Income-Generating Processes of Free Web-Based Digital Health Tools to Engage Patients: Qualitative Analysis.

BACKGROUND: In recent years, digital tools have become a viable means for patients to address their health and information needs. Governments and health care organizations are offering digital tools such as self-assessment tools, symptom tracking tools, or chatbots. Other sources of digital tools, such as those offered through patient platforms, are available on the internet free of charge. We define patient platforms as health-specific websites that offer tools to anyone with internet access to engage them in their health care process with peer networks to support their learning. Although numerous social media platforms engage users without up-front charges, patient platforms are specific to health. As little is known about their business model, there is a need to understand what else these platforms are trying to achieve beyond supporting patients so that patients can make informed decisions about the benefits and risks of using the digital tools they offer. OBJECTIVE: The aim of this study is to explore what patient platforms are trying to achieve beyond supporting patients and how their digital tools can be used to generate income. METHODS: Textual and visual data collected from a purposeful selection of 11 patient platforms from September 2013 to August 2014 were analyzed using framework analysis. Data were systematically and rigorously coded and categorized according to key issues and themes by following 5 steps: familiarizing, identifying a thematic framework, indexing, charting, and mapping and interpretation. We used open coding to identify additional concepts not captured in the initial thematic framework. This paper reports on emergent findings on the business models of the platforms and their income-generating processes. RESULTS: Our analysis revealed that in addition to patients, the platforms support other parties with interests in health and information exchanges. Patient platforms did not charge up-front fees but generated income from other sources, such as advertising, sponsorship, marketing (eg, sending information to users on behalf of sponsors or providing means for sponsors to reach patients directly), supporting other portals, and providing research services. CONCLUSIONS: This study reports on the mechanisms by which some patient platforms generate income to support their operations, gain profit, or both. Although income-generating processes exist elsewhere on social media platforms in general, they pose unique challenges in the health context because digital tools engage patients in health and information exchanges. This study highlights the need to minimize the potential for unintended consequences that can pose health risks to patients or can lead to increased health expenses. By understanding other interests that patient platforms support, our findings point to important policy implications, such as whether (and how) authorities might protect users from processes that may not always be in their best interests and can potentially incur costs to the health system.

Relationships between work outcomes, work attitudes and work environments of health support workers in Ontario long-term care and home and community care settings.

BACKGROUND: Our overarching study objective is to further our understanding of the work psychology of Health Support Workers (HSWs) in long-term care and home and community care settings in Ontario, Canada. Specifically, we seek novel insights about the relationships among aspects of these workers' work environments, their work attitudes, and work outcomes in the interests of informing the development of human resource programs to enhance elder care. METHODS: We conducted a path analysis of data collected via a survey administered to a convenience sample of Ontario HSWs engaged in the delivery of elder care over July-August 2015. RESULTS: HSWs' work outcomes, including intent to stay, organizational citizenship behaviors, and performance, are directly and significantly related to their work attitudes, including job satisfaction, work engagement, and affective organizational commitment. These in turn are related to how HSWs perceive their work environments including their quality of work life (QWL), their perceptions of supervisor support, and their perceptions of workplace safety. CONCLUSIONS: HSWs' work environments are within the power of managers to modify. Our analysis suggests that QWL, perceptions of supervisor support, and perceptions of workplace safety present particularly promising means by which to influence HSWs' work attitudes and work outcomes. Furthermore, even modest changes to some aspects of the work environment stand to precipitate a cascade of positive effects on work outcomes through work attitudes.

Treating Health Care: How the Canadian System Works and How It Could Work Better.

Health policy analysis requires an understanding of a broad range of topics that are often taught in different disciplines spanning economics, political science, ethics, health administration, public health and healthcare. Professor Raisa Deber's Treating Health Care is essential reading for anyone interested in understanding the basic fundamentals of the healthcare system, eloquently weaving together key concepts across disciplines and background information to equip the reader with a "toolkit" for decision making in health policy analysis.

Organizational responses to accountability requirements: Do we get what we expect?

