Virtual Pharmacy: An Integrated Collaborative Redesign Targeting Medication-Related Problems in Patients with Chronic Kidney Disease.

INTRODUCTION: Collaborative management of kidney disease relies on coordinated and effective partnerships between multiple providers. Siloed traditional health systems often result in delays, barriers to treatment access, and inefficient monitoring. METHODS: We conducted a 1-year observational mixed-methods study. We included all consecutive referrals except for patients without telephone access. We assessed 4 domains of outcomes: (1) patient and caregiver experience, (2) provider experience (e.g., physicians and pharmacists), (3) clinical outcomes specific to medication-related outcomes (e.g., adherence, adverse drug events [ADEs]), and (4) value and efficiency (i.e., medication access, defined as time to treatment and resolution of medication reimbursement issues). RESULTS: Sixty-five patients were referred to the integrated virtual pharmacy (iVRx) model. Most (72%) patients were male. Patients had a median (min, max) age of 60 (27, 85) years and were taking 8 (4, 13) medications. Compared with traditional care delivery models, medication access improved for 56% of participants. Direct home delivery of medication resulted in 91% of patients receiving prescriptions within 2 days of a nephrologist visit. During more than 2,000 pharmacist-patient encounters, 208 ADEs were identified that required clinician intervention to prevent patient harm. When these ADEs were classified by severity, 53% were mild, 45% were moderate (e.g., delaying dose titration in patients initiated on glucagon-like peptide 1 (GLP-1) agonists due to intolerable gastrointestinal side effects), and the remaining 2% of ADEs were severe, meaning clinical intervention was required to prevent a serious outcome (e.g., uncontrolled blood pressure, prevention of acute kidney injury). Nephrologists reported high satisfaction with iVRx, citing efficiency, timely response, and collaboration with pharmacists as key facilitators. Of the 65 patient participants, 98% reported being extremely satisfied. CONCLUSIONS: The iVRx is an acceptable and feasible clinical strategy. Our pilot program was associated with improved kidney care by increasing medication access for patients and avoiding potential harms associated with ADEs.

Lost in the System: Responsibilisation and Burden for Women With Multiple Long-Term Health Conditions During Pregnancy.

INTRODUCTION: Over a fifth of pregnant women are living with multiple long-term health conditions, which is associated with increased risks of adverse outcomes for mothers and infants. While there are many examples of research exploring individuals' experiences and care pathways for pregnancy with a single health condition, evidence relating to multiple health conditions is limited. This study aimed to explore experiences and care of women with multiple long-term health conditions around the time of pregnancy. METHODS: Semistructured interviews were conducted between March 2022 and May 2023 with women with multiple long-term health conditions who were at least 28 weeks pregnant or had had a baby in the last 2 years, and healthcare professionals with experience of caring for these women. Participants were recruited from across the United Kingdom. Data were analysed using thematic analysis. RESULTS: Fifty-seven women and 51 healthcare professionals participated. Five themes were identified. Women with long-term health conditions and professionals recognised that it takes a team to avoid inconsistent care and communication, for example, medication management. Often, women were required to take a care navigation role to link up their healthcare providers. Women described mixed experiences regarding care for their multiple identities and the whole person. Postnatally, women and professionals recognised a downgrade in care, particularly for women's long-term health conditions. Some professionals detailed the importance of engaging with women's knowledge, and recognising their own professional boundaries of expertise. Many participants described difficulties in providing informational continuity and subsequent impacts on care. Specifically, the setup of care systems made it difficult for everyone to access necessary information, especially when care involved multiple sites. CONCLUSION: Pregnant women with long-term health conditions can experience a substantial burden of responsibility to maintain communication with their care team, often feeling vulnerable, patronised, and let down by a lack of acknowledgement of their expertise. These results will be used to inform the content of coproduction workshops aimed at developing a list of care recommendations for affected women. It will also inform future interventional studies aimed at improving outcomes for these women and their babies. PATIENT OR PUBLIC CONTRIBUTION: Our Patient and Public Involvement group were involved in the design of the study and the analysis and interpretation of the data, and a public study investigator was part of the author group.

