a gap in knowledge to reveal what is known about motivators and factors influencing implementation and maintenance of patient navigation programs in primary care that link patients to CBHSS. It also reports on outcomes from these studies to help identify gaps in research that can inform future studies. METHODS: This scoping literature review involved: i) electronic database searches; ii) a web site search; iii) a search of reference lists from literature reviews; and, iv) author follow up. It included papers from Canada, the United States, the United Kingdom, Australia, New Zealand, and/or Western Europe published between January 1990 and June 2013 if they discussed navigators or navigation programs in primary care settings that linked patients to CBHSS. RESULTS: Of 34 papers, most originated in the United States (n = 29) while the remainder were from the United Kingdom, Canada and Australia. Motivators for initiating navigation programs were to: a) improve delivery of health and social care services; b) support and manage specific health needs or specific population needs, and; c) improve quality of life and wellbeing of patients. Eleven factors were found to influence implementation and maintenance of these patient navigation programs. These factors closely aligned with the Diffusion of Innovation in Service Organizations model, thus providing a theoretical foundation to support them. Various positive outcomes were reported for patients, providers and navigators, as well as the health and social care system, although they need to be considered with caution since the majority of studies were descriptive. CONCLUSIONS: This study contributes new knowledge that can inform the initiation and maintenance of primary care patient navigation programs that link patients with CBHSS. It also provides directions for future research.

Built environment interventions aimed at improving physical activity levels in rural Ontario health units: a descriptive qualitative study.

BACKGROUND: Few studies to date have explored the relationship between the built environment and physical activity specifically in rural settings. The Ontario Public Health Standards policies mandate that health units in Ontario address the built environment; however, it is unclear how public health practitioners are integrating the built environment into public health interventions aimed at improving physical activity in chronic disease prevention programs. METHODS: This descriptive qualitative study explored interventions that have or are being implemented which address the built environment specifically related to physical activity in rural Ontario health units, and the impact of these interventions. Data were collected through twelve in-depth semi-structured interviews with rural public health practitioners and managers representing 12 of 13 health units serving rural communities. Key themes were identified using qualitative content analysis. RESULTS: Themes that emerged regarding the types of interventions that health units are employing included: Engagement with policy work at a municipal level; building and working with community partners, committees and coalitions; gathering and providing evidence; developing and implementing programs; and social marketing and awareness raising. Evaluation of interventions to date has been limited. CONCLUSIONS: Public health interventions, and their evaluations, are complex. Health units who serve large rural populations in Ontario are engaging in numerous activities to address physical activity levels. There is a need to further evaluate the impact of these interventions on population health.

Community health nurses' learning needs in relation to the Canadian community health nursing standards of practice: results from a Canadian survey.

BACKGROUND: CANADIAN COMMUNITY HEALTH NURSES (CHNS) WORK IN DIVERSE URBAN, RURAL, AND REMOTE SETTINGS SUCH AS: public health units/departments, home health, community health facilities, family practices, and other community-based settings. Research into specific learning needs of practicing CHNs is sparsely reported. This paper examines Canadian CHNs learning needs in relation to the 2008 Canadian Community Health Nursing Standards of Practice (CCHN Standards). It answers: What are the learning needs of CHNs in Canada in relation to the CCHN Standards? What are differences in CHNs' learning needs by: province and territory in Canada, work setting (home health, public health and other community health settings) and years of nursing practice? METHODS: Between late 2008 and early 2009 a national survey was conducted to identify learning needs of CHNs based on the CCHN Standards using a validated tool. RESULTS: Results indicated that CHNs had learning needs on 25 of 88 items (28.4%), suggesting CHNs have confidence in most CCHN Standards. Three items had the highest learning needs with mean scores > 0.60: two related to epidemiology (means 0.62 and 0.75); and one to informatics (application of information and communication technology) (mean = 0.73). Public health nurses had a greater need to know about "…evaluating population health promotion programs systematically" compared to home health nurses (mean 0.66 vs. 0.39, p <0.010). Nurses with under two years experience had a greater need to learn "… advocating for healthy public policy…" than their more experienced peers (p = 0.0029). Also, NPs had a greater need to learn about "…using community development principles when engaging the individual/community in a consultative process" compared to RNs (p = 0.05). Many nurses were unsure if they applied foundational theoretical frameworks (i.e., the Ottawa Charter of Health Promotion, the Jakarta Declaration, and the Population Health Promotion Model) in practice. CONCLUSIONS: CHN educators and practice leaders need to consider these results in determining where to strengthen content in graduate and undergraduate nursing programs, as well as professional development programs. For practicing CHNs educational content should be tailored based on learner's years of experience in the community and their employment sector.

Online communities of practice as a communication resource for community health nurses working with homeless persons.

