Nurse practitioner and physician end-of-life home visits and end-of-life outcomes.

OBJECTIVES: Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death. METHODS: We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit. RESULTS: Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both. CONCLUSIONS: Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients' preferences-emphasising the importance of NPs and physicians' role in supporting people near the end of life.

Snapshot of family medicine around the world: Introducing the global family medicine website.

OBJECTIVE: To develop an interactive, living map of family medicine training and practice; and to appreciate the role of family medicine within, and its effect on, health systems across the world. COMPOSITION OF THE COMMITTEE: A subgroup of the College of Family Physicians of Canada's Besrour Centre for Global Family Medicine developed connections with selected international colleagues with expertise in international family medicine practice and teaching, health systems, and capacity building to map family medicine globally. In 2022, this group received support from the Foundation for Advancing Family Medicine's Trailblazers initiative to advance this work. METHODS: In 2018 groups of Wilfrid Laurier University (Waterloo, Ont) students conducted broad searches of relevant articles about family medicine in different regions and countries around the world; they conducted focused interviews and then synthesized and verified information, developing a database of family medicine training and practice around the world. Outcome measures were age of family medicine training programs and duration and type of family medicine postgraduate training. REPORT: To approach the question of how delivery of the family medicine model of primary care can affect health system performance, relevant data on family medicine were collated-the presence, nature, duration, and type of training and role within health care systems. The website https://www.globalfamilymedicine.org now has up-to-date country-level data on family medicine practice around the world. This publicly available information will allow such data to be correlated together with health system outputs and outcomes and will be updated as necessary through a wiki-type process. While Canada and the United States only have residency training, countries such as India have master's or fellowship programs, in part accounting for the complexity of the discipline. The maps also identify where family medicine training does not yet exist. CONCLUSION: Mapping family medicine around the world will allow researchers, policy makers, and health care workers to have an accurate picture of family medicine and its impact using relevant, up-to-date information. The group's next aim is to develop data on parameters by which performance in various domains can be measured across settings and to display these in an accessible form.

Protocol for a cross-sectional study on COVID-19 vaccination programmes in primary health care.

BACKGROUND: An integrated primary health care approach, where primary care and public health efforts are coordinated, is a key feature of routine immunisation campaigns. AIM: The aim of the study is to describe the approach used by a diverse group of international primary health care professionals in delivering their coronavirus disease 2019 (COVID-19) vaccination programmes, as well as their perspectives on public health and primary care integration while implementing national COVID-19 vaccination programmes in their own jurisdictions. SETTING: This is a protocol for a study, which consists of a cross-sectional online survey disseminated among a convenience sample of international primary health care professional through member-based organisations and professional networks via email and online newsletters. METHODS: Survey development followed an iterative validation process with a formative committee developing the survey instrument based on study objectives, existing literature and best practices and a summative committee verifying and validating content. RESULTS: Main outcome measures are vaccination implementation approach (planning, coordination service deliver), level or type of primary care involvement and degree of primary care and public health integration at community level. CONCLUSION: Integrated health systems can lead to a greater impact in the rollout of the COVID-19 vaccine and can ensure that we are better prepared for crises that threaten human health, not only limited to infectious pandemics but also the rising tide of chronic disease, natural and conflict-driven disasters and climate change.Contribution: This study will provide insight and key learnings for improving vaccination efforts for COVID-19 and possible future pandemics.

Mental health and neurocognitive disorder-related hospitalization rates in immigrants and Canadian-born population: a linkage study.

