A qualitative study exploring hospital-based team dynamics in discharge planning for patients experiencing delayed care transitions in Ontario, Canada.

BACKGROUND: In attempt to improve continuity of patient care and reduce length of stay, hospitals have placed an increased focus on reducing delayed discharges through discharge planning. Several benefits and challenges to team-based approaches for discharge planning have been identified. Despite this, professional hierarchies and power dynamics are common challenges experienced by healthcare providers who are trying to work as a team when dealing with delayed discharges. The objective of this study was to explore what was working well with formal care team-based discharge processes, as well as challenges experienced, in order to outline how teams can function to better support transitions for patients experiencing a delayed discharge.  METHODS: We conducted a descriptive qualitative study with hospital-based healthcare providers, managers and organizational leaders who had experience with delayed discharges. Participants were recruited from two diverse health regions in Ontario, Canada. In-depth, semi-structured interviews were conducted in-person, by telephone or teleconference between December 2019 and October 2020. All interviews were recorded and transcribed. A codebook was developed by the research team and applied to all transcripts. Data were analyzed inductively, as well as deductively through directed content analysis. RESULTS: We organized our findings into three main categories - (1) collaboration with physicians makes a difference; (2) leadership should meaningfully engage with frontline providers and (3) partnerships across sectors are critical. Regular physician engagement, as equal members of the team, was recommended to improve consistent communication, relationship building between providers, accessibility, and in-person communication. Participants highlighted the need for a dedicated senior leader who ensured members of the team were treated as equals and advocated for the team. Improved partnerships across sectors included the enhanced integration of community-based providers into discharge planning by placing more focus on collaborative practice, combined discharge planning meetings, and having embedded and physically accessible care coordinators in the hospital. CONCLUSIONS: Team-based approaches for delayed discharge can offer benefits. However, to optimize how teams function in supporting these processes, it is important to consistently collaborate with physicians, ensure senior leadership engage with and seek feedback from frontline providers through co-design, and actively integrate the community sector in discharge planning.

All together: Integrated care for youth with type 1 diabetes.

OBJECTIVE: We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression. RESEARCH DESIGN AND METHODS: The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods. RESULTS: There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team. CONCLUSION: The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

Making sense of symptoms, clinicians and systems: a qualitative evaluation of a facilitated support group for patients with medically unexplained symptoms.

OBJECTIVES: Health services to date have inadequately addressed the physical and mental health needs of patients with medically unexplained symptoms. This qualitative study evaluates a piloted facilitated support group (FSG) developed for patients with medically unexplained symptoms to inform recommendations and resources for this patient population. METHODS: Using a qualitative descriptive design, we conducted and thematically analyzed semi-structured interviews with participants (n = 8) and facilitators (n = 4) to explore their experiences of the facilitated support group. Common themes that captured strengths and challenges of the facilitated support group were identified. RESULTS: The following key themes were identified through analysis of the data: Participants described 1) feeling validated through sharing similar experiences with peers; 2) learning practical symptom management and coping strategies; and 3) gaining new perspectives for navigating conversations with PCPs. CONCLUSIONS: Our findings show that a facilitated support group may provide additional forms of support and resources for patients with medically unexplained symptoms, filling a gap in currently available clinical care offered by health care professionals. Potential implications: This paper highlights lessons learned that can inform the design and delivery of future supports and resources directed toward optimizing patient care for this underserved patient population. Our findings are relevant to those who are involved in direct patient care or involved in designing and implementing self-management programs.

An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges.

OBJECTIVE: To engage with patients, caregivers and care providers to co-design components of an intervention that aims to improve delayed hospital discharge experiences. DESIGN: This is a qualitative study, which entailed working groups and co-design sessions utilizing World Café and deliberative dialogue techniques to continually refine the intervention. SETTING AND PARTICIPANTS: Our team engaged with 61 participants (patients, caregivers and care providers) in urban and rural communities across Ontario, Canada. A 7-member Patient and Caregiver Advisory Council participated in all stages of the research. RESULTS: Key challenges experienced during a delayed discharge by patients, caregivers and care providers were poor communication and a lack of care services. Participants recommended a communication guide to support on-going conversation between care providers, patients and caregivers. The guide included key topics to cover and questions to ask during initial and on-going conversations to manage expectations and better understand the priorities and goals of patients and caregivers. Service recommendations included getting out of bed and dressed each day, addressing the psycho-social needs of patients through tailored activities and having a storyboard at the bedside to facilitate on-going engagement. DISCUSSION AND CONCLUSIONS: Our findings outline ways to meaningfully engage patients and caregivers during a delayed hospital discharge. Combining this with a minimal basket of services can potentially facilitate a better care experience and outcomes for patients, their care providers and families.