Oral health and healthy ageing: a scoping review.

BACKGROUND: Good oral health is an important part of healthy ageing, yet there is limited understanding regarding the status of oral health care for older people globally. This study reviewed evidence (policies, programs, and interventions) regarding oral health care for older people. METHODS: A systematic search of six databases for published and grey literature in the English language by the end of April 2022 was undertaken utilising Arksey and O'Malley's scoping review framework. RESULTS: The findings from oral health policy documents (n = 17) indicated a lack of priorities in national health policies regarding oral health care for older people. The most common oral health interventions reported in the published studies (n = 62) included educational sessions and practical demonstrations on oral care for older adults, nurses, and care providers. Other interventions included exercises of facial muscles and the tongue, massage of salivary glands, and application of chemical agents, such as topical fluoride. CONCLUSION: There is currently a gap in information and research around effective oral health care treatments and programs in geriatric dental care. Efforts must be invested in developing guidelines to assist both dental and medical healthcare professionals in integrating good oral health as part of healthy ageing. Further research is warranted in assessing the effectiveness of interventions in improving the oral health status of the elderly and informing approaches to assist the integration of oral health into geriatric care.

We need a radical change to take place now´-The potential of integrated healthcare for rural long-term care facilities.

OBJECTIVES: This study explores healthcare professionals' perceptions in rural German long-term care facilities, focusing on integrated health systems. The aim is to understand experiences, challenges, and preferences. METHODS: Twenty nurses and paramedics participated in in-depth interviews. Thematic analysis was applied to transcripts, revealing key themes: acute healthcare provision, interdisciplinary collaboration, telemedicine use, and preferences for the future healthcare landscape. RESULTS: Themes highlighted factors influencing acute care situations and the crucial role of interdisciplinary collaboration. Integrated care was infrequently encountered despite high demand in rural long-term care facilities. CONCLUSIONS: Though uncommon, integrated healthcare remains crucial in addressing long-term care facility residents' complex needs. Healthcare professionals express a strong demand for integrated care in rural areas, citing potential benefits for resident wellbeing, healthcare effectiveness, and job satisfaction. The findings guide healthcare organizations in developing institutional-level strategies for integrated care integration, emphasizing its importance in rural settings.

Results of the study of the attitude of women of reproductive age to the integrated gynecological care provision by family physicians.

OBJECTIVE: Aim: To study and analyze the attitude of women of reproductive age to the integrated gynecological care provision by family physicians, their readiness to receive some gynecological services from family physicians, as well as to analyze the level of women's support and readiness for the integrated provision of gynecological care depending on age and level of education. PATIENTS AND METHODS: Materials and Methods: For the survey, anonymous questionnaires containing questions on the attitude of women of reproductive age to the integrated provision of certain types of gynecological care by family physicians were developed. 181 women from the Kyiv region took part in the survey. RESULTS: Results: Support of more than 80% of respondents regarding the integrated gynecological care provision by family physicians received the following questions: counseling on the prevention of sexually transmitted infections and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (92,3%); counseling on family planning and prevention of unwanted pregnancy (83,4%); counseling on the use of various methods of contraception (82,3%); examination and palpation of mammary glands (80,1%); referral of women to a higher level of obstetric and gynecological care (if necessary (86,2%). CONCLUSION: Conclusions: The majority of respondents (67,4%) are ready or better ready than not ready to receive certain types of gynecological care services from family physicians. Almost the same percentage ratio (more than 60%) of women of each age group and all levels of education are ready or better ready than not ready to receive gynecological care services, which they supported, from family physicians.

Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?"

Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. CONTEXT: Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems. METHODS: A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time. FINDINGS: The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. CONCLUSIONS: Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.

Evaluation of the Oral Health Knowledge Network's Impact on Pediatric Clinicians and Patient Care.

