Quality of palliative and end-of-life care: a quantitative study of temporal trends and differences according to illness trajectories in Quebec (Canada).

BACKGROUND: Our aim was to assess temporal trends and compare quality indicators related to Palliative and End-of-Life Care (PEoLC) experienced by people dying of cancer (trajectory I), organ-failure (Trajectory II), and frailty/dementia (trajectory III) in Quebec (Canada) between 2002 and 2016. METHODS: This descriptive population-based study focused on the last month of life of decedents who, based on the principal cause of death, would have been likely to benefit from palliative care. Five PEoLC indicators were assessed: home deaths (1), deaths in acute care beds with no PEoLC services (2), at least one Emergency Room (ER) visit in the last 14 days of life (3), ER visits on the day of death (4) and at least one Intensive Care Unit (ICU) admission in the last month of life (5). Data were obtained from Quebec's Integrated Chronic Disease Surveillance System (QICDSS). RESULTS: The annual percentage of home deaths increased slightly between 2002 and 2016 in Quebec, rising from 7.7 to 9.1%, while the percentage of death during a hospitalization in acute care without palliative care decreased from 39.6% in 2002 to 21.4% in 2016. Patients with organ failure were more likely to visit the ER on the day of death (20.9%) than patients dying of cancer and dementia/frailty with percentages of 12.0% and 6.4% respectively. Similar discrepancies were observed for ICU visits in the last month and ER visits in the last 14 days. CONCLUSION: PEoLC indicators showed more aggressiveness of care for patients with organ failure and highlight the need for more equitable access to quality PEoLC between malignant and non-malignant illness trajectories. These results underline the challenges of providing timely and optimal PEoLC.

Clinical and Organizational Nursing Innovations in Primary Care: Findings From a Stakeholders' Symposium.

Nursing innovations in primary care, based on interprofessional care models, could be better identified, recognized, and deployed. This article presents the results of a symposium discussing the implementation of nursing innovations in primary care in Quebec, Canada, in partnership with researchers and stakeholders. Built on the appreciative inquiry approach, 9 nursing innovations were described. To support the implementation of such nursing innovations responding to current primary care issues and population needs, 4 recommendations emerged: the need to implement strategies to achieve optimal scope of practice for primary care nurses; the importance to develop funding and organizational models that support primary care nursing innovation; the need to enhance a collaborative and democratic governance open to innovation; and the opportunity to create partnerships with the research community and teaching institutions.

Effectiveness of emergency department based interventions for frequent users with mental health issues: A systematic review.

Frequent emergency department (ED) users with mental health issues are particularly vulnerable patients, who often receive insufficient or inadequate outpatient care. This systematic review identified and evaluated studies on ED-based interventions to reduce acute care use by this population, while improving outpatient service use and patient outcomes. Searches were conducted in five databases for studies published between January 1, 2000, and April 30, 2022. Eligibility criteria included: patients with mental health issues who made 2+ ED visits in the previous 6 months or were high ED users (3+ visits/year), and who received ED-based interventions to reduce ED use. The review included 12 studies of 11,082 articles screened. Four intervention groups were identified: care plan (n = 4), case management (n = 4), peer-support (n = 2) and brief interventions (n = 2). The definitions of frequent users varied considerably, while the quality assessment rated studies from moderate to good and risk of bias from low to high. Eight studies used pre-post design, and four were randomized controlled trials. Ten studies assessed outcomes related to use of other services than ED, mainly hospitalizations, while five assessed patients' clinical conditions and three, social conditions (e.g., housing status). This review revealed that case management and care plan interventions, based in ED, decrease ED use among frequent users, while case management also showed promising results for outpatient service use and clinical and social outcomes. Thus, the results support continued deployment of intensive ED-based interventions for frequent ED users with mental health issues although firm conclusions regarding the effectiveness of these interventions, particularly outcomes related to services other than ED, require further investigation.

Supporting Reassigned Hospital Staff During the COVID-19 Pandemic in the Montreal Region: What Does it say About Leadership Styles?