The Healthfulness of Eateries at the University of Waterloo: A Comparison across 2 Time Points.

Purpose: The aim of this study was to assess the healthfulness of a sample of campus eateries at 2 time points, 2 years apart. Methods: Five eateries at the University of Waterloo were audited using the Nutrition Environment Measures Survey adapted for university campuses (NEMS-UC) in 2015 and late 2017-early 2018. Based on the availability of healthy options and facilitators of and barriers to healthy eating, possible NEMS-UC scores ranged from -5 to 23 points. Results: Scores were low, ranging from 7 to 14 (mean = 10.8, SD = 2.59) points in 2015 and 7 to 13 (mean = 9.6, SD = 2.19) points in 2017-2018. For all eateries except 1 residence cafeteria, scores at time 2 were the same or lower than scores at time 1. All venues carried whole fruit and vegetable options and lower-fat milks, and most offered whole-wheat options. However, healthier items were often located in low-traffic areas, priced higher than less healthy options, and sometimes limited to prepackaged items. Misleading health messaging was also evident. Conclusions: Increased availability, accessibility, and visibility of healthy offerings is needed to enhance campus food environments and support healthy eating patterns, while barriers such as contradictory messaging should be minimized.

The Provision of Assistance Does Not Substantially Impact the Accuracy of 24-Hour Dietary Recalls Completed Using the Automated Self-Administered 24-H Dietary Assessment Tool among Women with Low Incomes.

Background: Evidence is lacking informing the use of the Automated Self-Administered 24-h Dietary Assessment Tool (ASA24) with populations characterized by low income. Objective: This study was conducted among women with low incomes to evaluate the accuracy of ASA24 recalls completed independently and with assistance. Methods: Three hundred and two women, aged ≥18 y and with incomes below the Supplemental Nutrition Assistance Program thresholds, served themselves from a buffet; amounts taken as well as plate waste were unobtrusively weighed to enable calculation of true intake for 3 meals. The following day, women completed ASA24-2016 independently (n = 148) or with assistance from a trained paraprofessional in a small group (n = 154). Regression modeling examined differences by condition in agreement between true and reported foods; energy, nutrient, and food group intakes; and portion sizes. Results: Participants who completed ASA24 independently and those who received assistance reported matches for 71.9% and 73.5% (P = 0.56) of items truly consumed, respectively. Exclusions (consumed but not reported) were highest for lunch (at which participants consumed approximately 2 times the number of distinct foods and beverages compared with breakfast and dinner). Commonly excluded foods were additions to main dishes (e.g., tomatoes in salad). On average, excluded foods contributed 43.6 g (46.2 kcal) and 40.1 g (43.2 kcal) among those in the independent and assisted conditions, respectively. Gaps between true and reported intake were different between conditions for folate and iron. Within conditions, significant gaps were observed for protein, vitamin D, and meat (both conditions); vitamin A, iron, and magnesium (independent); and folate, calcium, and vegetables (assisted). For foods and beverages for which matches were reported, no difference in the gap between true and reported portion sizes was observed by condition (P = 0.22). Conclusions: ASA24 performed relatively well among women with low incomes; however, accuracy was somewhat lower than previously observed among adults with a range of incomes. The provision of assistance did not significantly impact accuracy.

An Exploration of Milk Product Health Beliefs and Dietary Calcium Intake in Young Adults.

Purpose: Milk products (fluid milk, cheese, yogurt) typically provide a rich source of calcium and other nutrients, yet consumption is declining in Canada. This study examined milk product health beliefs among young adults and the association between these beliefs and dietary calcium intake. Methods: Seventy-nine participants (25 ± 4 y; 40 males) completed a milk product health belief questionnaire to determine a milk product health belief score (MPHBS) and a 3-day food record to assess dietary intake. Results: Despite generally positive views, young adults were uncertain about milk products in relation to health, weight management, and ethical concerns. Females would be more likely than males to increase milk product intake if they were confident that milk products are ethically produced. There was no significant association between MPHBS and dietary calcium intake. Energy-adjusted dietary calcium intake was positively associated with intakes of vitamin A (r = 0.3, P < 0.05), riboflavin (r = 0.5, P < 0.01), vitamin B12 (r = 0.5, P = < 0.01), vitamin D (r = 0.4, P < 0.01), phosphorus (r = 0.4, P < 0.01), zinc (r = 0.3, P < 0.01), and with milk and alternatives servings (r = 0.8, P < 0.01). Conclusion: Nutrition education efforts focused on increasing calcium-rich food consumption will help consumers to be better informed when making dietary choices.

