What Do We Know About Nurse Practitioner/Physician Care Models in Long-Term Care: Results of a Scoping Review.

OBJECTIVES: Due to the rise of the nurse practitioner (NP) role in long-term care settings, it is important to understand the underlying structures and processes that influence NP and physician care models. This scoping review aims to answer the question, "What are the structures, processes, and outcomes of care models involving NPs and physicians in long-term care (LTC) homes?" A secondary aim was to describe the structural enablers and barriers across care models. RESEARCH DESIGN AND METHODS: Seven databases were searched. Studies that described NPs and physicians working in LTC were identified and included in the review. We stratified the findings by care model and synthesized using the Donabedian model, which evaluates health care quality based on 3 dimensions: structure, process, and outcome. We then categorized macro, meso, and micro structural enablers and barriers. RESULTS: Sixty papers were included in the review. The main structural influencers within 5 care models included policies on scope of practice, clarity of role description, and workload. A limited number of papers referred to the process of enabling the development of a working relationship. Thirty-five (49%) studies described resident, staff, and health system outcomes. CONCLUSIONS AND IMPLICATIONS: Although structural characteristics of NP and physician care models are described in-depth, there is less detail on the processes that occur within the NP and physician care models. We highlight structural barriers and enablers within the care models, allowing for recognition of the importance of organizational influence on the NP and physician relationship. Future work should focus on the processes of the relationships in the models by identifying the drivers and initiators of collaboration between NPs and physicians and how these relationships influence outcomes.

Applicant and Match Trends to Geriatric-Focused Postgraduate Medical Training in Canada: A Descriptive Analysis.

Physicians with postgraduate training in caring for older adults-geriatricians, geriatric psychiatrists, and Care of the Elderly family physicians (FM-COE)-have expertise in managing complex care needs. Deficits in the geriatric-focused physician workforce coupled with the aging demographic necessitate an increase in training and clinical positions. Descriptive analyses of data from established matching systems have not occurred to understand the preferences and outcomes of applicants to geriatric-focused postgraduate training. This study describes applicant and match trends for geriatric-focused postgraduate training in Canada. In this retrospective cohort study, data from the Canadian Resident Matching Service and FM-COE program directors were analysed to examine program quotas, applicants' preferences, and match outcomes by medical school and over time. Based on their first-choice specialty ranking, applicants to geriatric medicine and FM-COE signalled a preference to pursue these programs and tended to match successfully. The proportion of unfilled training positions has increased in recent years, and the number of applicants has not increased consistently over time. There is a disparity between applicants to geriatric-focused training and the health human resources to meet population-level needs. Garnering interest among medical trainees is essential to address access and equity gaps.

A scoping review to inform the development of dementia care competencies.

Health professionals and care partners of persons living with dementia have expressed that learning needs related to dementia care are a priority. There are currently a variety of training programs available in Ontario (Canada) to address aspects of dementia care, but no commonly accepted description of the core knowledge, skills, and abilities, (i.e., competencies) that should underpin dementia-related training and education in the province. The aim of this study was to review current evidence to inform the later development of competency statements describing the knowledge, skills and actions required for dementia care among care providers ranging from laypersons to health professionals. We also sought to validate existing dementia care principles and align new concepts to provide a useful organizing framework for future competency development. We distinguished between micro-, meso- and macro-level concepts to clarify the competencies required by individuals situated in different locations across the healthcare system, linking competency development in dementia care to broader system transformation. This review precedes the co-development of a holistic competency framework to guide approaches to dementia care training in Ontario.

Nurse practitioner/physician collaborative models of care: a scoping review protocol.

BACKGROUND: Before the COVID-19 pandemic, many long-term care (LTC) homes experienced difficulties in providing residents with access to primary care, typically delivered by community-based family physicians or nurse practitioners (NPs). During the pandemic, legislative changes in Ontario, Canada enabled NPs to act in the role of Medical Directors thereby empowering NPs to work to their full scope of practice. Emerging from this new context, it remains unclear how NPs and physicians will best work together as primary care providers. NP/physician collaborative models appear key to achieving optimal resident outcomes. This scoping review aims to map available evidence on existing collaborative models of care between NPs and physicians within LTC homes. METHODS: The review will be guided by the research question, "What are the structures, processes and outcomes of collaborative models of care involving NPs and Physicians in LTC homes?" This scoping review will be conducted according to the methods framework for scoping reviews outlined by Arksey and O'Malley and refined by Levac et al., Colquhoun et al., and Daudt et al., as well as the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Statement. Electronic databases (MEDLINE, Embase + Embase Classic, APA PsycInfo, Cochrane Central Register of Controlled Trials, AMED, CINAHL, Ageline, and Scopus), grey literature, and reference lists of included articles will be searched. English language studies that describe NP and physician collaborative models within the LTC setting will be included. DISCUSSION: This scoping review will consolidate what is known about existing NP/physician collaborative models of care in LTC homes. Results will be used to inform the development of a collaborative practice framework for long-term care clinical leadership.

