Improving Care for the Frail in Nova Scotia: An Implementation Evaluation of a Frailty Portal in Primary Care Practice.

BACKGROUND: Understanding and addressing the needs of frail patients has been identified as an important strategy by the Nova Scotia Health Authority (NSHA). Primary care (PC) providers are in a key position to aid in the identification of, and response to frailty as part of routine care. Unlike singular chronic conditions such as diabetes and hypertension which garner a disease-based approach and identification as part of standard practice, frailty is only just emerging as a concept for PC. The web-based Frailty Portal was developed to aid in the identification of, assessment and care planning for frail patients in PC practice. In this study we assess the implementation feasibility and impact of the Frailty Portal by: (1) identifying factors influencing the Frailty Portal's use in community PC practice, and (2) examination of the immediate impact of the 'Frailty Portal' on frail patients, their caregivers and PC providers. METHODS: A convergent mixed method approach was implemented among PC providers in community-based practice in the NSHA, Central Zone. Quantitative and qualitative data were collected concurrently over a 9-month period. A sample of patients who underwent assessment and/or their caregiver were approached for survey participation. RESULTS: Fourteen community PC providers (10 family physicians, 4 nurse practitioners) completed 48 patient assessments and completed or begun 41 care plans; semi-structured interviews were conducted among 9 providers. Nine patients and 5 caregivers participated in the survey. PC providers viewed frailty as an important concept but implementation challenges were met, primarily with respect to the time required for use and lack of fit with traditional practice routines. Additional barriers included tool usability and accessibility, training and care planning steps, and privacy. Impacts of the tools use with respect to confidence and knowledge showed early promise. CONCLUSION: This feasibility study highlights the need for added health system supports, resources and financial incentives for successful implementation of the Frailty Portal in community PC practice. We suggest future implementation integrate the Frailty Portal to practice electronic medical records (EMRs) and target providers with largely geriatric practice populations and those practicing within interdisciplinary, collaborative primary healthcare (PHC) teams.

Development of a quality scoring tool to assess quality of discharge summaries.

INTRODUCTION: Timely, precise, and relevant communication between hospital-based clinicians and primary care physicians post-discharge (DC) ensures quality transitions, thereby reducing patient safety incidents and preventing readmission. At the present time there is limited knowledge of elements of quality or methods to score the quality criteria in the context of DC summaries. The Nova Scotia Health Authority, a provincial health system responsible for the delivery of services in a small Canadian province, embarked on a system-level approach to the standardization of DC summaries in an effort to improve quality and safety at care transitions from hospital to primary care. MATERIALS AND METHODS: A comprehensive literature review to retrieve items relevant to quality in DC summaries, retrospective audit of charts, a consensus development process, and, finally, validation of a scoring tool were conducted in order to develop a quality scoring tool for DC summaries. RESULTS: Relevant items were identified through the literature review and consensus development process. Corresponding definitions that were established assisted the development of the quality criteria, which were subsequently used to score the quality of DC summaries in our organization. CONCLUSION: The scoring tool developed through this work will be applied to help us gain a more in-depth understanding of quality in DC summaries and support the development of suitable education and quality processes in the health authority that can best support safe care transitions for patients.

Applying the consolidated framework for implementation research to identify barriers affecting implementation of an online frailty tool into primary health care: a qualitative study.

BACKGROUND: Frailty is associated with multi-system deterioration, and typically increases susceptibility to adverse events such as falls. Frailty can be better managed with early screening and intervention, ideally conducted in primary health care (PHC) settings. This study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework during the second stage piloting of a novel web-based tool called the Frailty Portal, developed to aid in the screening, identification, and care planning of frail patients in community PHC. METHODS: This qualitative study conducted semi-structured key informant interviews with a purposive sample of PHC providers (family physicians, nurse practitioners) and key PHC stakeholders who were administrators, decision makers and staff. The CFIR was used to guide data collection and analysis. Framework Analysis was used to determine the relevance of the CFIR constructs to implementing the Frailty Portal. RESULTS: A total of 17 interviews were conducted. The CFIR-inspired interview questions helped clarify critical aspects of implementation that need to be addressed at multiple levels if the Frailty Portal is to be successfully implemented in PHC. Finding were organized into three themes 1) PHC Practice Context, 2) Intervention attributes affecting implementation, and 3) Targeting providers with frail patients. At the intervention level the Frailty Portal was viewed positively, despite the multi-level challenges to implementing it in PHC practice settings. Provider participants perceived high opportunity costs to using the Frailty Portal due to changes they needed to make to their practice routines. However, those who had older patients, took the time to learn how to use the Frailty Portal, and created processes for sharing tasks with other PHC personnel become proficient at using the Frailty Portal. CONCLUSIONS: Structuring our evaluation around the CFIR was instrumental in identifying multi-level factors that will affect large-scale adoption of the Frailty Portal in PHC practices. Incorporating CFIR constructs into evaluation instruments can flag factors likely to impede future implementation and impact the effectiveness of innovative practices. Future research is encouraged to identify how best to facilitate changes in PHC practices to address frailty and to use implementation frameworks that honor the complexity of implementing innovations in PHC.

The Newcomer Health Clinic in Nova Scotia: A Beacon Clinic to Support the Health Needs of the Refugee Population.