AIMS: This study explored community health nurses' viewpoints about a Canadian online community of practice to support their practice with homeless or under-housed populations. BACKGROUND: Community health nurses who specifically work with homeless and marginally housed populations often report feelings of isolation and stress in managing complex problems in resource constraints. To strengthen intra-professional ties and enhance information access, an online community of practice was designed, implemented and evaluated by and for them. METHODS: Q-methodology was used. Sixty-six statements about the community of practice were collected from an online survey and focus groups, refined and reduced to 44 statements. In 2009, sixteen participants completed the Q-sort activity, rating each statement relative to the others. Scores for each participant were subjected to by-person factor analysis. RESULTS: Respondents fell into two groups -tacit knowledge warriors and tacit knowledge communicators. Warriors strongly believed that the community of practice could combat stigma associated with homelessness and promote awareness of homelessness issues, and valued its potential to validate and improve practice. Communicators would have used the community of practice more with increased discussion, facilitation and prompt responses. Generally, nurses viewed the community of practice as a place to share stories, validate practice and adapt best practices to their work context. CONCLUSIONS: Online communities of practice can be valuable to nurses in specialized fields with limited peer support and access to information resources. Tacit knowledge development is important to nurses working with homeless populations: this needs to be valued in conjunction with scientifically based knowledge.

A questionnaire for assessing community health nurses' learning needs.

Learning needs assessment is an important stage of every educational process that aims to inform changes in practice and policy for continuing professional development. Professional competencies have been widely used as a basis for the development of learning needs assessment. The Canadian Community Health Nursing Standards of Practices (CCHN Standards) were released in 2003. However, it is not known whether community health nurses (CHNs) have the educational background to enable them to meet these standards. This article reports on the development of a learning needs assessment questionnaire for CHNs. Exploratory and confirmatory factor analyses were conducted to examine the consistency of factors underpinning the CCHN Standards. Also, validity and reliability of the questionnaire were evaluated using appropriate techniques. This process resulted in a valid and reliable CHN learning needs assessment questionnaire to measure learning needs of large groups of practitioners, where other forms of measurement cannot be feasibly conducted.

Nurse faculty perceptions of simulation use in nursing education.

In this study nursing faculty perceptions of the implementation of simulation in schools of nursing across Ontario, Canada, were explored using the Q-methodology technique. Following Q-methodology guidelines, 104 statements were collected from faculty and students with exposure to simulation to determine the concourse (what people say about the issue). The statements were classified into six domains, including teaching and learning, access/reach, communication, technical features, technology set-up and training, and comfort/ease of use with technology. They were then refined into 43 final statements for the Q-sample. Next, 28 faculty from 17 nursing schools participated in the Q-sorting process. A by-person factor analysis of the Q-sort was conducted to identify groups of participants with similar viewpoints. Results revealed four major viewpoints held by faculty including: (a) Positive Enthusiasts, (b) Traditionalists, (c) Help Seekers, and (d) Supporters. In conclusion, simulation was perceived to be an important element in nursing education. Overall, there was a belief that clinical simulation requires (a) additional support in terms of the time required to engage in teaching using this modality, (b) additional human resources to support its use, and (c) other types of support such as a repository of clinical simulations to reduce the time from development of a scenario to implementation. Few negative voices were heard. It was evident that with correct support (human resources) and training, many faculty members would embrace clinical simulation because it could support and enhance nursing education.

Preparing the community health nursing workforce: internal and external enablers and challenges influencing undergraduate nursing programs in Canada.

The Canadian Schools of Nursing (CASN) task force on public health was mandated to facilitate Schools of Nursing to provide students with the foundation required to meet the Canadian Community Health Nursing Standards of Practice. This paper reports on an environmental scan that explored barriers and enablers influencing the integration of community health nursing content in baccalaureate education in Canada. Data was collected over three phases including: 1) a pan-Canadian survey of nursing schools, 2) completion of open-ended workbook questions by educators, policy makers, administrators, and community health nursing managers attending a pan-Canadian symposium on community health nursing, and 3) recorded notes from the symposium. The response rate for the survey was 72.5% (n = 61 schools) and approximately 125 stakeholders participated in symposium activities. Internal and external enablers and challenges as well as recommendations for practice and education are presented.

Online discussions with pregnant and parenting adolescents: perspectives and possibilities.

The Internet is an innovative strategy to increase public participation. It is important to include pregnant and parenting teens' perspectives when planning programs to meet their needs. This qualitative study explored online discussions as a strategy to enhance participation by this population. Findings showed that online communication was preferred over face-to-face group discussions. Being anonymous online encouraged open and honest feedback. Participants experienced various forms of social support, however, there was an overall lack of teen involvement online. Strategies to engage adolescents in online discussions and reduce barriers are discussed. Strategies included the use of teen moderators, home computer access, technical support, and engagement in naturally flowing online discussions to meet social support needs. Blending researchers' with teens' needs for social support in an online environment is encouraged. With careful planning and design, online communications can result in mutual benefits for researchers, service providers, and pregnant and parenting adolescents.

Problem-based learning online: perceptions of health science students.