BACKGROUND: In health care, accountability is being championed as a promising approach to meeting the dual imperatives of improving care quality while managing constrained budgets. PURPOSES: Few studies focus on public sector organizations' responsiveness to government imperatives for accountability. We applied and adapted a theory of organizational responsiveness to community care agencies operating in Ontario, Canada, asking the question: What is the array of realized organizational responses to government-imposed accountability requirements among community agencies that receive public funds to provide home and community care? METHODOLOGY/APPROACH: A sequential complementary mixed methods approach was used. It gathered data through a survey of 114 home and community care organizations in Ontario and interviews with 20 key informants representing 13 home and community care agencies and four government agencies. It generated findings using a parallel mixed analysis technique. FINDINGS: In addition to responses predicted by the theory, we found that organizations engage in active, as well as passive, forms of compliance; we refer to this response as internal modification in which internal policies, practices, and/or procedures are changed to meet accountability requirements. We also found that environmental factors, such as the presence of an association representing organizational interests, can influence bargaining tactics. PRACTICE IMPLICATIONS: Our study helps us to better understand the range of likely responses to accountability requirements and is a first step toward encouraging the development of accountability frameworks that favor positive outcomes for organizations and those holding them to account. Tailoring agreements to organizational environments, aligning perceived compliance with behaviors that encourage improved performance, and allowing for flexibility in accountability arrangements are suggested strategies to support beneficial outcomes.

The Canada Health Act for the Twenty-First Century?.

As the participants in the Canada Health Act, Version 2.0 conference made clear, there is a strong case to be made that this key piece of legislation no longer captures some key challenges to managing health care in Canada. Particular issues include 'portability' across provincial/territorial boundaries, and the definition of insured services. However, the CHA is not a barrier to reform; it acts as a floor, rather than a ceiling. Health reform may thus require a combination of new legislation to set conditions for which new services should be insured, and developing mechanisms to identify priorities, ensure appropriateness, and improve efficiency, which are unlikely to be addressed through overarching legislation. The CHA should thus be maintained, recognizing that it is necessary, but not sufficient.

Paying for Primary Care: The Factors Associated with Physician Self-selection into Payment Models.

To determine the factors associated with primary care physician self-selection into different payment models, we used a panel of eight waves of administrative data for all primary care physicians who practiced in Ontario between 2003/2004 and 2010/2011. We used a mixed effects logistic regression model to estimate physicians' choice of three alternative payment models: fee for service, enhanced fee for service, and blended capitation. We found that primary care physicians self-selected into payment models based on existing practice characteristics. Physicians with more complex patient populations were less likely to switch into capitation-based payment models where higher levels of effort were not financially rewarded. These findings suggested that investigations aimed at assessing the impact of different primary care reimbursement models on outcomes, including costs and access, should first account for potential selection effects.

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States.

BACKGROUND: Why do many patients not die at their preferred location? AIM: Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators). DESIGN: Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews. SETTING: Case study of Canada, England, Germany, and the United States. RESULTS: While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception ("giving up hope") challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators. CONCLUSION: Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.

Information and communication technology (ICT) and eHealth policy in Latin America and the Caribbean: a review of national policies and assessment of socioeconomic context.

OBJECTIVE: To examine the availability of national information and communication technology (ICT) or eHealth policies produced by countries in Latin America and the Caribbean (LAC), and to determine the influence of a country's socioeconomic context on the existence of these policies. METHODS: Documents describing a national ICT or eHealth policy in any of the 33 countries belonging to the LAC region as listed by the United Nations were identified from three data sources: academic databases; the Google search engine; and government agencies and representatives. The relationship between the existence of a policy and national socioeconomic indicators was also investigated. RESULTS: There has been some progress in the establishment of ICT and eHealth policies in the LAC region. The most useful methods for identifying the policies were 1) use of the Google search engine and 2) contact with Pan American Health Organization (PAHO) country representatives. The countries that have developed a national ICT policy seem to be more likely to have a national eHealth policy in place. There was no statistical significant association between the existence of a policy and a country's socioeconomic context. CONCLUSIONS: Governments need to make stronger efforts to raise awareness about existing and planned ICT and eHealth policies, not only to facilitate ease of use and communication with their stakeholders, but also to promote collaborative international efforts. In addition, a better understanding of the effect of economic variables on the role that ICTs play in health sector reform efforts will help shape the vision of what can be achieved.

Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West End-of-Life Shared-Care Project.