Globally, the COVID-19 pandemic took a high toll on health human resources, especially in contexts where these resources were already fragile. In Quebec, to make up for the shortage of health human resources, and to contain the COVID-19 outbreaks in long-term care facilities, many hospital staff (including a majority of nurses) were sent to those facilities, with varying degrees of support. Building on the body of evidence linking leadership style and resilience, we conducted a qualitative comparative analysis of two hospitals in the Montreal Metropolitan Area, Quebec. We explored respondents' experience of psychosocial support tools provided to hospital staff reassigned to COVID-affected facilities. Data from 27 in-depth interviews with high- and mid-level managers, and front-line workers, was analyzed through the lens of leadership styles. Our findings highlighted how the design and implementation of support tools revealed major differences across the two hospitals' leadership styles (i.e., one hospital expressing leader-centered styles vs. the other expressing follower-centered leadership styles). The expression of these leadership styles was largely shaped by recent policies, notably a major political reform of 2015, which enforced more centralized decision-making. Our study offered additional empirical evidence that leadership styles fostering the recovery of health human resources may be a key indicator of successful response to crises.

Adapting Hospital Work During COVID-19 in Quebec (Canada).

Among hospital responses to the COVID19 pandemic worldwide, service reorganization and staff reassignment have been some of the most prominent ways of adapting hospital work to the expected influx of patients. In this article, we examine work reorganization induced by the pandemic by identifying the operational strategies implemented by two hospitals and their staff to contend with the crisis and then analyzing the implications of those strategies. We base our description and analysis on two hospital case studies in Quebec. We used a multiple case study approach, wherein each hospital is considered a unique case. In both cases, work adaptation through staff reassignment was one of the critical measures undertaken to ensure absorption of the influx of patients into the hospitals. Our results showed that this general strategy was designed and applied differently in the two cases. More specifically, the reassignment strategies revealed numerous healthcare resource disparities not only between health territories, but also between different types of facilities within those territories. Comparing the two hospitals' adaptation strategies showed that past reforms in Quebec determined what these reorganizations could achieve, as well as how they would affect workers and the meaning they gave to their work.

How Did an Integrated Health and Social Services Center in the Quebec Province Respond to the COVID-19 Pandemic? A Qualitative Case Study.

During the first and second waves of the pandemic, Quebec was among the Canadian provinces with the highest COVID-19 mortality rates. Facing particularly large COVID-19 outbreaks in its facilities, an integrated health and social services center in the province of Quebec (Canada), developed resilience strategies. To explore these diverse responses to the crisis, we conducted a case study analysis of a Quebec integrated health and social services center, building on a conceptualization of resilience strategies using "configurations" of effects, strategies, and impacts. Qualitative data from 14 indepth interviews conducted in the summer and fall of 2020 with managers and frontline practitioners were analyzed through the lens of situations of "anticipation," "reaction," or "inaction." The findings were discussed in three results dissemination workshops, two with practitioners and one with managers, to discern lessons they learned. Three major configurations emerged: 1) reorganization of services and spaces to accommodate more COVID-19 patients; 2) management of contamination risks for patients and professionals; and 3) management of personal protective equipment (PPE), supplies, and medications. Within these configurations, the responses to the crisis were strongly shaped by the 2015 health care system reforms in Quebec and were constrained by organizational challenges that included a centralized model of governance, a history of substantial budget cuts to longterm care facilities, and a systematic lack of human resources.

Community Pharmacists and Influenza Vaccination: Opportunities and Challenges From a Public Health Perspective.

Context: In Quebec, Bill 31, adopted on March 18, 2020, extended vaccination to pharmacists. Despite many advantages, this new practice comes with public health issues reinforced in the context of COVID-19. Therefore, it is essential to understand the opportunities and challenges of the participation of community pharmacists in influenza vaccination, from a public health perspective by (i) describing the year of 2020-2021 influenza vaccination offer, (ii) its opportunities and challenges, and (iii) its impact on the accessibility of this service newly offered by pharmacists to the most vulnerable people. Methods: This research is a case study from one of the most affected areas by COVID-19 in Canada: Laval. Our method combines documentary analysis and semi-structured interviews with health professionals and public health actors (n = 23). Researchers used a thematic analysis to analyze these results. Results: Most partners (pharmacists, public health administrators) underlined multiple opportunities of this new practice, ie, pharmacists who can vaccinate, particularly for chronically ill patients. However, structural and strategical challenges remain. More specifically, vaccination seemed to only rely on a "first come, first served" basis, which questions public health objectives of vaccination, such as equitable access. Conclusion: The introduction of new actors, such as pharmacists, represents a major opportunity to improve vaccination coverage and reduce the burden of COVID-19 on the health system. However, this delegation of a public health activity to the private sector undoubtedly requires closer coordination with public health institutions.