A Near Four-Decade Time Series Shows the Hawaiian Islands Have Been Browning Since the 1980s.

The Hawaiian Islands have been identified as a global biodiversity hotspot. We examine the Normalized Difference Vegetation Index (NDVI) using Climate Data Records products (0.05 × 0.05°) to identify significant differences in NDVI between neutral El Niño-Southern Oscillation years (1984, 2019) and significant long-term changes over the entire time series (1982-2019) for the Hawaiian Islands and six land cover classes. Overall, there has been a significant decline in NDVI (i.e., browning) across the Hawaiian Islands from 1982 to 2019 with the islands of Lana'i and Hawai'i experiencing the greatest decreases in NDVI (≥44%). All land cover classes significantly decreased in NDVI for most months, especially during the wet season month of March. Native vegetation cover across all islands also experienced significant declines in NDVI, with the leeward, southwestern side of the island of Hawai'i experiencing the greatest declines. The long-term trends in the annual total precipitation and annual mean Palmer Drought Severity Index (PDSI) for 1982-2019 on the Hawaiian Islands show significant concurrent declines. Primarily positive correlations between the native ecosystem NDVI and precipitation imply that significant decreases in precipitation may exacerbate the decrease in NDVI of native ecosystems. NDVI-PDSI correlations were primarily negative on the windward side of the islands and positive on the leeward sides, suggesting a higher sensitivity to drought for leeward native ecosystems. Multi-decadal time series and spatially explicit data for native landscapes provide natural resource managers with long-term trends and monthly changes associated with vegetation health and stability.

Interprofessional primary care: indispensable for family physicians yet invisible to older patients.

There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.

Updated Inventory and Projected Requirements for Specialist Physicians in Geriatrics.

BACKGROUND: The predicted growth of Canadians aged 65+ and the resultant rise in the demand for specialized geriatric services (SGS) requires physician resource planning. We updated the 2011 Canadian Geriatrics Society physician resource inventory and created projections for 2025 and 2030. METHODS: The number and full-time equivalents (FTEs) of geriatricians and Care of the Elderly (COE) physicians working in SGS were determined. FTE counts for 2025 and 2030 were estimated by accounting for retirements and trainees. A ratio of 1.25/10,000 population 65+ was used to predict physician resource requirements. RESULTS: Between 2011 and 2019 the number of geriatricians and COE physicians increased from 276 (235.8 FTEs) and 128 (89.9 FTEs), respectively, to 376 (319.6 FTEs) and 354 (115.5 FTEs). This increase did not keep pace with the 65+ population growth. The current gap between supply and need is expected to increase. DISCUSSION: The physician supply gap is projected to widen in 2025 and 2030. Increased recruitment and interdisciplinary team-based care, supported by enhanced funding models, and full integration of COE physicians in SGS could reduce this increasing gap. In contrast to pediatrician supply in Canada, the specialist physician resources available to the population 65+ reflect a disparity.

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care.

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.

Ontario Geriatric Specialist Physician Resources 2018.

BACKGROUND: The number of older adults with complex health needs in Ontario is growing. The Ministry of Health and Long-Term Care requested a resource mapping project to assess the current 2018 and projected 2025 number of specialist physician resources. METHODS: Geriatric specialist physicians were defined as geriatricians, geriatric psychiatrists, and Care of the Elderly (COE) physicians. We determined the current number of geriatricians, geriatric psychiatrists, and COEs and clinical full-time-equivalent complement (CFTE) for geriatric medicine and geriatric psychiatry specialists. We projected the number of new trainees expected to enter practice and the number of physicians expected to retire by 2025. We compared these numbers and projections against established specialist/population ratios for geriatricians and geriatric psychiatrists. RESULTS: There was a deficit of geriatricians and geriatric psychiatrists (geriatricians: CFTE deficit of 150.5; geriatric psychiatrists: CFTE deficit of 116.3). In 2025, the projected CFTE deficit of geriatricians will increase to at least 210.35 and geriatric psychiatrists to 194.6. Only about 30% of COE physicians work in direct support of specialized services for the elderly. CONCLUSIONS: There is significant current and anticipated undersupply in the required number of geriatricians, geriatric psychiatrists, and COE physicians to meet anticipated population demand.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions.

BACKGROUND: Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario. METHODS: Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation. RESULTS: The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period. CONCLUSIONS: Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions.

Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario. Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation. The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period. Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Goal-Based Care Planning in Regional Geriatric Services for Older Persons Living with Frailty.

