Using information communication technology in models of integrated community-based primary health care: learning from the iCOACH case studies

The Political Economy of Digital Health Equity: Structural Analysis

Digital technologies have produced many innovations in care delivery and enabled continuity of care for many people when in-person care was impossible. However, a growing body of research suggests that digital health can also exacerbate health inequities for those excluded from its benefits for reasons of cost, digital literacy, and structural discrimination related to characteristics such as age, race, ethnicity, and socioeconomic status. In this paper, we draw on a political economy perspective to examine structural barriers to progress in advancing digital health equity at the policy level. Considering the incentive structures and investments of powerful actors in the field, we outline how characteristics of neoliberal capitalism in Western contexts produce and sustain digital health inequities by describing 6 structural challenges to the effort to promote health equity through digital health, as follows: (1) the revenue-first incentives of technology corporations, (2) the influence of venture capital, (3) inequitable access to the internet and digital devices, (4) underinvestment in digital health literacy, (5) uncertainty about future reimbursement of digital health, and (6) justified mistrust of digital health. Building on these important challenges, we propose future immediate and long-term directions for work to support meaningful change for digital health equity.

Factors influencing interprofessional collaboration in long-term care from a multidisciplinary perspective: a case study approach

Systematic assessments of interprofessional collaboration barriers and enablers in long-term care settings are critical for delivering person-centered healthcare. However, research on factors influencing interprofessional collaboration in long-term care settings is limited. For this study, 65 healthcare professionals across multiple facilities experienced in long-term care in Japan participated in online focus group discussions and individual interviews to discuss cases. The qualitative data were analyzed using qualitative content analysis. Seven themes emerged: coordination, the need for care manager training, hierarchy among healthcare professionals, specialization but not the mind-set of overspecialization, casual conversations, electronic group communication tools, and excessive fear of personal information protection. These findings highlight the need to develop coordinator roles and for interprofessional education on the proper approach to personal information protection laws. Furthermore, daily casual conversations, the use of online platforms, and the prevention of patients being left behind due to overspecialization are required.

Factors identified as barriers or facilitators to EMR/EHR based interprofessional primary care: a scoping review

As interprofessional collaboration (IPC) in primary care receives increasing attention, the role of electronic medical and health record (EMR/EHR) systems in supporting IPC is important to consider. A scoping review was conducted to synthesize the current literature on the barriers and facilitators of EMR/EHRs to interprofessional primary care. Four online databases (OVID Medline, EBSCO CINAHL, OVID EMBASE, and OVID PsycINFO) were searched without date restrictions. Twelve studies were included in the review. Of six facilitator and barrier themes identified, the key facilitator was teamwork support and a significant barrier was data management. Other important barriers included usability related mainly to interoperability, and practice support primarily in terms of patient care. Additional themes were organization attributes and user features. Although EMR/EHR systems facilitated teamwork support, there is potential for team features to be strengthened further. Persistent barriers may be partly addressed by advances in software design, particularly if interprofessional perspectives are included. Organizations and teams might also consider strategies for working with existing EMR/EHR systems, for instance by developing guidelines for interprofessional use. Further research concerning the use of electronic records in interprofessional contexts is needed to support IPC in primary care.

Older Adults' Experiences With Participation and eHealth in Care Coordination: Qualitative Interview Study in a Primary Care Setting

BACKGROUND

Owing to the demographic changes in the elderly population worldwide, delivering coordinated care at home to multimorbid older adults is of great importance. Older adults living with multiple chronic conditions need information to manage and coordinate their care. eHealth can be effective for gaining sufficient information, communicating, and self-managing chronic conditions. However, incorporating older adults' health preferences and ensuring active involvement remain challenging. More knowledge is needed to ensure successful participation and eHealth use in care coordination.

OBJECTIVE

This study aimed to explore multimorbid older adults' experiences with participation and eHealth in care coordination with general practitioners (GPs) and district nurses (DNs).

METHODS

The study had a qualitative explorative approach. Data collection included semistructured interviews with 20 older adults with multimorbidity receiving primary care services from their GPs and DNs. The participants were included by their GPs or nurses at a local intermunicipal acute inpatient care unit. The data analysis was guided by systematic text condensation.