BACKGROUND: Increasing emphasis is being placed on the economics of health care service delivery - including home-based palliative care. AIM: This paper analyzes resource utilization and costs of a shared-care demonstration project in rural Ontario (Canada) from the public health care system's perspective. DESIGN: To provide enhanced end-of-life care, the shared-care approach ensured exchange of expertise and knowledge and coordination of services in line with the understood goals of care. Resource utilization and costs were tracked over the 15 month study period from January 2005 to March 2006. RESULTS: Of the 95 study participants (average age 71 years), 83 had a cancer diagnosis (87%); the non-cancer diagnoses (12 patients, 13%) included mainly advanced heart diseases and COPD. Community Care Access Centre and Enhanced Palliative Care Team-based homemaking and specialized nursing services were the most frequented offerings, followed by equipment/transportation services and palliative care consults for pain and symptom management. Total costs for all patient-related services (in 2007 $CAN) were $1,625,658.07 - or $17,112.19 per patient/$117.95 per patient day. CONCLUSION: While higher than expenditures previously reported for a cancer-only population in an urban Ontario setting, the costs were still within the parameters of the US Medicare Hospice Benefits, on a par with the per diem funding assigned for long-term care homes and lower than both average alternate level of care and hospital costs within the Province of Ontario. The study results may assist service planners in the appropriate allocation of resources and service packaging to meet the complex needs of palliative care populations.

The evolving role of health care aides in the long-term care and home and community care sectors in Canada.

Health Care Aides (HCAs) provide up to 80% of the direct care to older Canadians living in long-term care facilities, or in their homes. They are an understudied workforce, and calls for health human resources strategies relating to these workers are, we feel, precipitous. First, we need a better understanding of the nature and scope of their work, and of the factors that shape it. Here, we discuss the evolving role of HCAs and the factors that impact how and where they work. The work of HCAs includes role-required behaviors, an increasing array of delegated acts, and extra-role behaviors like emotional support. Role boundaries, particularly instances where some workers over-invest in care beyond expected levels, are identified as one of the biggest concerns among employers of HCAs in the current cost-containment environment. A number of factors significantly impact what these workers do and where they work, including market-level differences, job mobility, and work structure. In Canada, entry into this 'profession' is increasingly constrained to the Home and Community Care sector, while market-level and work structure differences constrain job mobility to transitions of only the most experienced workers, to the long-term care sector. We note that this is in direct opposition to recent policy initiatives designed to encourage aging at home. Work structure influences what these workers do, and how they work; many HCAs work for three or four different agencies in order to sustain themselves and their families. Expectations with regard to HCA preparation have changed over the past decade in Canada, and training is emerging as a high priority health human resource issue. An increasing emphasis on improving quality of care and measuring performance, and on integrated team-based care delivery, has considerable implications for worker training. New models of care delivery foreshadow a need for management and leadership expertise--these workers have not historically been prepared for leadership roles. We conclude with a brief discussion of the next steps necessary to generating evidence necessary to informing a health human resource strategy relating to the provision of care to older Canadians.

The Disadvantaged Home Care Personal Support Worker: Differences in Job Characteristics, Unionization, Pensions, Participation, and Wages by Care Sector in Canada.

Personal Support Worker (PSW) supply is struggling to match the rising demand within many countries, particularly in the home and community (HC) sector. Although care demand projections are often sector-specific, our understanding of sector discrepancies on the PSW labour supply side is limited. This paper compares PSW job characteristics by means, proportions, and tests of significance across HC, nursing and long-term care home (LTC), and hospital sectors utilizing a sample of Canadian PSWs (1996-2010). Compared to LTC and hospital sectors, HC PSWs had significantly lower average wages, labour participation levels, permanent positions, job duration, and unionization rates. Relative wage distribution graphs showed how sector wage discrepancies existed across the wage distribution. These distinctions made the comparatively disadvantaged HC PSW position particularly salient, with important labour supply implications by sector. The relative attractiveness of HC sector jobs will become more critical as the rise in HC demand is projected to continue.

Personal Support Worker Socio-Demographic Differences Across Care Sectors in Canada.

With the growing reliance on Personal Support Workers (PSWs) in health care delivery for older adults across hospital, nursing and long-term care home, and home and community (HC) sectors, understanding the PSW labor market is critical for healthcare human resource capacity to care for an aging population. This study utilizes a longitudinal, cross-provincial, individual-level dataset of PSWs in Canada from 1996-2010 to provide socio-demographic characteristics of PSWs by sector. Means, proportions, and multivariate tests of significance showed that PSWs differed significantly by care sector across many factors-including sex, health, family, and education characteristics. That HC PSWs were more likely to be older with lower health and higher disability status is important to consider when examining labor policies. Evidence of sector heterogeneity can lead to important differential effects on PSW labor supply behaviors and this research highlights the importance of tailoring initiatives aimed at recruitment and retention by sector.

