Supporting Goal-Oriented Primary Health Care for Seniors’ with Multimorbidity and Complex Care Needs using Mobile Technology: Mixed-Methods, Stepped-Wedge Cluster Randomized Trial of the ePRO Tool. (Preprint)

2021 ◽  
Author(s):  
Carolyn Steele Gray ◽  
Phat (Eduard) Chau ◽  
Farah Tahsin ◽  
Sarah Harvey ◽  
Mayura Loganathan ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Primary Care ◽  
Control Period ◽  
Self Management ◽  
Care Needs ◽  
Ethnographic Data ◽  
Care Practices ◽  
Primary Care Practices ◽  
Complex Care Needs

BACKGROUND Goal-oriented care is being adopted to deliver person-centred primary care to older adults with multimorbidity and complex care needs. While this model holds promise, implementation remains a challenge. Digital health solutions may enable processes to improve adoption, however, they require evaluation to determine feasibility and impact. OBJECTIVE This study evaluates the implementation and effectiveness of the electronic Patient Reported Outcome (ePRO) mobile application and portal system, designed to enable goal-oriented care delivery in inter-professional primary care practices. The research questions driving this study are: 1) Does ePRO improve quality of life and self-management in older adults with complex needs, and 2) what mechanisms are likely driving observed outcomes? METHODS A multi-method pragmatic randomized control trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrolment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the mid-point and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data was analyzed using qualitative description and framework analysis methods. RESULTS Recruitment challenges resulted in fewer sites and participants than expected; only 142 of the 176 eligible patients were identified due to lower than expected provider participation and fewer than expected patients willing to participate or perceived as ready to engage in goal setting. Of 142 patients approached, 45 patients participated (32%). Patients set a variety of goals related to self-management, mental health, social health and overall well-being. Due to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however the intervention group, ePRO plus usual care (M = 15.28, SD = 18.60), demonstrated non-significant slight decrease in quality of life, t(24)= -1.20, P = 0.24, when compared to usual care only (M = 21.76, SD = 2.17). The ethnographic data reveals a complex implementation process, in which the meaningfulness (or coherence) of the technology to individuals lives and work acted as a key driver to adoption and tool appraisal. CONCLUSIONS This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinic settings, dynamic goal-oriented care process, and readiness of provider and patient participants. CLINICALTRIAL ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954?intr=epro&cntry=CA&rank=1

scholarly journals Geriatric Resource Teams: Equipping Primary Care Practices to Meet the Complex Care Needs of Older Adults

Geriatrics ◽  
2019 ◽  
Vol 4 (4) ◽  
pp. 59 ◽  
Author(s):  
Gwendolen Buhr ◽  
Carrissa Dixon ◽  
Jan Dillard ◽  
Elissa Nickolopoulos ◽  
Lynn Bowlby ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Cognitive Impairment ◽  
Assessment Process ◽  
Complex Care ◽  
Care Needs ◽  
Care Practices ◽  
Primary Care Practices ◽  
Complex Care Needs ◽  
The Impact

Primary care practices lack the time, expertise, and resources to perform traditional comprehensive geriatric assessment. In particular, they need methods to improve their capacity to identify and care for older adults with complex care needs, such as cognitive impairment. As the US population ages, discovering strategies to address these complex care needs within primary care are urgently needed. This article describes the development of an innovative, team-based model to improve the diagnosis and care of older adults with cognitive impairment in primary care practices. This model was developed through a mentoring process from a team with expertise in geriatrics and quality improvement. Refinement of the existing assessment process performed during routine care allowed patients with cognitive impairment to be identified. The practice team then used a collaborative workflow to connect patients with appropriate community resources. Utilization of these processes led to reduced referrals to the geriatrics specialty clinic, fewer patients presenting in a crisis to the social worker, and greater collaboration and self-efficacy for care of those with cognitive impairment within the practice. Although the model was initially developed to address cognitive impairment, the impact has been applied more broadly to improve the care of older adults with multimorbidity.

scholarly journals A study protocol for a non-randomised comparison trial evaluating the feasibility and effectiveness of a mobile cognitive–behavioural programme with integrated coaching for anxious adults in primary care

BMJ Open ◽  
2018 ◽  
Vol 8 (1) ◽  
pp. e019108 ◽  
Author(s):  
Eva Szigethy ◽  
Francis Solano ◽  
Meredith Wallace ◽  
Dina L Perry ◽  
Lauren Morrell ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Primary Care ◽  
Anxiety Disorder ◽  
Healthcare Utilisation ◽  
Anxiety Symptoms ◽  
Generalised Anxiety Disorder ◽  
Cognitive Behavioural ◽  
Care Practices ◽  
Primary Care Practices