RESULTS

We identified 2 categories: (1) older adults in charge of and using eHealth in care coordination, and (2) older adults with a loss of control in care coordination. The first category describes how communication with GPs and DNs can facilitate participation, the importance of managing own medication, and how eHealth can support older adults' information needs. The second category focuses on older adults who depend on guidance and help from their GPs and DNs to manage their health, describing how a lack of capacity and system support to be involved makes these adults lose control of their care coordination.

CONCLUSIONS

Being in charge of care coordination is important for older multimorbid adults. The results show that older adults are willing to use eHealth to be informed and to seek information, which ensures high levels of participation in care coordination. Future research should investigate how older adults can be involved in electronic information sharing with health care providers.

Patient-clinician digital health interventions for the hip fracture population: a scoping review

INTRODUCTION

Older adults with hip fracture often require extensive post-surgery care across multiple sectors, making follow-up care even more important to ensure an ideal recovery. With the increased adoption of technology, patient-clinician digital health interventions can potentially improve post-surgery outcomes of hip fracture patients by helping them and their caregivers better understand the various aspects of their care, post-hip fracture surgery. The purpose of this study was to examine the available literature on the impact of hip fracture-specific, patient-clinician digital health interventions on patient outcomes and health care delivery processes. We also aimed to identify the barriers and enablers to the uptake and implementation of these technologies and to provide strategies for improved use of these digital health interventions.

METHODS

We conducted a scoping review following the six stages of Arksey and O'Malley's framework and following the PRISMA-ScR reporting format. Searches were conducted in five databases. In addition to hand searching for relevant studies from the references of all included studies, we also conducted a grey literature search to identify relevant primary studies. Screening of titles and abstracts as well as full texts were performed independently by two reviewers. Two reviewers also performed the data extraction of the included studies.

RESULTS

After screening 3,638 records, 20 articles met the criteria and 1 article was identified through hand searching. Various patient-clinician digital health interventions were described including telehealth /telerehabilitation programs (n = 6), care transition /follow-up interventions (n = 5), online resources (n = 2), and wearable devices /sensor monitoring (n = 1). Outcomes were varied and included functional status, gait/mobility, quality of life, psychological factors, satisfaction, survival/complications, caregiver outcomes, compliance, technology-user interactions, and feedback on the use of the digital health interventions. For clinicians, a key barrier to the use of the digital health interventions was the acceptability of the technology. However, the usefulness of the digital health intervention by clinicians was seen as both a barrier and an enabler. For patients and caregivers, all the themes were seen as both a barrier and an enabler depending on the study. These themes included: 1) availability and access, 2) usability, 3) knowledge and skills, 4) acceptability, and 5) usefulness of the digital health intervention.

CONCLUSION

Many behavioural factors affect the use of patient-clinician digital health interventions. However, a specific attention should be focused on the acceptability of the technology by the clinicians to encourage uptake of the digital health interventions. The results of this scoping review can help to better understand the factors that may be targeted to increase the use of these technologies by clinicians, patients, and caregivers.

The digitized chronic disease management model: scalable strategies for implementing standardized healthcare and big data analytics in Shanghai

Background

Chronic disease management (CDM) falls under production relations, and digital technology belongs to the realm of productivity. Production relations must adapt to the development of productivity. Simultaneously, the prevalence and burden of chronic diseases are becoming increasingly severe, leveraging digital technology to innovate chronic disease management model is essential.

Methods

The model was built to cover experts in a number of fields, including administrative officials, public health experts, information technology staff, clinical experts, general practitioners, nurses, metrologists. Integration of multiple big data platforms such as General Practitioner Contract Platform, Integrated Community Multimorbidity Management System and Municipal and District-Level Health Information Comprehensive Platform. This study fully analyzes the organizational structure, participants, service objects, facilities and equipment, digital technology, operation process, etc., required for new model in the era of big data.