Nurses' work, work psychology, and the evolution & devolution of care provision in nursing homes: A scoping review.

Background: Societal aging is exerting profound impacts on providers of long-term care. Nurses provide much of the direct care in the long-term care sector, and they increasingly provide unit- and facility-level leadership and fill top administrative and clinical roles.The work health and quality of work life of long-term care nurses are emergent concerns and the foci of research across multiple disciplines. Objectives: To enhance our understanding of factors influencing long-term care nurses' work health and quality of work life, we summarize the findings of disparate studies across diverse disciplines, time, and jurisdictions. Eligibility criteria: No restrictions were placed on study date, design, or country. Searches were restricted to English language only or translated studies. Included studies reported associations and relationships between/amongst nurses' work (role and work design), work environments, work attitudes, and work outcomes. Published peer-reviewed studies and reviews were included, as were reports. Editorials and opinion pieces were excluded. The search included publications up to March 2022. Sources of evidence: Medline, CINAHL, PsychINFO, EMBASE, Scopus, PSNet. Charting methods: Data abstraction from full-text articles. Results: The evolution of long-term care nurses' work to include both medical and administrative responsibilities has generally not been managed well, resulting in persistent role ambiguity, job dissatisfaction, and burnout. Nurses are concerned about their capacity to provide resident care and the adequacy of their preparation. Their work environments are under-resourced, and they are at high risk for workplace injury or violence. Supervisory and organizational support can be protective of negative aspects of nurses' work environments. Supervisory support can improve the immediate work environment, assist nurses in fulfilling their roles, and afford greater role clarity, and supervisors can influence their nursing staff's perceptions of the work safety and the value that their organization places on them. Organizational support can reduce work stress, enhance feelings of self-worth, and mitigate some of the self-stigmatization that influences long-term care nurses' attitudes toward themselves and their work, which influences work outcomes, including job performance and quality of resident care. Conclusions: Work stress, burnout, increased turnover, decreased morale and work motivation, increased health and safety concerns, and decreases in job satisfaction accompanied by self-stigmatization are all indicators of a system that has failed nurses, other long-term care staff, and nursing home residents. We consider the implications of our findings for enhancing the work health and quality of life of nurses working in long-term care and identify gaps in knowledge about their psychological health that merit future study. Tweetable Abstract: The long-term care sector is failing nurses globally. This review is a step toward understanding how we can improve the work psychology, including work-related psychological health, of nurses in long-term care.

A narrative review on the effect of economic downturns on the nursing labour market: implications for policy and planning.

Economic downturns and recession lead to budget cuts and service reductions in the healthcare sector which often precipitate layoffs and hiring freezes. Nurses, being the largest professional group in healthcare, are strongly affected by cost reductions. Economic downturns destabilize the nursing labour market with potential negative outcomes, including serious shortages, extending beyond the recessionary period. The objectives of this manuscript are to provide an overview of the potential short- and long-run impact of economic downturns on the supply and demand of nurses, and present healthcare decision makers with a framework to enhance their ability to strategically manage their human resources through economic cycles.A narrative review of the literature on the effects of economic downturns on the nursing labour market in developed countries was carried out with a special focus on studies offering a longitudinal examination of labour force trends. Analysis indicates that economic downturns limit the ability of public payers and institutions to finance their existing health workforce. As salaried healthcare workers, nurses are especially susceptible to institutional budget cuts. In the short run, economic downturns may temporarily reduce the demand for and increase the supply of nurses, thereby influencing nursing wages and turnover rates. These effects may destabilise the nursing labour market in the long run. After economic downturns, the market would quickly display the pre-recessionary trends and there may be serious demand-supply imbalances resulting in severe shortages. Potential long-term effects of recession on the nursing labour market may include a downsized active workforce, difficulty in retaining younger nurses, a decreased supply of nurses and workforce casualisation.Lack of understanding of labour market dynamics and trends might mislead policy makers into making misinformed workforce downsizing decisions that are often difficult and expensive to reverse. In the aftermath of an economic downturn, the costs of attracting nurses back often outweigh the short term cost savings. Effective management should support the nursing workforce by creating attractive and stable work environments to retain nurses at a manageable cost.

Attractiveness of employment sectors for physical therapists in Ontario, Canada (1999-2007): implication for the long term care sector.