Breakfast Cereal Consumption Moderates the Association Between Body Composition and Body Esteem in Young Women but not in Young Men.

PURPOSE: To explore the role of breakfast cereal consumption on the relationships among BMI, percent fat mass (%FM), and body esteem in young adults. METHODS: Weight, height, and %FM (by air displacement plethysmography) were measured in 29 males (aged 25.1 ± 4.0 years) and 28 females (aged 24.6 ± 4.0 years). Body esteem was measured using the Body Esteem Scale for Adolescents and Adults (BESAA). Three-day food records classified participants as breakfast cereal consumers (n = 27, any amount of ready-to-eat or cooked cereal consumed at breakfast) versus nonconsumers (n = 30, no cereal consumed at breakfast). RESULTS: The %FM was significantly (P ≤ 0.05) inversely correlated with weight esteem (r = -0.769), appearance esteem (r = -0.723), and external attribution (r = -0.620) in female noncereal consumers. BMI was similarly correlated with BESAA scores. These relationships were not significant in female cereal consumers (all r < 0.426), despite no difference in confounding variables between female cereal consumers and nonconsumers. Neither BMI nor %FM were correlated with measures of body esteem (all r < 0.466, NS) in either male cereal consumers or nonconsumers. CONCLUSIONS: Breakfast cereal consumption may moderate the relationship among BMI, %FM, and body esteem in young adult women and may be useful for improving body esteem without focusing on weight loss.

"I think we did the best that we could in the space:" A qualitative study exploring individuals' experiences with three unconventional environments for patients with a delayed hospital discharge.

BACKGROUND: Given growing hospital capacity pressures, persistent delayed discharges, and ongoing efforts to improve patient flow, the use of unconventional environments (newly created or repurposed areas for patient care) is becoming increasingly common. Despite this, little is known about individuals' experiences in providing or receiving care in these environments. OBJECTIVES: The objectives of this study were to: (1) describe the characteristics of three unconventional environments used to care for patients experiencing a delayed discharge, and (2) explore individuals' experiences with the three unconventional environments. METHODS: This was a multi-method qualitative study of three unconventional environments in Ontario, Canada. Data were collected through semi-structured interviews and observations. Participants included patients, caregivers, healthcare providers, and clinical managers who had experience with delayed discharges. In-person observations of two environments were conducted. Interviews were transcribed and notes from the observations were recorded. Data were coded and analyzed thematically. RESULTS: Twenty-nine individuals participated. Three themes were identified for unconventional environments: (1) implications on the physical safety of patients; (2) implications on staffing models and continuity of care; and, (3) implications on team interactions and patient care. Participants discussed how the physical set-up of some unconventional spaces was not conducive to patient needs, especially those with cognitive impairment. Limited space made it difficult to maintain privacy and develop social relationships. However, the close proximity of team members allowed for more focused collaborations regarding patient care and contributed to staff fulfilment. A smaller, consistent care team and access to onsite physicians seemed to foster improved continuity of care. CONCLUSIONS: There is potential to learn from multi-stakeholder perspectives in unconventional environments to improve experiences and optimize patient care. Key considerations include keeping hallways and patient rooms clear, having communal spaces for activities and socialization, co-locating team members to improve interactions and access to resources, and ensuring a consistent care team.