PURPOSE: Oral disease has a major impact on the overall health of US children, with dental caries being the most prevalent chronic disease in this age group. Given nationwide shortages of dental professionals, interprofessional clinicians and staff with proper training can influence oral health access. The American Academy of Pediatrics created the Oral Health Knowledge Network (OHKN) in 2018 to bring together pediatric clinicians via monthly virtual sessions to learn from experts, share resources, and network. METHODS: The Center for Integration of Primary Care and Oral Health partnered with the American Academy of Pediatrics to evaluate the OHKN in 2021. The mixed method evaluation included an online survey and qualitative interviews among program participants. They were asked to provide information on their professional role and prior commitment to medical-dental integration as well as feedback on the OHKN learning sessions. RESULTS: Of the 72 program participants invited, 41 (57%) completed the survey questionnaire and 11 took part in the qualitative interviews. Analysis showed that OHKN participation supported both clinicians and nonclinicians in integrating oral health into primary care. The greatest clinical impact was incorporating oral health training for medical professionals (cited by 82% of respondents), while the greatest nonclinical impact was learning new information (cited by 85% of respondents). The qualitative interviews highlighted the participants' prior commitment to medical-dental integration as well as drivers for their current medical-dental integration work. CONCLUSIONS: Overall, the OHKN had a positive impact on pediatric clinicians and nonclinicians and, as a learning collaborative, successfully educated and motivated health care professionals to improve their patients' access to oral health through rapid resource sharing as well as clinical practice change.

Disparities in melanoma-specific mortality by race/ethnicity, socioeconomic status, and health care systems.

BACKGROUND: Despite encouraging trends in survival, sociodemographic inequalities persist among patients with melanoma. OBJECTIVE: We sought to quantify the effect of race/ethnicity, socioeconomic status, and health care systems on melanoma-specific mortality within an insured population of patients. METHODS: Using a retrospective cohort study, we identified insured adults diagnosed with Stage I to IV melanoma from January 1, 2009, to December 31, 2014, followed through 2017, from the California Cancer Registry. We compared melanoma-specific mortality between insured patients diagnosed within the largest vertically integrated health care system in California, Kaiser Permanente Southern California, and insured patients with other private insurance (OPI). RESULTS: Our cohort included 14,614 adults diagnosed with melanoma. Multivariable analyses demonstrated that race/ethnicity was not associated with survival disparities, while socioeconomic status was a strong predictor of melanoma-specific mortality, particularly for those with OPI. For example, hazard ratios demonstrate that the poorest patients with OPI have a 70% increased risk of dying from their melanoma compared to their wealthiest counterparts, while the poorest patients in Kaiser Permanente Southern California have no increased risk. LIMITATIONS: Our main limitation includes inadequate data for certain racial/ethnic groups, such as Native Americans. CONCLUSIONS: Our findings underscore the persistence of socioeconomic disparities within an insured population, specifically among those in non-integrated health care systems.

Integrating Palliative Care into Oncology Care Worldwide: The Right Care in the Right Place at the Right Time.

OPINION STATEMENT: While the benefits of early palliative care are indisputable, most of the current evidence has emerged from resource-rich settings in urban areas of high-income countries, with an emphasis on solid tumors in outpatient settings; this model of palliative care integration is not currently scalable internationally. A shortage of specialist palliative care clinicians means that in order to meet the needs of all patients who require support at any point along their advanced cancer trajectory, palliative care must also be provided by family physicians and oncology clinicians who require training and mentorship. Models of care that facilitate the timely provision of seamless palliative care across all settings (inpatient, outpatient, and home-based care), with clear communication between clinicians, are crucial to the provision of patient-centred palliative care. The unique needs of patients with hematological malignancies must be further explored and existing models of palliative care provision modified to meet these needs. Finally, care must be provided in an equitable and culturally sensitive manner, recognizing the challenges associated with the delivery of high-quality palliative care to both patients in high-income countries who live in rural areas, as well as to those in low- and middle-income countries. A one-size-fits-all model will not suffice, and there is an urgent need to develop innovative context-specific models of palliative care integration worldwide, in order to provide the right care, in the right place, and at the right time.

Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT-2) trials.

AIM: We conducted a prospective cohort study to evaluate the effectiveness of an integrated care model on delaying chronic kidney disease (CKD) progression in routine clinical practice in rural primary care setting. METHODS: After enrolment, patients with stages 3 to 4 CKD patients from five district hospitals in a northern province of Thailand (400 km from Bangkok) received integrated care comprising hospital multidisciplinary care and home visits by community care teams. Clinical characteristics and biochemical data were collected at baseline and every 3-month interval thereafter for 36 months. The primary outcome was the rate of estimated glomerular filtration rate (eGFR) decline. RESULTS: Nine hundred and fourteen stage -3 and - 4 CKD patients were enrolled. The mean age of our cohort was 62 years. Diabetic kidney disease (DKD) was the main cause of CKD (53%) whereas hypertension was the most common co-morbidity (92%). The mean rate of eGFR decline was -0.92 mL/min/1.73 m2 /year. The rate of eGFR decline among patients with DKD was about three times faster than patients without DKD. Patients with higher blood pressure, metabolic acidosis, proteinuria or anaemia had a faster rate of eGFR decline. CONCLUSION: This integrated care model at the community level was effective in delaying CKD progression in routine clinical practice situation.

[VIG-Express: Consensus on an express multidimensional/geriatric assessment system in Catalonia]. / VIG-Express: Consenso de un sistema de valoración multidimensional/geriátrica rápida en Cataluña.

OBJECTIVE: To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions. DESIGN: Three-phase consensus of professionals, combining in-person sessions with telematics. LOCATION: Catalonia. PARTICIPANTS: A group of 27 interdisciplinary professionals from different care settings. METHOD: The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3). RESULTS: In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (<10 min), identify altered dimensions using trigger questions and facilitate the diagnosis of the condition (ideally quantified). In Phase 2, a prototype of a new RMGA tool containing 15 + 2 questions (VIG-Express) was developed, which was then tested in 35 patients in Phase 3. CONCLUSIONS: Based on preliminary results, the VIG-Express tool seems to facilitate a simple, rapid multidimensional assessment and the customization of interventions, as well as provide a unique look and shared narrative between professionals from different care settings. More studies will be required to corroborate these findings.

Two-eyed seeing of the integration of oral health in primary health care in Indigenous populations: a scoping review.

BACKGROUND: Indigenous people experience significant poor oral health outcomes and poorer access to oral health care in comparison to the general population. The integration of oral health care with primary health care has been highlighted to be effective in addressing these oral health disparities. Scoping studies are an increasingly popular approach to reviewing health research evidence. Two-eyed seeing is an approach for both Western and Indigenous knowledge to come together to aid understanding and solve problems. Thus, the two-eyed seeing theoretical framework advocates viewing the world with one eye focused on Indigenous knowledge and the other eye on Western knowledge. This scoping review was conducted to systematically map the available integrated primary oral health care programs and their outcomes in these communities using the two-eyed seeing concept. METHODS: This scoping review followed Arksey and O'Malley's five-stage framework and its methodological advancement by Levac et al. A literature search with defined eligibility criteria was performed via several electronic databases, non-indexed Indigenous journals, Indigenous health organizational websites, and grey literature. The charted data was classified, analyzed, and reported using numeral summary and qualitative content analysis. The two-eyed seeing concept guided the interpretation and synthesis of the evidence on approaches and outcomes. RESULTS: A total of 29 publications describing 30 programs conducted in Australia and North America from 1972 to 2019 were included in the final analysis. The following four program categories emerged from the analysis: oral health promotion and prevention programs (n = 13), comprehensive dental services (n = 13), fly in, fly out dental services (n = 3), and teledentistry (n = 1). Biomedical approaches for integrated primary oral health care were leadership and governance, administration and funding, capacity building, infrastructure and technology, team work, and evidence-based practice. Indigenous approaches included the vision for holistic health, culturally appropriate services, community engagement, shared responsibility, and cultural safety. The program outcomes were identified for biological, mental, and emotional dimensions of oral health; however, measurement of the spiritual dimension was missing. CONCLUSION: Our results suggest that a multiple integrated primary oral health care approach with a particular focus on Indigenous culture seems to be efficient and relevant in improving Indigenous oral health.