OBJECTIVES: Mental health and neurocognitive conditions are important causes of hospitalization among immigrants, though patterns may vary by immigrant category, world region of origin, and time since arrival in Canada. This study uses linked administrative data to explore differences in mental health hospitalization rates between immigrants and individuals born in Canada. METHODS: Hospital records from the Discharge Abstract Database and the Ontario Mental Health Reporting System for 2011 to 2017 were linked to the 2016 Longitudinal Immigrant Database and to Statistics Canada's 2011 Canadian Census Health and Environment Cohort. Age-standardized hospitalization rates for mental health-related conditions (ASHR-MHs) were derived for immigrants and the Canadian-born population. ASHR-MHs overall and for leading mental health conditions were compared between immigrants and the Canadian-born population, stratified by sex and selected immigration characteristics. Quebec hospitalization data were not available. RESULTS: Overall, immigrants had lower ASHR-MHs compared to the Canadian-born population. Mood disorders were leading causes of mental health hospitalization for both cohorts. Psychotic, substance-related, and neurocognitive disorders were also leading causes of mental health hospitalization, although there was variation in their relative importance between subgroups. Among immigrants, ASHR-MHs were higher among refugees and lower among economic immigrants, those from East Asia, and those who arrived in Canada most recently. CONCLUSION: Differences in hospitalization rates among immigrants from various immigration streams and world regions, particularly for specific types of mental health conditions, highlight the importance of future research that incorporates both inpatient and outpatient mental health services to further understand these relationships.

RéSUMé: OBJECTIFS: Les problèmes de santé mentale et les troubles neurocognitifs sont des causes importantes d'hospitalisation chez les immigrants, bien que les tendances puissent varier selon la catégorie d'immigrants, la région d'origine mondiale et le temps écoulé depuis l'arrivée au Canada. Cette étude utilise des données administratives couplées afin d'explorer les différences dans les taux d'hospitalisation en santé mentale entre les immigrants et les personnes nées au Canada. MéTHODES: Les dossiers hospitaliers de la Base de données sur les congés des patients et du Système d'information ontarien sur la santé mentale de 2011 à 2017 ont été couplés à la Base de données longitudinales sur l'immigration de 2016 et aux cohortes santé et environnement du Recensement canadien de 2011 de Statistique Canada. Les taux d'hospitalisation normalisés selon l'âge pour les problèmes de santé mentale (THNA-SM) ont été comparés entre les immigrants et la population née au Canada, stratifiés selon le sexe et certaines caractéristiques d'immigration. Les données sur les hospitalisations au Québec n'étaient pas disponibles. RéSULTATS: Dans l'ensemble, les immigrants avaient des THNA-SM plus faibles que la population née au Canada. Les troubles de l'humeur étaient les principales causes d'hospitalisation en santé mentale pour les deux cohortes. Les troubles psychotiques, liés aux substances et neurocognitifs étaient également les principales causes d'hospitalisation en santé mentale, bien que leur importance relative varie entre les sous-groupes. Chez les immigrants, les THNA-SM étaient plus élevés chez les réfugiés et plus faibles chez les immigrants économiques, ceux de l'Asie de l'Est et ceux qui sont arrivés au Canada plus récemment. CONCLUSION: Les différences dans les taux d'hospitalisation chez les immigrants des divers groupes d'immigration et régions du monde, plus particulièrement pour certains types de problèmes de santé mentale, soulignent l'importance de recherches futures qui intègrent les services de santé mentale aux patients hospitalisés ainsi qu'aux patients externes afin de mieux comprendre ces relations.

All-cause acute care hospitalization rates of immigrants and the Canadian-born population: A linkage study.

BACKGROUND: As Canadian immigration levels increase, knowledge concerning immigrant health becomes increasingly important for health system policy and planning. This study compares the rate of all-cause hospitalization among immigrants with that of their Canadian-born counterparts. DATA AND METHODS: Using records from the Discharge Abstract Database (2004/2005 to 2016/2017) and the Ontario Mental Health Reporting System (2006/2007 to 2017/2018) linked to the 2016 Longitudinal Immigration Database, this study compared the age-standardized hospitalization rates (ASHRs) among immigrants with those of the Canadian-born population; the latter were obtained from a linkage based on the 2011 National Household Survey. Comparisons were made at the International Classification of Diseases chapter level by immigrant landing year, admission category and world region of birth. Quebec data were not available. RESULTS: Overall, ASHRs among immigrants were lower than for the Canadian-born population. Immigrants in the economic class had the lowest ASHR, followed by those in the family class and among refugees. After pregnancy was excluded, leading hospitalization causes were similar for immigrants and the Canadian-born population, where top causes included digestive system and circulatory diseases, injuries, and cancer. In male and female immigrants, the ASHRs were lowest among those from East Asia. By landing year, males arriving earlier had the highest ASHR compared with the most recent arrivals. When pregnancy was excluded and while the differential in ASHRs among females by landing year remained, the magnitude was smaller. INTERPRETATION: These results corroborate those from previous studies suggesting a healthy immigrant effect, but also reveal heterogeneity in ASHRs within the immigrant population. They provide a baseline for comparison of health status between populations, which enables further monitoring and informs health-system policy and planning.