This qualitative study explored health sciences students' perceptions of their experiences in online problem based learning (PBL) and focused on their views about learning and group process in the online environment. Participants were novices to online learning and highly experienced in PBL, therefore, they could reflect on past face-to-face PBL experiences. Three groups of learners were involved, including undergraduate nursing and midwifery students and graduate students in a neonatal nurse practitioner program. Findings are presented using the six steps of the PBL process (Rideout & Carpio, 2001). Results indicated that it is feasible to conduct PBL online. Students felt that it increased their flexibility for learning, enhanced their ability to deeply process content, and provided access to valuable learning resources. Students experienced a period of adaptation to the online environment, perceived a heavy workload, and had difficulties making group decisions online. In addition to using asynchronous communication, chats (synchronous communication) were valued to support group decision-making online. Students appreciated validation of their online contributions from their peers and wanted clear expectations of what constituted successful tutorial participation from their tutors. Although online PBL can work effectively, tutors and students need to develop online literacy skills to smooth their transition to an online PBL environment.

A Severe Acute Respiratory Syndrome Extranet: supporting local communication and information dissemination.

BACKGROUND: The objective of this study was to explore the use and perceptions of a local Severe Acute Respiratory Syndrome (SARS) Extranet and its potential to support future information and communication applications. The SARS Extranet was a single, managed electronic and limited access system to manage local, provincial and other SARS control information. METHODS: During July, 2003, a web-based and paper-based survey was conducted with 53 SARS Steering Committee members in Hamilton. It assessed the use and perceptions of the Extranet that had been built to support the committee during the SARS outbreak. Before distribution, the survey was user-tested based on a think-aloud protocol, and revisions were made. Quantitative and qualitative questions were asked related to frequency of use of the Extranet, perceived overall usefulness of the resource, rationale for use, potential barriers, strengths and limitations, and potential future uses of the Extranet. RESULTS: The response rate was 69.4% (n = 34). Of all respondents, 30 (88.2%) reported that they had visited the site, and rated it highly overall (mean = 4.0; 1 = low to 5 = high). However, the site was rated 3.4 compared with other communications strategies used during the outbreak. Almost half of all respondents (44.1%) visited the site at least once every few days. The two most common reasons the 30 respondents visited the Extranet were to access SARS Steering Committee minutes (63.3%) and to access Hamilton medical advisories (53.3%). The most commonly cited potential future uses for the Extranet were the sending of private emails to public health experts (63.3%), and surveillance (63.3%). No one encountered personal barriers in his or her use of the site, but several mentioned that time and duplication of email information were challenges. CONCLUSION: Despite higher rankings of various communication strategies during the SARS outbreak, such as email, meetings, teleconferences, and other web sites, users generally perceived a local Extranet as a useful support for the dissemination of local information during public health emergencies.

Public health nurses' perceptions of mobile computing in a school program.

The use of mobile computing (MC) in healthcare practice has grown substantially in recent years, yet little is known about its impact. This descriptive, exploratory, qualitative study explored the perceptions of public health nurses (PHNs) in a school health program about their use of MC. Public health nurses participated in focus group interviews and completed weekly reflections. They perceived that MC (a) increased PHNs' flexibility although they were constrained by work rules, (b) increased peer and employer connectedness yet increased isolation, (c) and increased PHNs' status while creating a wider gap between PHNs and their clients. Public health nurses described their practice as being more efficient and client-focused with MC. Over time, PHNs grew more comfortable with the tool, developed a dependence on it, and learned to deal with technological problems. Although this new technology shows promise, there is a need for further research to examine its impact as a tool to promote public health nursing practice.

Computers and the internet: tools for youth empowerment.

BACKGROUND: Youth are often disenfranchised in their communities and may feel they have little voice. Since computers are an important aspect of youth culture, they may offer solutions to increasing youth participation in communities. OBJECTIVE: This qualitative case study investigated the perceptions of 19 (predominantly female) inner-city school youth about their use of computers and the Internet in a school-based community development project. METHODS: Youth working with public health nurses in a school-based community development project communicated with local community members using computer-mediated communication, surveyed peers online, built websites, searched for information online, and prepared project materials using computers and the Internet. Participant observation, semistructured interviews, analysis of online messages, and online- and paper-based surveys were used to gather data about youth's and adults' perceptions and use of the technologies. Constant comparison method and between-method triangulation were used in the analysis to satisfy the existence of themes. RESULTS: Not all youth were interested in working with computers. Some electronic messages from adults were perceived to be critical, and writing to adults was intimidating for some youth. In addition, technical problems were experienced. Despite these barriers, most youth perceived that using computers and the Internet reduced their anxiety concerning communication with adults, increased their control when dealing with adults, raised their perception of their social status, increased participation within the community, supported reflective thought, increased efficiency, and improved their access to resources. CONCLUSIONS: Overall, youth perceived computers and the Internet to be empowering tools, and they should be encouraged to use such technology to support them in community initiatives.