A qualitative study exploring how patient engagement activities were sustained or adapted in Canadian healthcare organizations during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic caused disruptions across healthcare systems globally exposing the precarious state of patient engagement across all levels of healthcare. While evidence is emerging to describe how engagement was affected across various settings, insights about how some organizations at the policy and practice level of healthcare were able to sustain or adapt patient engagement activities is lacking. OBJECTIVE: This paper addresses the following research question: "How were healthcare, government, and patient partner organizations able to sustain or adapt patient engagement activities during the COVID-19 pandemic?" METHODS: A qualitative descriptive study was conducted to understand how patient engagement activities were maintained or adapted in a variety of healthcare, government, and patient partner organizations in Canada throughout the pandemic. This analysis was part of a larger qualitative, multiple case study where one-to-one interviews were conducted with organizational leaders, managers and patient partners. RESULTS: The following themes were identified as key aspects of maintaining or adapting patient engagement activities: 1) having an embedded organizational culture of patient engagement; 2) adapting patient engagement activities to focus on COVID-19 response efforts; 3) having patient partners who exercised leadership and advocacy to support patient care and experiences during the pandemic; and 4) leveraging virtual technology as a communication tool to engage patient partners. CONCLUSION: This paper highlights important insights that may be useful to other health care organizations on how to sustain or adapt patient engagement activities during a healthcare crisis. Having patient engagement embedded within an organization's culture supported by, but not limited to, infrastructure, resources, investments in dedicated staff and patient partner leadership, and communication strategies and tools enabled continued patient engagement activities during the pandemic.

Negotiation of collective and individual candidacy for long Covid healthcare in the early phases of the Covid-19 pandemic: Validated, diverted and rejected candidacy.

This analysis of people's accounts of establishing their need and experiences of healthcare for long Covid (LC) symptoms draws on interview data from five countries (UK, US, Netherlands, Canada, Australia) during the first ∼18 months of the Covid-19 pandemic when LC was an emerging, sometimes contested, condition with scant scientific or lay knowledge to guide patients and professionals in their sense-making of often bewildering constellations of symptoms. We extend the construct of candidacy to explore positive and (more often) negative experiences that patients reported in their quest to understand their symptoms and seek appropriate care. Candidacy usually considers how individuals negotiate healthcare access. We argue a crucial step preceding individual claims to candidacy is recognition of their condition through generation of collective candidacy. "Vanguard patients" collectively identified, named and fought for recognition of long Covid in the context of limited scientific knowledge and no established treatment pathways. This process was technologically accelerated via social media use. Patients commonly experienced "rejected" candidacy (feeling disbelieved, discounted/uncounted and abandoned, and that their suffering was invisible to the medical gaze and society). Patients who felt their candidacy was "validated" had more positive experiences; they appreciated being believed and recognition of their changed lives/bodies and uncertain futures. More positive healthcare encounters were described as a process of "co-experting" through which patient and healthcare professional collaborated in a joint quest towards a pathway to recovery. The findings underpin the importance of believing and learning from patient experience, particularly vanguard patients with new and emerging illnesses.

Expanding our understanding of factors impacting delayed hospital discharge: Insights from patients, caregivers, providers and organizational leaders in Ontario, Canada.

INTRODUCTION: The purpose of this paper was to understand the nature of delayed hospital discharge through the lens of a policy framework (ideas, institutions and interests; 3-I framework). MATERIALS AND METHODS: One-to-one in-depth interviews were conducted with 57 participants, including 18 patients, 18 caregivers, 11 providers and 10 organizational leaders across two hospital networks in urban and rural regions of Ontario, Canada. RESULTS: Delayed discharge was a product of spill-over effects (due to rules and eligibility in other health sectors) and variable implementation of policies and guidelines (institutions); competing priorities and tensions among patients, caregivers, providers and organizational leaders (interests); as well as a number of perceived root causes including patient complexity, caregiver burnout, lack of system infrastructure, and an imbalance of system and personal responsibility to support aging adults (ideas). CONCLUSIONS: The 3-I framework allowed us to examine the contributing factors to delayed discharge in a comprehensive way. Based on our findings we suggest that cross-sectoral collaboration and strengthening of relationships among stakeholders is required to address this complex policy problem.

The Accuracy of Portion Size Reporting on Self-Administered Online 24-Hour Dietary Recalls Among Women With Low Incomes.