[Quality indicators of person-centred and recovery-oriented care for mental health issues]. / Indicateurs de qualité des soins en santé mentale pour les approches centrées sur la personne et axées sur le rétablissement.

Objective Meeting the mental health needs of the population is a priority of the Quebec government. To do so, it is important to evaluate and improve the quality of mental health care in primary and community care settings, particularly with respect to person-centred and recovery-oriented care. The purpose of this study is to identify existing quality indicators that measure these dimensions, and to report on their strengths and weaknesses. Method A review of systematic reviews was conducted in MEDLINE, EMBASE, PsycINFO and CINAHL, using combinations of search terms related to the concepts of "mental disorders," "primary care," "health care quality," and "review." The review of titles and abstracts review was completed by single reviewers and full-text review by pairs of reviewers working independently. Consultation with an expert in mental health care quality and a hand search of the references of identified articles finalized the search. A review of the grey literature, including the reports and websites of Canadian or international organizations, was also conducted. Results From 2837 initial references, the review of systematic reviews led to the inclusion of 6 systematic reviews. For the grey literature, relevant indicators were found on the websites of 13 organizations, including 7 international and 6 Canadian ones, from 25 organizations consulted. A total of 106 indicators were retrieved, including 91 for person-centred care approaches and 15 for recovery-oriented approaches. Among the indicators for person-centred care, two levels emerged: the organizational level, focusing mainly on continuity issues, and the practice level, focusing on processes related to the care providers or the individual. For recovery-oriented approaches to care, four categories emerged: community connections, discrimination and stigma, social roles, and social support. Conclusion Evaluating person-centered, recovery-oriented care for people with mental disorders based on robust quality indicators poses a major challenge and our review revealed several limitations related to the current set of indicators that exist to measure these approaches. Further efforts must be made to improve the measurement of quality of mental health care in terms of person-centred and recovery-oriented care, so that the governmental and clinical strategies currently in place, such as the Programme Québécois pour les Troubles Mentaux (PQPTM), can achieve their goals.

A Descriptive Comparison of Mass Testing During the COVID-19 Pandemic in Montreal, Paris, Bamako, and Recife.

Objective: The aim of this descriptive article was to compare mass testing for SARS-CoV-2 during the first wave of the COVID-19 pandemic in Montreal, Canada; Bamako, Mali; Paris, France; and Recife, Brazil. Methods: Data was collected through interviews with key informants involved in the testing response and a review of the grey literature. The TIDieR-PHP checklist was then used to provide the basis of the intervention descriptions and to compare the data between cities. Results: Descriptive comparisons revealed that the type of test, the testing process, and materials used were similar between the cities during the first wave of the pandemic. In addition, all cities experienced similar material and personnel resource shortages, directly affecting testing accessibility and capacity. The main differences were related to testing capacity and implementation timelines, which were dependent on the state of the health care systems, governance, and access to resources. Conclusion: Results of this study highlight the similarities and differences in testing between the cities and demonstrate the importance of comprehensive intervention descriptions to highlight lessons learned, increase knowledge sharing, and inform policy decisions.

Investigating characteristics of patients with mental disorders to predict out-patient physician follow-up within 30 days of emergency department discharge.

BACKGROUND: Prompt follow-up at emergency department discharge is a key indicator of healthcare quality and patient recovery. To improve services, better knowledge of predictors for out-patient physician follow-up within 30 days after discharge is needed. AIMS: We investigated clinical and sociodemographic characteristics and service use to predict patients with mental disorders with or without physician follow-up after emergency department use. METHOD: This study used data extracted from clinical administrative databases for 9514 patients who attended an emergency department in Quebec (Canada) in 2014-2015 (index visit) for mental health reasons. Patient clinical and sociodemographic characteristics from 2012-2013 to 2014-2015, and service use 12 months before the index visit, were investigated as predictors for patients with or without prompt follow-up, using hierarchical logistic regression. RESULTS: Two-thirds of patients did not receive prompt physician follow-up. Patients with level 1-2 illness acuity at emergency department triage (needing immediate or urgent care); those with adjustment or bipolar disorders, but without alcohol-related disorders (clinical characteristics); and patients with higher continuity of physician care, more psychosocial interventions in community healthcare centres and prior hospital admission (service use characteristics) were more likely to receive prompt out-patient follow-up. CONCLUSIONS: Access to medical care was poor, considering the high needs of this population. The role of the emergency department as a gateway for accessing out-patient care may be strengthened by strategies like screening, brief intervention including motivational treatments, brief case management offered by emergency department staff, timely referral to services and better post-discharge planning. Collaborative care for patients attending emergency departments should also be improved.