Refugees tend to have greater vulnerability compared to the general population reporting greater need for physical, emotional, or dental problems compared to the general population. Despite the importance of creating strong primary care supports for these patients, it has been demonstrated that there is a significant gap in accessing primary care providers who are willing to accept the refugee population. These have resulted in bottlenecks in the transition or bridge clinics and have left patients orphaned without a primary care provider. This in turn results in higher use of emergency service and other unnecessary costs to the healthcare system. Currently there are few studies that have explored these challenges from primary care provider perspectives and very few to none from patient perspectives. A novel collaborative implementation initiative in primary healthcare (PHC) is seeking to improve primary medical care for the refugee population by creating a globally recommended transition or beacon clinic to support care needs of new arrivals and transitions to primary care providers. We discuss the innovative elements of the clinic model in this paper.

Bringing Value-Based Perspectives to Care: Including Patient and Family Members in Decision-Making Processes.

BACKGROUND: Recent evidence shows that patient engagement is an important strategy in achieving a high performing healthcare system. While there is considerable evidence of implementation initiatives in direct care context, there is limited investigation of implementation initiatives in decision-making context as it relates to program planning, service delivery and developing policies. Research has also shown a gap in consistent application of system-level strategies that can effectively translate organizational policies around patient and family engagement into practice. METHODS: The broad objective of this initiative was to develop a system-level implementation strategy to include patient and family advisors (PFAs) at decision-making points in primary healthcare (PHC) based on wellestablished evidence and literature. In this opportunity sponsored by the Canadian Foundation for Healthcare Improvement (CFHI) a co-design methodology, also well-established was applied in identifying and developing a suitable implementation strategy to engage PFAs as members of quality teams in PHC. Diabetes management centres (DMCs) was selected as the pilot site to develop the strategy. Key steps in the process included review of evidence, review of the current state in PHC through engagement of key stakeholders and a co-design approach. RESULTS: The project team included a diverse representation of members from the PHC system including patient advisors, DMC team members, system leads, providers, Public Engagement team members and CFHI improvement coaches. Key outcomes of this 18-month long initiative included development of a working definition of patient and family engagement, development of a Patient and Family Engagement Resource Guide and evaluation of the resource guide. CONCLUSION: This novel initiative provided us an opportunity to develop a supportive system-wide implementation plan and a strategy to include PFAs in decision-making processes in PHC. The well-established co-design methodology further allowed us to include value-based (customer driven quality and experience of care) perspectives of several important stakeholders including patient advisors. The next step will be to implement the strategy within DMCs, spread the strategy PHC, both locally and provincially with a focus on sustainability.

Evaluating the Implementation and Feasibility of a Web-Based Tool to Support Timely Identification and Care for the Frail Population in Primary Healthcare Settings.

BACKGROUND: Understanding and addressing the needs of frail persons is an emerging health priority for Nova Scotia and internationally. Primary healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not standard practice and, in general, there is a lack of awareness about how to identify and respond to frailty. A web-based tool called the Frailty Portal was developed to aid in identifying, screening, and providing care for frail patients in PHC settings. In this study, we will assess the implementation feasibility and impact of the Frailty Portal to: (1) support increased awareness of frailty among providers and patients, (2) identify the degree of frailty within individual patients, and (3) develop and deliver actions to respond to frailtyl in community PHC practice. METHODS: This study will be approached using a convergent mixed method design where quantitative and qualitative data are collected concurrently, in this case, over a 9-month period, analyzed separately, and then merged to summarize, interpret and produce a more comprehensive understanding of the initiative's feasibility and scalability. Methods will be informed by the 'Implementing the Frailty Portal in Community Primary Care Practice' logic model and questions will be guided by domains and constructs from an implementation science framework, the Consolidated Framework for Implementation Research (CFIR). DISCUSSION: The 'Frailty Portal' aims to improve access to, and coordination of, primary care services for persons experiencing frailty. It also aims to increase primary care providers' ability to care for patients in the context of their frailty. Our goal is to help optimize care in the community by helping community providers gain the knowledge they may lack about frailty both in general and in their practice, support improved identification of frailty with the use of screening tools, offer evidence based severity-specific care goals and connect providers with local available community supports.

A Patient-Centred Redesign Framework to Support System-Level Process Changes for Multimorbidities and Chronic Conditions.

Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.

A novel community-based model to enhance health promotion, risk factor management and chronic disease prevention.

Chronic disease is a highly expensive but preventable problem to the healthcare system. Evidence suggests that impacting modifiable behaviours and risk management factors in the areas of physical inactivity, unhealthy diet, stress and obesity can alleviate the burden of chronic disease problem to a large extent. Despite this recognition, the challenge is embedding these recognized priorities into the community and in primary care in a sustainable and meaningful manner. Primary Health Care in Capital Health responded to this challenge by developing and implementing a free, interprofessional and community-based service, namely, the Community Health Teams (CHTs), that offers health and wellness, risk factor management, wellness navigation and behaviour-based programming. In this paper, the development and implementation of the CHTs are discussed. Preliminary outcomes for the model are significant and promising. Formal and large-scale studies are planned to validate these outcomes with additional research rigour.

Development and evaluation of a "working together" framework and a tool kit to enhance inter-organizational relationships in healthcare.

Healthcare is in a constant state of change and evolution driven by a multitude of complex factors and interactions. Consequently, organizations, teams and individuals in healthcare have to habitually realign their working relationships. Furthermore, research has shown that "working together" relationships fail in the absence of a defined framework. In this research, a novel framework and a tool kit for working together have been developed and evaluated. The framework has a formal process to articulate the intended purpose/outcome, clearly align the type of working relationship with the purpose and identify the barriers and facilitators to working relationships in healthcare.