Results

Based on information technology, we build Integrated Community Multimorbidity Care Model (ICMCM). This model is based on big data, is driven by "technology + mechanism," and uses digital technology as a tool to achieve the integration of services, technology integration, and data integration, thereby providing patients with comprehensive people-centered services. In order to promote the implementation of the ICMCM, Shanghai has established an integrated chronic disease management information system, clarified the role of each module and institution, and achieved horizontal and vertical integration of data and services. Moreover, we adopt standardized service processes and accurate blood pressure and blood glucose measurement equipment to provide services for patients and upload data in real time. On the basis of Integrated Community Multimorbidity Care Model, a platform and index system have been established, and the platform's multidimensional cross-evaluation and indicators are used for management and visual display.

Conclusions

The Integrated Community Multimorbidity Care Model guides chronic disease management in other countries and regions. We have utilized models to achieve a combination of services and management that provide a grip on chronic disease management.

Implementation considerations for non-communicable disease-related integration in primary health care: a rapid review of qualitative evidence

BACKGROUND

Integrated delivery of primary health care (PHC) services is a health reform recommended for achieving ambitious targets of the Sustainable Development Goals and Universal Health Coverage, responding to growing challenges of managing non-communicable and multimorbidity. However, more evidence is needed on effective implementation of PHC integration in different country settings.

OBJECTIVE

This rapid review synthesized qualitative evidence on implementation factors affecting integration of non-communicable disease (NCD) into PHC, from the perspective of implementers. The review contributes evidence to inform the World Health Organizations' guidance on integration of NCD control and prevention to strengthen health systems.

METHOD

The review was guided by standard methods for conducting rapid systematic reviews. Data analysis was guided by the SURE and WHO health system building blocks frameworks. We used Confidence in the Evidence of Reviews of Qualitative Research (GRADE-CERQual) to assess the confidence of the main findings.

RESULTS

The review identified 81 records eligible for inclusion, from 595 records screened. We sampled 20 studies for analysis (including 3 from expert recommendations). Studies covered a wide range of countries (27 countries from 6 continents), the majority from low-and middle-income countries (LMICs), with a diverse set of NCD-related PHC integration combinations and implementation strategies. The main findings were categorised into three overarching themes and several sub-themes. These are, A: Policy alignment and governance, B: Health systems readiness, intervention compatibility and leadership, and C: Human resource management, development, and support. The three overarching findings were assessed as each having a moderate level of confidence.

CONCLUSION

The review findings present insights on how health workers responses may be shaped by the complex interaction of individual, social, and organizational factors that may be specific to the context of the intervention, the importance of cross-cutting influences such as policy alignment, supportive leadership and health systems constraints, knowledge that can inform the development of future implementation strategies and implementation research.

Perceived technology use, attitudes, and barriers among primary care nurses

BACKGROUND

In primary healthcare, health information technology has the potential to facilitate the delivery of healthcare services by improving quality of care, efficiency and patient safety. However, little is known about the uptake and technology acceptance among primary healthcare nurses.

AIM

The aim of this study was to describe health information technology acceptance and use among primary healthcare nurses.

SETTING

Primary healthcare centres in the Western Cape.

METHODS

A quantitative descriptive survey was conducted with a sample of 160 nurses working in primary healthcare for more than 6 months, using a self-administered questionnaire based on the technology acceptance model constructs. Eighteen primary healthcare centres were randomly selected with a sample of 160 using nonprobability purposive sampling.

RESULTS

Ninety-three (58.1%) respondents completed the survey. Three-quarters of the respondents reported positive attitudes, positive perceptions of usefulness and ease of use towards the use of health information technology. Barriers of access and training were reported by 75%, with around half the respondents reporting poor computer and information accessing skills. Health information technology use was varied, with high ratings for seeking and using and low ratings of ability to use health information technology for patient administration and management. Health information technology use was predicted by perceptions of ease of use.

CONCLUSION

This research presents a mixed picture of acceptance of technology among primary healthcare nurses and highlights the lack of access to computers and Internet in these settings.

CONTRIBUTION

This study contributes to the field of technology acceptance among primary healthcare nurses.