Caring for patients with lived experience of homelessness.

OBJECTIVE: To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. SOURCES OF INFORMATION: The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient's Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. MAIN MESSAGE: Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. CONCLUSION: Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.

Soigner les patients ayant connu l'itinérance.

OBJECTIF: Guider les médecins de famille de divers types de pratique familiale quant à la façon de dispenser des soins et du soutien aux patients logés précairement ou qui vivent l'itinérance. SOURCES D'INFORMATION: L'approche intègre les recommandations tirées des lignes directrices cliniques fondées sur les données probantes, l'opinion des personnes avec une expérience vécue de l'itinérance, les principes théoriques du cadre de travail du Centre de médecine de famille et des leçons pratiques provenant de médecins de famille qui travaillent dans des contextes cliniques variés. MESSAGE PRINCIPAL: Les médecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinérants ou logés précairement; franchir les premières étapes pour faciliter l'accès au logement, à l'aide financière, à la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel à des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les médecins de famille ont un solide pouvoir de plaidoyer et peuvent s'associer aux organisations communautaires locales et aux personnes ayant vécu l'itinérance pour revendiquer des réformes politiques qui tiennent compte des iniquités sociales. CONCLUSION: Les médecins de famille ont la capacité de répondre directement aux besoins sociaux et aux besoins en matière de santé physique et de santé mentale des patients itinérants ou logés précairement. En outre, ils peuvent promouvoir les programmes d'approche et d'intégration qui aident les personnes avec une expérience vécue de l'itinérance à accéder aux centres de médecine de famille et peuvent militer pour l'adoption de mesures générales visant à contrer les causes structurelles sous-jacentes de l'itinérance.

Fostering global primary care research: a capacity-building approach.

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research-a core element of high-quality PHC-in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and 'brain drain' may reduce available research support; however, we provide recommendations on how to deal with these tensions.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond.

Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review.

BACKGROUND: Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. METHODS AND FINDINGS: We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. CONCLUSIONS: Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond / A contribuição da Medicina de Família e dos líderes em Medicina de Família para o desenvolvimento da Atenção Primária à Saúde nas Américas - de Alma-Ata à Astana e além

Abstract Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

Resumo Desde 2012, o Centro Besrour de Medicina Global de Família, na Faculdade de Medicina de Família do Canadá, reúne seus parceiros das Américas anualmente para refletir sobre a evolução da Medicina de Família no continente desde Alma-Ata e para os desafios futuros. Os médicos de família são apenas um elemento de um forte sistema de saúde. A Medicina de Família fornece ingredientes-chave para responder às necessidades de saúde da população, especialmente à medida em que os países passam pela transição epidemiológica para enfrentar um fardo maior de doenças crônicas e de multimorbidade. Neste artigo, fornecemos uma visão geral de alto nível do estado da Medicina de Família no continente. Em seguida, analisamos as tendências na educação dos médicos de família para enfrentar esse cenário em mudança, incluindo a ênfase no papel de líder dos futuros médicos de família. Os programas de pós-graduação em Medicina de Família nas Américas estão enfatizando cada vez mais o ensino do cuidado colaborativo, a fim de criar equipes de saúde verdadeiramente interdisciplinares para o benefício dos pacientes.