Profiles, Correlates and Outcomes Among Patients Experiencing an Onset of Mental Disorder Based on Outpatient Care Received Following Index Emergency Department Visits.

OBJECTIVE: This 5-year longitudinal study evaluated patients with an onset of mental disorder (MD) following index emergency department (ED) visits, in terms of (1) patient profiles based on 12-month outpatient follow-up care received, (2) sociodemographic and clinical correlates, and (3) adverse health outcomes for the subsequent 2 years. METHODS: Data from administrative databases were collected for 2541 patients with an onset of MD, following discharge from Quebec ED. Latent class analysis was performed to identify patient profiles based on the adequacy of follow-up care after ED discharge. Bivariate analyses examined associations between class membership and sociodemographic and clinical correlates, high ED use (3 + visits/yearly), hospitalizations, and suicidal behaviors. RESULTS: Five classes of patients were identified. Class 1, the smallest, labeled "patient psychiatrist only," included mainly young patients with serious MD. Classes 2 and 3, roughly 20%, were labeled "high use of patient general practitioner (GP) and psychiatrist" and "low use of patient GP and psychiatrist," respectively. Both included patients with complex MD, but Class 2 had more women and older patients with chronic physical illnesses. The 2 largest classes were labeled "no usual patient service provider" (Class 5) and "patient GP only" (Class 4). Class 5 included more younger men with substance-related disorders, while Class 4 had the older patients living in rural areas, many with common MD and chronic physical illnesses. Class 3 patients had the poorest outcomes, followed by Classes 1 and 2, while Classes 4 and 5 had the best outcomes. CONCLUSIONS: Results revealed that nearly 40% of patients experiencing an onset of MD received little or no outpatient care following ED discharge. Higher severity or complexity of MD and, to a lesser extent, no or low GP follow-up may explain these adverse outcomes. More adequate, continuous care, including collaborative care, is needed for these vulnerable, high-needs patients.

Assessment of community pharmacists' engagement in pharmacy-delivered influenza vaccination: a mixed-methods study.

OBJECTIVES: This study aimed to identify factors contributing to pharmacists' engagement in vaccination services during the first influenza vaccination campaign in 2019-2020 for the Canadian province of Quebec, led by community pharmacists. METHODS: A mixed-methods study was conducted using a sequential exploratory design. Semi-structured interviews were administered to pharmacists and key informants (n = 23) and data were analysed according to the Consolidated Framework for Implementation Research in community pharmacy. The findings were then used to construct a survey of community pharmacists' engagement in vaccination, which was tested in a Quebec urban community. The study participation rate was 34.6% (n = 29). KEY FINDINGS: Pharmacists expressed positive attitudes towards the implementation of vaccination services, following legislative reform. Factors such as previous involvement in vaccination campaigns and the number of pharmacists on duty were positively associated with engagement in influenza vaccination, whereas staff shortages and logistical problems were a barrier to engagement. Qualitative findings provided in-depth understanding of the value of interprofessional collaboration between pharmacists and nurses. CONCLUSIONS: Vaccination in pharmacies is currently more reflective of individual choice than an indication of collective change in the profession. Logistical factors are key to enhancing the uptake of vaccination in community pharmacies throughout Quebec. External support from professional associations and interprofessional collaboration should be enhanced to promote the implementation of vaccination services in pharmacies.

[Follow-up of Post-Transitional Housing for Homeless Women: Needs, Implementation and Outcomes of a Pilot Study]. / Le soutien postlogement transitoire auprès des femmes en situation d'itinérance : besoins, implantation et impact d'une étude pilote.