BACKGROUND: Older adults living with frailty represent a complex group who are increasingly accessing regional geriatric services. Goal-based care planning is the industry standard in the care of older adults, yet few studies illustrate how goal-based care planning is being conducted with this population. Understanding how frailty impacts goal-based care planning in regional geriatric services is key to improving patient care. METHODS: In this "Go-Along" method of data collection, nine observational experiences were conducted, nine responses from the Interprofessional Role Shadowing Tool were obtained, and eight responses to follow-up questions were received. Open coding of the data was performed retrospectively, and indexed themes were identified. RESULTS: Although the Geriatric Clinicians indicated that goal-based care planning and frailty were central to practice, the observations indicated no clear process to patient-centred goal-setting or frailty identification in practice. The results infer a gap between theoretical knowledge and practical application. CONCLUSIONS: A clear process to goal-based care planning in interprofessional geriatric services is needed. This objective requires practical education that emphasizes the skills necessary to implement goal-setting within unique, interprofessional care environments. Further research is necessary to establish if frailty identification is necessary in goal-based care planning, or if a patient-centred approach is more advantageous in practice.

Academic family health teams: Part 2: patient perceptions of access.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on patients' perceptions of access and patients' satisfaction with services. DESIGN: Self-administered survey. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Answers to questions about access from the Primary Care Assessment Tool Adult Expanded Version, the Primary Care Assessment Survey, and research team questions. RESULTS: The response rate was 47.3% (1026 of 2167). The mean (SD) Primary Care Assessment Tool first-contact accessibility score was 2.28 (0.36) out of 4, with 96.5% of patients rating access less than 3, which was the minimum expected level of care. Two-thirds (66.6%) indicated someone from their aFHTs would definitely or probably see them the same day if they were sick, 56.8% could definitely or probably get advice quickly by telephone, and 14.5% indicated it was definitely or probably difficult to be seen by their primary health care provider (HCP). Additionally, 46.9% indicated they would like to get medical advice by e-mail. For a routine or follow-up visit, 73.4% would be willing to see another aFHT physician if their regular provider were unavailable, while only 48.3% would see a nonphysician HCP. If sick, 88.2% would see another aFHT physician and 55.2% would see a nonphysician HCP. Most (75.3%) were satisfied with access to their regular HCP. CONCLUSION: Although patients are generally satisfied with care, there is room for improvement in access. Strategies are needed to enhance access to care, including addressing appropriate roles and scopes of practice for nonphysician HCPs. The accessibility challenges for aFHTs will likely affect new family physicians and other HCPs training in these practices and their approach to future practice.

Academic family health teams: Part 1: patient perceptions of core primary care domains.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on the 4 core domains of PC. DESIGN: Self-administered survey using the Primary Care Assessment Tool Adult Expanded Version (PCAT), which addresses 4 core domains of PC (first contact, continuity, comprehensiveness, and coordination). The PCAT uses a 4-point Likert scale (from definitely not to definitely) to capture patients' responses about the occurrence of components of care. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Mean PCAT domain scores, with a score of 3 chosen as the minimum expected level of care. Multivariate log binomial regression models were used to estimate the adjusted relative risks of PCAT score levels as functions of patient- and clinic-level characteristics. RESULTS: The response rate was 47.3% (1026 of 2167). The mean age of respondents was 49.6 years, and most respondents were female (71.6%). The overall PC score (2.92) was just below the minimum expected care level. Scores for first contact (2.28 [accessibility]), coordination of information systems (2.67), and comprehensiveness of care (2.83 [service available] and 2.36 [service provided]) were below the minimum. Findings suggest some patient groups might not be optimally served by aFHTs, particularly recent immigrants. Characteristics of aFHTs, including a large number of physicians, were not associated with high performance on PC domains. Distributed practices across multiple sites were negatively associated with high performance for some domains. The presence of electronic medical records was not associated with improved performance on coordination of information systems. CONCLUSION: Patients of these aFHTs rated several core domains of PC highly, but results indicate room for improvement in several domains, particularly first-contact accessibility. A future study will determine what changes were implemented in these aFHTs and if patient ratings have improved. This reflective process is essential to ensuring that aFHTs provide effective models of PC to learners of all disciplines.

Using patient history to distinguish between patients with non-epileptic and patients with epileptic events.

Information obtained during psychological evaluations of 93 patients with epileptic events (EEs) and 63 with nonepileptic events (NEEs) was used to test the relative contributions of multiple risk factors to prediction of NEEs during video/EEG monitoring. The best group of independent predictors of NEEs comprised: (1) age at first spell, (2) symptoms of a psychiatric diagnosis other than anxiety or depression, (3) marital instability, (4) symptoms of an anxiety disorder other than panic disorder, and (5) years of education. Report of childhood abuse or neglect and taking psychotropic medication correlated with most of the other risk factors for NEEs. It may not be necessary to gather data on all of the variables shown to be associated with NEEs. Although there is a high prevalence of risk factors for psychopathology in patients with EEs, it is lower compared with that of patients with NEEs, and patients with EEs are less likely to report multiple risk factors.