BACKGROUND: Accurately estimating portion sizes remains a challenge in dietary assessment. Digital images used in online 24-hour dietary recalls may be conducive to accuracy. OBJECTIVE: The current analyses were conducted to examine the accuracy of portion size estimation by women with low incomes who completed 24-hour dietary recalls using the online Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) in the Food and Eating Assessment Study II. DESIGN: True dietary intake was observed for 3 meals on 1 day through a controlled feeding study conducted from May through July 2016. The following day, participants completed an unannounced 24-hour dietary recall using ASA24, independently or with assistance in a small-group setting. PARTICIPANTS/SETTING: Participants included 302 women aged 18 to 82 years living in the Washington, DC, area who met the income thresholds for the Supplemental Nutrition Assistance Program. MAIN OUTCOME MEASURES: The accuracy of portion size estimation was assessed by comparing the weight truly consumed (observed) and the weight reported for predetermined categories of foods and beverages. STATISTICAL ANALYSES PERFORMED: The differences between observed and reported portions were examined and linear regression tested differences by recall condition. Analyses were conducted by condition and repeated with stratification by racial/ethnic identity, education, and body mass index. RESULTS: On average across foods and beverages, reported portion sizes were 7.4 g (95% CI, 4.3-10.5) and 6.4 g (95% CI, 2.8-10.0) higher than observed portion sizes in the independent and assisted conditions, respectively. Portion sizes were overestimated for small pieces and shaped foods in both conditions, as well as for amorphous/soft foods in the assisted condition and underestimated for single-unit foods in both conditions. Misestimation was fairly consistent by participants' race/ethnicity, education, and body mass index, to varying magnitudes. CONCLUSIONS: Women with low incomes overestimated the amounts of foods and beverages consumed across several categories using online 24-hour dietary recalls with digital images to support portion size estimation. Assistance with ASA24 had little impact on accuracy.

A scoping review of patient engagement activities during COVID-19: More consultation, less partnership.

BACKGROUND: The COVID-19 pandemic has had a devastating impact on healthcare systems and care delivery, changing the context for patient and family engagement activities. Given the critical contribution of such activities in achieving health system quality goals, we undertook to address the question: What is known about work that has been done on patient engagement activities during the pandemic? OBJECTIVE: To examine peer-reviewed and grey literature to identify the range of patient engagement activities, broadly defined (inclusive of engagement to support clinical care to partnerships in decision-making), occurring within health systems internationally during the first six months of the COVID-19 pandemic, as well as key barriers and facilitators for sustaining patient engagement activities during the pandemic. METHODS: The following databases were searched: Medline, Embase and LitCOVID; a search for grey literature focused on the websites of professional organizations. Articles were required to be specific to COVID-19, describe patient engagement activities, involve a healthcare organization and be published from March 2020 to September 2020. Data were extracted and managed using Microsoft Excel. A content analysis of findings was conducted. RESULTS: Twenty-nine articles were included. Few examples of more genuine partnership with patients were identified (such as co-design and organizational level decision making); most activities related to clinical level interactions (e.g. virtual consultations, remote appointments, family visits using technology and community outreach). Technology was leveraged in almost all reported studies to interact or connect with patients and families. Five main descriptive categories were identified: (1) Engagement through Virtual Care; (2) Engagement through Other Technology; (3) Engagement for Service Improvements/ Recommendations; (4) Factors Impacting Patient Engagement; and (5) Lessons Learned though Patient Engagement. CONCLUSIONS: Evidence of how healthcare systems and organizations stayed connected to patients and families during the pandemic was identified; the majority of activities involved direct care consultations via technology. Since this review was conducted over the first six months of the pandemic, more work is needed to unpack the spectrum of patient engagement activities, including how they may evolve over time and to explore the barriers and facilitators for sustaining activities during major disruptions like pandemics.

Young Adults' Perceptions of Calcium Intake and Health: A Qualitative Study.

Many young Canadian adults are not meeting dietary calcium recommendations. This is concerning as adequate calcium is important throughout young adulthood to maximize peak bone mass for osteoporosis prevention. There are limited studies that have explored young adults' perceptions toward calcium and health. Our objectives were to determine young adults' (18-34 years) knowledge of calcium in relation to health, facilitators and barriers to adequate calcium intake, and to explore both their suggestions for individual strategies to increase calcium intake and ways to communicate calcium-related messaging to this population. Eight gender-specific focus groups (18 men; 35 women) were conducted using a semistructured interview guide, guided by social cognitive theory. Deductive thematic analysis was used to generate themes. Participants perceived adequate calcium intake to be important for children and older adults but were uncertain of the benefits for their own age group. Perceived positive outcomes (e.g., aesthetics such as strong nails) associated with adequate calcium intake were cited as a motivator to increase intake. Perceived barriers to achieving increased calcium intake included the high cost and inconvenience of milk products and negative practices of dairy farmers. Participants suggested planning healthy well-balanced meals and forming a habit of consuming calcium-rich foods as individual strategies to increase calcium intake. Strategies to convey calcium-related information to young adults included increasing awareness of the importance of calcium via credible sources of information and developing nutrition education curricula. Social media and advertising were perceived as ineffective. Our findings provide key information for nutrition education initiatives.