Objectives Consolidation of supported housing policies is a primary source of solutions aimed at addressing the problem of homelessness. Transitional housing (TH) offers a sequential housing trajectory from emergency shelters, to TH, to permanent housing with or without supports. Post-TH follow-up may improve residential stability and community integration. Yet little information is available on successful conditions and effectiveness related to post-TH follow-up for improving residential stability and community integration among homeless people, and especially homeless women. This pilot case study aimed to identify the needs of women who were previous TH residents before acquiring permanent housing with supports, the implementation process for post-TH follow-up activities and intensity of services offered and conditions for success of the follow-up, as well as the outcomes of post-TH follow-up in meeting the needs of these homeless women. Methods Two non-profit organizations for housing reintegration in the Montreal area were selected for study. Mixed methods based on a case study approach were used, triangulating the data collected from homeless women, case managers, and housing managers. Two interviews were conducted at 6-month intervals with homeless women (n=10), whose needs and outcomes related to post-TH follow-up were identified through a questionnaire with open and closed questions. To document implementation of the post-TH follow-up, case managers (n=2) recorded information on follow-up activities and intensity of services offered for the 6-month period using contact sheets. Factors facilitating and hindering post-TH follow-up were also identified in a group interview with case managers (n=2) and resource managers (n=4). Results Users identified health maintenance, support for daily activities and improved socialization as their primary needs. Most women were satisfied with activities offered and the frequency of follow-up, ease of access to case managers, and the overall capacity of follow-up to meet their needs. The intensity of follow-up, user/case manager therapeutic alliance, and user motivation to recover were identified as facilitating factors that influenced effectiveness of post-TH follow-up. Factors that hindered effectiveness included: the limited duration of TH before post-TH follow-up particularly among users with major trauma; refractory behavior; reluctance to take medications and consumption of psychoactive substances; problems in accessing health services, particularly specialized mental health services; and for case managers: time constraints, logistical difficulties related to follow-up, and lack of affordable permanent housing adequate to user needs. After six months, 80% of users remained in their housing and no changes were identified in community integration. Conclusion Post-TH follow-up seems particularly adapted to promote residential stability among chronically homeless women with mental health or dependence issues, as the essential first step toward community integration. The study underlined the importance of offering multiple service modalities adapted to user needs and post-TH follow-up geared toward recovery. Better funding of post-TH follow-up, tighter collaboration with other public services, case manager training, and increase in affordable and adequate permanent housing would promote more effective deployment of post-TH follow-up.

Implementation of three innovative interventions in a psychiatric emergency department aimed at improving service use: a mixed-method study.

BACKGROUND: Emergency department (ED) use is often viewed as an indicator of health system quality. ED use for mental health (MH) reasons is increasing and costly for health systems, patients, and their families. Patients with mental disorders (MD) including substance use disorders (SUD) and suicidal behaviors are high ED users. Improving ED services for these patients and their families, and developing alternatives to ED use are thus key issues. This study aimed to: (1) describe the implementation of three innovative interventions provided by a brief intervention team, crisis center team, and family-peer support team in a Quebec psychiatric ED, including the identification of implementation barriers, and (2) evaluate the impacts of these ED innovations on MH service use and response to needs. METHOD: Using mixed methods with data triangulation, the implementation and impact of the three above-named ED interventions were studied. Quantitative data were collected from 101 participants (81 patients, 20 family members) using a user questionnaire and patient medical records. Qualitative data were gathered from focus groups (n = 3) with key intervention staff members (n = 14). The user questionnaire also included open-ended questions. Descriptive, comparative and content analyses were produced. RESULTS: Key implementation issues were identified in relation to system, organizational and patient profiles, similar to results identified in most studies in the ED implementation literature aimed at improving responsiveness to patients with MD. Results were encouraging, as the innovations had a significant impact for improved patient MH service use and adequacy of care. Services also seemed adapted to patient profiles. Family members were grateful for the help received in the ED. CONCLUSIONS: Before implementing innovations, managers need to recognize the basic issues common to all new healthcare interventions: the need for staff training and strong involvement, particularly among physicians, development of collaborative tools especially in cases of potential cultural clash between staff and organizations, and continuous quality assessment. Future research needs to confirm the pertinence of these interventions, especially use of family-peer support teams in ED, as a highly innovative intervention. Broader ED strategies could also be deployed to improve MH services and decrease ED use for MH reasons.

Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness.

This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg-Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.