Exploring the nurse navigator role: A thematic analysis.

BACKGROUND: Patients with complex chronic conditions experience fragmentation of care, unnecessary hospitalization and reduced quality of life, with an increased incidence of poor health outcomes. AIM(S): The aim of this paper was to explore how nurse navigators manage client care. This was achieved through an examination of narratives provided by the nurse navigator that evaluated their scope of practice. METHOD(S): All nurse navigators employed by Queensland Health were invited to participate in a study evaluating the effectiveness of the service. Eighty-four self-reported vignettes were thematically analysed to understand the work from the nurses' perspectives. RESULTS: Two themes emerged from the vignettes. Theme 1, the layers of complexity, is comprised of three sub-themes: the complex patient, the complex system and patient outcomes. Theme 2, professional attributes, has two sub-themes: person-centred care and clinical excellence. CONCLUSION: Navigators innovatively integrate services and address the fragmented nature of the health system. They apply expert clinical and social skills, through consistent and robust communication, to meet the needs of those with multiple chronic conditions. IMPLICATIONS FOR NURSING MANAGEMENT: Results provide insight into the new role, illuminating the work they achieve, despite system complexities.

Barriers to eliciting patient goals and values in shared decision-making breast cancer surgery consultations: An ethnographic and interview study.

OBJECTIVE: Previous research has demonstrated the importance of eliciting patients' goals and values during shared decision-making (SDM), but this does not occur in most SDM conversations. Understanding challenges to eliciting patients' goals and values is crucial. This study assessed how clinicians balanced sharing medical information and considering patients' goals and values during breast cancer surgery consultation in an integrated health care system. METHODS: We conducted interviews with clinicians (n = 6) and patients (n = 11) and conducted naturalistic, ethnographic observations of eight surgical consultations in a multidisciplinary breast cancer clinic. We analyzed the data following the template method using the qualitative software NVivo 10. RESULTS: Clinicians prioritized sharing medical information. We identified four patient factors necessary to integrate patients' values and goals into the conversation in addition to sharing medical information: ability to process large quantities of information quickly, willingness to embrace swift decision-making, ability to quickly formulate one's values, and prioritization of surgical choice as the goal of the conversation. CONCLUSIONS: We found that SDM implementation results in practices that emphasize information and choice, with less focus on patient goals and values. More research is needed to explore factors that may encourage the elicitation of patients' goals and values.

Vulnerabilities in diabetic eye screening for children and young people in England.

BACKGROUND: Children and young people (CYP) living with diabetes require integrated child-centered care. We hypothesized that suboptimal uptake to diabetic retinopathy screening in CYP may be partly related to the degree of services integration. We investigated the structure of the current pediatric diabetic eye care pathway and associations between service-level characteristics and screening uptake. METHODS: A quality improvement project between January and May 2017 comprising a survey of practice of all 158 pediatric diabetes services (pediatric diabetes units, PDUs) across England and secondary data analysis of routinely collected service data. Generalized linear models for proportional responses were fitted to investigate associations between reported PDU characteristics and screening uptake. RESULTS: 124 PDUs (78%) responded. In 67% (n = 83), patients could be referred directly to screening programs; the remainder relied on primary care for onward referral. 97% (n = 120) considered eye screening results useful for counseling patients but only 65% (n = 81) reported it was "easy" to obtain them. Factors independently associated with higher screening uptake were a higher proportion of patients referred from primary care (OR = 1.005; 95%CI = 1.004-1.007 per 1% of increase), absence of "out-of-catchment area" patients (OR = 1.13; 95%CI = 1.04-1.22), and easy access to eye screening results (OR = 1.45; 95%CI = 1.34-1.56). CONCLUSIONS: There is limited direct communication between the services involved in diabetic eye care for CYP in England. This risks reducing the effectiveness of diabetic retinopathy screening. Similar vulnerabilities are likely to exist in other countries where retinopathy screening for CYP has been "bolted on" to provision for adults.

Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey.

BACKGROUND: Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption. METHODS: Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption. RESULTS: The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients' treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care. CONCLUSIONS: HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient's preferences in the care process - preferably before starting treatment through discussions in a multidisciplinary meeting.

Development and Evaluation of a Web-Based Resource for Suicidal Thoughts: NowMattersNow.org.

BACKGROUND: Nearly half of people who die by suicide see a health care provider in the month before their death. With the release of new care guidelines, detection of suicidal patients will likely increase. Providers need access to suicide-specific resources that can be used as part of immediate, brief interventions with a suicidal patient. Web-based suicide prevention resources have the potential to address this need. OBJECTIVE: This study aimed to describe the development of the NowMattersNow.org website as a resource for individuals with suicidal thoughts and to evaluate the utility of the site via user experience surveys. METHODS: NowMattersNow.org is an online video-based free public resource that provides evidence-based teachings, examples, and resources for managing suicidal thoughts and intense emotions focused largely around skills from dialectical behavior therapy. Developed with assistance from mental health consumers, it is intended to address gaps in access to services for suicidal patients in health care systems. Visitors stay an average of a minute and a half on the website. From March 2015 to December 2017, a user experience survey measured self-reported changes on a 1 (not at all) to 5 (completely overwhelming) scale regarding intensity of suicidal thoughts and negative emotions while on the website. Longitudinal regression analyses using generalized estimating equations evaluated the magnitude and statistical significance of user-reported changes in suicidal ideation and negative emotion. In secondary analyses, user-reported changes specific to subgroups, including men aged 36 to 64 years, mental health care providers, and other health care providers were evaluated. RESULTS: During the period of analysis, there were 138,386 unique website visitors. We analyzed surveys (N=3670) collected during that time. Subsamples included men aged 36 to 64 years (n=512), mental health providers (n=460), and other health care providers (n=308). A total of 28% (1028/3670) of survey completers rated their suicidal thoughts as a 5 or "completely overwhelming" when they entered the website. We observed significant reductions in self-reported intensity of suicidal thoughts (-0.21, P<.001) and negative emotions (-0.32, P<.001), including decreases for users with the most severe suicidal thoughts (-6.4%, P<.001), most severe negative emotions (-10.9%, P<.001), and for middle-aged men (-0.13, P<001). Results remained significant after controlling for length of visit to website (before the survey) and technology type (mobile, desktop, and tablet). CONCLUSIONS: Survey respondents reported measurable reductions in intensity of suicidal thoughts and emotions, including those rating their suicidal thoughts as completely or almost completely overwhelming and among middle-aged men. Although results from this user-experience survey administered at one point in time to a convenience sample of users must be interpreted with caution, results provide preliminary support for the potential effectiveness of the NowMattersNow.org website as a tool for short-term management of suicidal thoughts and negative emotions.

Relational continuity of oral health care in Indigenous communities: a qualitative study.