IntroductionGeneralised anxiety disorder (GAD) and subclinical GAD are highly prevalent in primary care. Unmanaged anxiety worsens quality of life in patients seen in primary care practices and leads to increased medical utilisation and costs. Programmes that teach patients cognitive–behavioural therapy (CBT) techniques have been shown to improve anxiety and to prevent the evolution of anxiety symptoms to disorders, but access and engagement have hampered integration of CBT into medical settings.Methods and analysisThis pragmatic study takes place in University of Pittsburgh Medical Center primary care practices to evaluate a coach-supported mobile cognitive– behavioural programme (Lantern) on anxiety symptoms and quality of life. Clinics were non-randomly assigned to either enhanced treatment as usual or Lantern. All clinics provide electronic screening for anxiety and, within clinics assigned to Lantern, patients meeting a threshold level of mild anxiety (ie, >5 on Generalised Anxiety Disorder 7-Item Questionnaire (GAD-7)) are referred to Lantern. The first study phase is aimed at establishing feasibility, acceptability and effectiveness. The second phase focuses on long-term impact on psychosocial outcomes, healthcare utilisation and clinic/provider adoption/sustainable implementation using a propensity score matched parallel group study design. Primary outcomes are changes in anxiety symptoms (GAD-7) and quality of life (Short-Form Health Survey) between baseline and 6-month follow-ups, comparing control and intervention. Secondary outcomes include provider and patient satisfaction, patient engagement, durability of changes in anxiety symptoms and quality of life over 12 months and the impact of Lantern on healthcare utilisation over 12 months. Patients from control sites will be matched to the patients who use the mobile app.Ethics and disseminationEthics and human subject research approval were obtained. A data safety monitoring board is overseeing trial data and ethics. Results will be communicated to participating primary care practices, published and presented at clinical and scientific conferences.Trial registration numberNCT03035019.

ASSOCIATIONS BETWEEN FRAILTY, COMPLEX CARE NEEDS AND QUALITY OF LIFE IN MULTI-MORBID OLDER PEOPLE

2014 ◽  
pp. 1-6
Author(s):  
N. BLEIJENBERG ◽  
V.H. TEN DAM ◽  
I. DRUBBEL ◽  
M.E. NUMANS ◽  
N.J. DE WIT ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Older People ◽  
The Elderly ◽  
Complex Care ◽  
Care Needs ◽  
Self Assessment ◽  
Primary Care Practices ◽  
Complex Care Needs ◽  
The Relationship

Background:Little is known regarding the complex care needs, level of frailty or quality of life ofmulti-morbid older patients. Objectives:The objective of this study was to determine the relationship betweenfrailty, complexity of care and quality of life in multi-morbid older people. Design:Cross-sectional study.Setting: Thirteen primary care practices in the Netherlands. Participants:1,150 multi-morbid older people livingin the community. Measurements:The level of frailty was assessed with the Groningen Frailty Indicator.Complexity of care needs was measured with the Intermed for the Elderly Self-Assessment. Quality of life (QoL)was measured with two items of the RAND-36. Results:In total, 758 out of 1,150 (65.9%) patients were frail,8.3% had complex care needs, and the mean QoL score was 7.1 (standard deviation 1.2). Correlations betweenfrailty and complexity, frailty and QoL, and complexity of care and QoL were 0.67, -0.51 and -0.52 (all p<0.001)respectively. All patients with complex care needs were frail, but, only 12.5% of the frail patients had complexcare needs. Problems at climbing up stairs was associated with higher levels of frailty and complexity of care butwith a lower QoL. Conclusions:Higher levels of frailty and complexity of care are associated with a lower QoLin multi-morbid older people. The results of this study contribute to a better understanding these concepts and arevaluable for the development of tailored interventions for older persons in the future.

scholarly journals Assessing methods for measurement of clinical outcomes and quality of care in primary care practices

2012 ◽  
Vol 12 (1) ◽  
Author(s):  
Michael E Green ◽  
William Hogg ◽  
Colleen Savage ◽  
Sharon Johnston ◽  
Grant Russell ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Of Care ◽  
Clinical Outcomes ◽  
Care Practices ◽  
Primary Care Practices

scholarly journals The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Katrien Danhieux ◽  
Veerle Buffel ◽  
Anthony Pairon ◽  
Asma Benkheil ◽  
Roy Remmen ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Qualitative Study ◽  
Chronic Care ◽  
Self Management ◽  
Management Support ◽  
High Risk Patients ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices

Abstract Background The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic. Methods A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. Twenty-one people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM). Results Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated. Conclusion Our findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.

scholarly journals Characteristics of primary care practices associated with high quality of care

2013 ◽  
Vol 185 (12) ◽  
pp. E590-E596 ◽  
Author(s):  
M.-D. Beaulieu ◽  
J. Haggerty ◽  
P. Tousignant ◽  
J. Barnsley ◽  
W. Hogg ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Of Care ◽  
High Quality ◽  
Care Practices ◽  
Primary Care Practices

scholarly journals Effects of the “Living well with COPD” intervention in primary care: a comparative study

2018 ◽  
Vol 51 (1) ◽  
pp. 1701375 ◽  
Author(s):  
Claudia Steurer-Stey ◽  
Kaba Dalla Lana ◽  
Julia Braun ◽  
Gerben ter Riet ◽  
Milo A. Puhan
Keyword(s):  
Quality Of Life ◽  
Primary Care ◽  
Usual Care ◽  
Self Management ◽  
Health Related Quality ◽  
Management Intervention ◽  
Living Well ◽  
Related Quality ◽  
Health Related

The pivotal objective of chronic obstructive pulmonary disease (COPD) self-management programmes is behaviour change to avoid moderate and severe exacerbations and improve health related quality of life.In a prospectively planned, controlled study, COPD patients who participated in the “Living well with COPD” (LWWCOPD) self-management intervention were compared with usual care patients from the primary care COPD Cohort ICE COLD ERIC, who did not receive self-management intervention (NCT00706602) The primary outcome was behaviour change and disease-specific health related quality of life after 1 year. Secondary end-points included exacerbation rates. We calculated mixed linear, zero-inflated negative binomial and logistic regression models and used propensity scores to counteract confounding.467 patients, 71 from the LWWCOPD and 396 from the usual care cohort, were included. The differences between intervention and control were 0.54 (95% CI 0.13−0.94) on the Chronic Respiratory Questionnaire domain “mastery”, 0.55 (95% CI 0.11−0.99) on “fatigue”, 0.54 (0.14−0.93) on “emotional function” and 0.64 (95% CI 0.14−1.14) on “dyspnoea”. The intervention considerably reduced the risk of moderate and severe exacerbations (incidence rate ratio 0.36, 95% CI 0.25−0.52).Self-management coaching in primary care improves health-related quality of life and lowers exacerbation rates and health care use.

scholarly journals Implementing Community-Created Self-Management Support Tools in Primary Care Practices: Multimethod Analysis From the INSTTEPP Study

2018 ◽  
Vol 5 (4) ◽  
pp. 267-275
Author(s):  
Douglas H Fernald ◽  
Matthew J Simpson ◽  
Donald E Nease ◽  
David L Hahn ◽  
Amanda E Hoffmann ◽  
...  
Keyword(s):  
Primary Care ◽  
Self Management ◽  
Management Support ◽  
Support Tools ◽  
Care Practices ◽  
Primary Care Practices

scholarly journals A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices

2019 ◽  
Vol 32 (3) ◽  
pp. 341-352 ◽  
Author(s):  
W. Perry Dickinson ◽  
L. Miriam Dickinson ◽  
Bonnie T. Jortberg ◽  
Danielle M. Hessler ◽  
Douglas H. Fernald ◽  
...  
Keyword(s):  
Primary Care ◽  
Randomized Trial ◽  
Cluster Randomized Trial ◽  
Self Management ◽  
Management Support ◽  
Care Practices ◽  
Cluster Randomized ◽  
Primary Care Practices

scholarly journals The Impact of COVID-19 on Chronic Care: A Qualitative Study Among Primary Care Practices in Belgium

2020 ◽  
Author(s):  
Katrien Danhieux ◽  
Veerle Buffel ◽  
Anthony Pairon ◽  
Asma Benkheil ◽  
Roy Remmen ◽  
...  
Keyword(s):  
Primary Care ◽  
High Risk ◽  
Qualitative Study ◽  
Chronic Care ◽  
Self Management ◽  
Management Support ◽  
Risk Patients ◽  
Care Practices ◽  
Primary Care Practices ◽  
Second Wave

Abstract Background. The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for a second wave or flare-ups of the pandemic.Methods. A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. 21 people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM).Results. Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated.Conclusion: Our findings show the delivery of chronic care as disrupted. It indicates that the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during a second wave or in flare-ups.

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