BACKGROUND: Recruiting and retaining health professions remains a high priority for health system planners. Different employment sectors may vary in their appeal to providers. We used the concepts of inflow and stickiness to assess the relative attractiveness of sectors for physical therapists (PTs) in Ontario, Canada. Inflow was defined as the percentage of PTs working in a sector who were not there the previous year. Stickiness was defined as the transition probability that a physical therapist will remain in a given employment sector year-to-year. METHODS: A longitudinal dataset of registered PTs in Ontario (1999-2007) was created, and primary employment sector was categorized as 'hospital', 'community', 'long term care' (LTC) or 'other.' Inflow and stickiness values were then calculated for each sector, and trends were analyzed. RESULTS: There were 5003 PTs in 1999, which grew to 6064 by 2007, representing a 21.2% absolute growth. Inflow grew across all sectors, but the LTC sector had the highest inflow of 32.0%. PTs practicing in hospitals had the highest stickiness, with 87.4% of those who worked in this sector remaining year-to-year. The community and other employment sectors had stickiness values of 78.2% and 86.8% respectively, while the LTC sector had the lowest stickiness of 73.4%. CONCLUSION: Among all employment sectors, LTC had highest inflow but lowest stickiness. Given expected increases in demand for services, understanding provider transitional probabilities and employment preferences may provide a useful policy and planning tool in developing a sustainable health human resource base across all employment sectors.

The importance of employment status in determining exit rates from nursing.

To mitigate nurse shortages, health care decision makers tend to employ retention strategies that assume nurses employed in full-time, part-time, or casual positions and working in different sectors have similar preferences for work. However, this assumption has not been validated in the literature. The relationship between a nurse's propensity to exit the nurse profession in Ontario and employment status was explored by building an extended Cox Proportional Hazards Regression Model using a counting process technique. The differential exit patterns between part-time and casual nurses suggest that the common practice of treating part-time and casual nurses as equivalent is misleading. Health care decision makers should consider nurse retention strategies specifically targeting casual nurses because this segment of the profession is at the greatest risk of leaving. Nurse executives and nurse managers should investigate the different work preferences of part-time and casual nurses to devise tailored rather than "one-size fits all" nurse retention strategies to retain casual nurses.

Forecasting Staffing Needs for Ontario's Long-Term Care Sector.

This paper presents a forecasting model for personal support workers (PSWs) and nurses (registered nurses [RNs] and registered practical nurses [RPNs]) for Ontario's long-term care (LTC) sector. In the base-case scenario, the model projects a shortfall in the supply of full-time equivalent (FTE) workers required to meet the expected demand for care for all workers by 2035, which would require an estimated increase of 11,632 FTE PSWs, 6,031 FTE RNs and 10,178 FTE RPNs entering the market by 2035. The results of this paper may have important implications for health human resources policy planning in Ontario's LTC sector.

COVID-19 and Long-Term Care: What Have We Learned?

The COVID-19 pandemic has led to thousands of deaths; of these, a disproportionate number has occurred in long-term care settings. The papers presented here deal with a number of issues highlighted by this crisis in several jurisdictions, including Ontario, Quebec and the Netherlands. Analyzing these may give us some insight into what is necessary to prevent this disaster from happening again.

COVID-19 Issues in Long-Term Care in Ontario: A Document Analysis.

The COVID-19 crisis in long-term care in Canada has been characterized as a crisis upon a crisis. This study examines recent documents on the crisis in long-term care in Ontario, using document and thematic analysis to synthesize issues and recommendations from the perspectives of different groups and organizations. Thirty-three documents from 20 organizations were analysed and six thematic areas were identified: resident care; human resources; governance, leadership and management; financing; physical infrastructure and supplies; and training and preparation. The six common themes, as perceived by different perspectives, can inform policy makers on long-term care issues.

Exemplars in Long-Term Care during COVID-19: The Importance of Leadership.

Early in the pandemic, many long-term care (LTC) homes struggled to manage resources and care for vulnerable residents. Using an appreciative inquiry approach, we analyzed exemplar homes in Ontario that remained free of COVID-19 in wave one and interviewed executive directors, directors of care and staff. Findings demonstrate the importance of leadership styles; clear, consistent communication; focusing on staff and resident safety; using a team-based approach; and adapting staff roles to meet care needs. The exemplar homes showed what works in practice. The decisions and approaches that they implemented could be used to develop standards to improve LTC and strengthen the sector.