BACKGROUND: The relational continuity of care is an essential function of primary health care. This study reports on the perspectives of Cree communities and their primary health care providers regarding the barriers and enablers of relational continuity of oral health care integrated at a primary health care organization. METHODS: A multiple case study design within a qualitative approach and developmental evaluation methodology were used to conduct this research study in Cree communities of Northern Québec. Maximum variation sampling and snowball techniques were used to recruit the participants. Data collection consisted of individual interviews and focus group discussions. Thematic analysis was conducted which included transcription, debriefing, codification, data display, and interpretation. The consolidated criteria for reporting qualitative studies (COREQ) were used to guide the reporting of study findings. RESULTS: A total of six focus group discussions and 36 individual interviews were conducted. Five major themes emerged from the thematic analyses for barriers (two) and enablers (three). Themes for barriers included impermanence and lack of effective communication, whereas themes for enablers included culturally competent professionals, working across professional boundaries, and proactive organizational engagement. CONCLUSIONS: Based on these findings, relational continuity can be empowered by effective strategies for overcoming barriers and encouraging enablers, such as recruitment of permanent professionals, organizing cultural competency training, development of a Cree language dental glossary, encouraging inter-professional collaboration, and promoting the organization's efforts.

The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care.

BACKGROUND: In the western world, a growing number of the older people live at home. In the Netherlands, GPs are expected to play a pivotal role in the organization of integrated care for this patient group. However, little is known about how GPs can play this role best. Our aim for this study was to unravel how GPs can play a successful role in elderly care, in particular in multidisciplinary teams, and to define key concepts for success. METHODS: A mixed qualitative research model in four multidisciplinary teams for elderly care in the Netherlands was used. With these four teams, consisting of 46 health care and social service professionals, we carried out two rounds of focus-group interviews. Moreover, we performed semi-structured interviews with four GPs. We analysed data using a hybrid inductive/deductive thematic analysis. RESULTS: According to the health care and social service professionals in our study, the role of GPs in multidisciplinary teams for elderly care was characterized by the ability to 'see the bigger picture'. We identified five key activities that constitute a successful GP role: networking, facilitating, team building, integrating care elements, and showing leadership. Practice setting and phase of multidisciplinary team development influenced the way in which GPs fulfilled their roles. According to team members, GPs were the central professionals in care services for older people. The opinions of GPs about their own roles were diverse. CONCLUSIONS: GPs took an important role in successful care settings for older people. Five key concepts seemed to be important for best practices in care for frail older people: networking (community), facilitating (organization), team building (professional), integrating care elements (patient), and leadership (personal). Team members from primary care and social services indicated that GPs had an indispensable role in such teams. It would be advantageous for GPs to be aware of this attributed role. Attention to leadership competencies and to the diversity of roles in multidisciplinary teams in GP training programmes seems useful. The challenge is to convince GPs to take a lead, also when they are not inclined to take this role in organizing multidisciplinary teams for older people.

Cost-effectiveness of the 'Walcheren Integrated Care Model' intervention for community-dwelling frail elderly.

BACKGROUND: An important aim of integrated care for frail elderly is to generate more cost-effective health care. However, empirical research on the cost-effectiveness of integrated care for community-dwelling frail elderly is limited. OBJECTIVE: This study reports on the cost-effectiveness of the Walcheren Integrated Care Model (WICM) after 12 months from a societal perspective. METHODS: The design of this study was quasi-experimental. In total, 184 frail elderly patients from 3 GP practices that implemented the WICM were compared with 193 frail elderly patients of 5 GP practices that provided care as usual. Effects were determined by health-related quality of life (EQ-5D questionnaire). Costs were assessed based on questionnaires, GP files, time registrations and reports from multidisciplinary meetings. Average costs and effects were compared using t-tests. The incremental cost-effectiveness ratio (ICER) was calculated, and bootstrap methods were used to determine its reliability. RESULTS: Neither the WICM nor care as usual resulted in a change in health-related quality of life. The average total costs of the WICM were higher than care as usual (17089 euros versus 15189 euros). The incremental effects were 0.00, whereas the incremental costs were 1970 euros, indicating an ICER of 412450 euros. CONCLUSIONS: The WICM is not cost-effective, and the costs per quality-adjusted life year are high. The costs of the integrated care intervention do not outweigh the limited effects on health-related quality of life after 12 months. More analyses of the cost-effectiveness of integrated care for community-dwelling frail elderly are recommended as well as consideration of the specific costs and effects.