Improving Primary Care Quality Through Supportive Supervision and Mentoring: Lessons From the African Health Initiative in Ethiopia, Ghana, and Mozambique

Systematic approaches to positioning technical support, enhancing systems, and promoting sustainment are crucial to strengthening supportive supervision and mentoring in primary health care systems. The African Health Initiative projects in Ethiopia, Ghana, and Mozambique have lessons to share from such experiences that stakeholders can apply to similar efforts in other countries.

Introduction:

Supportive supervision and mentoring (SSM) is crucial to primary care quality and effectiveness. Yet, there is little clarity on how to design and implement SSM and make it sustainable in primary health care (PHC) systems. The 3 African Health Initiative partnership projects introduced strategies to do this in Ethiopia, Ghana, and Mozambique. We describe: (1) how each partnership adapted SSM implementation strategies, (2) the dynamics of implementation and change that ensued after intervening within PHC systems, and (3) insights on the SSM sustainability as a mainstay of PHC.

Methods:

Researchers from each project collaboratively wrote a cross-country protocol based on those objectives. For this, they adapted implementation science frameworks—the Exploration, Preparation, Implementation, and Sustainment model and the Consolidated Framework for Implementation Research—through a qualitative theme reduction process. This resulted in harmonized lines of inquiry on the design, implementation, and potential sustainability of each project’s SSM strategy. In-depth interviews and focus group discussions were conducted with stakeholders from PHC systems in each country and thematic analyses ensued.

Results:

Across the projects, SSM strategies acquired multiple components to address individual, systems, and process-related determinants. Benefits arose from efforts that addressed worker-level attitudes and barriers, promoted a wider learning environment, and enhanced collaborative structures and tools for monitoring performance. Peer exchanges and embedded implementation research were critical to the perceived effectiveness of SSM strategies.

Discussion:

Despite differences in their approach to SSM implementation, there are common crucial ingredients across the SSM strategies of the 3 AHI partner projects from which important lessons arise: (1) positioning learning and adaptation opportunities within the routine workings of PHC systems, facilitation, and technical support to reflect and utilize new knowledge; (2) multisectoral collaboration, particularly with academic organizations; and (3) building PHC decision-makers’ and implementation teams’ capacity for evidence-informed change.

Information and Communication Technologies (ICTs) enabling integrated primary care for complex patients: a protocol for a scoping review

INTRODUCTION

An increasing number of individuals are living with multiple chronic conditions, often combined with psychosocial complexities. For these patients with complex conditions, an integrated primary care model that provides care coordination and a team-based approach can help manage their multiple needs. Information and communication technologies (ICTs) are recognized as a critical enabler of integrated primary care. A better understanding of the use of ICTs in an integrated care setting and how ICTs are being leveraged would be beneficial to identify knowledge gaps and could lead to successful implementation for ICT-based interventions.

OBJECTIVE

This study will systematically scope the literature on the topic of ICT-enabled integrated healthcare delivery models for patients with complex care needs to identify which technologies have been used in integrated primary care settings.

METHOD

This study protocol outlines a scoping review of the peer-reviewed literature, using Arksey and O'Malley's (enhanced by Levac et al.) scoping review methodology. Peer-reviewed literature will be identified using a multi-database search strategy. The results of the search will be screened, abstracted, and charted in duplicate by six research team members.

DISCUSSION

The key findings of the study will be thematically analyzed to describe the implemented ICTs aimed for complex patients within the integrated primary care model. The finding will highlight what types of ICTs are being put in place to support these models, and how these ICTs are enabling care integration. This review will be the first step to formally identify how ICT is used to support integrated primary health care models. The results will be disseminated through peer-reviewed publications, conference presentations, and special interest groups.

An Integrated Community-Based Blood Pressure Telemonitoring Program - A Population-Based Observational Study

BACKGROUND

Home blood pressure telemonitoring (BPT) has been shown to improve blood pressure control. A community-based BPT program (the Health+ program) was launched in 2015 in an urban area around a medical center.

OBJECTIVES

To examine the impact of the BPT program on the use of medical resources.

METHODS

We conducted a retrospective propensity-score (PS)-matched observational cohort study using the National Health Insurance Research Database (NHIRD) 2013-2016 in Taiwan. A total of 9,546 adults with a high risk of cardiovascular disease participated in the integrated BPT program, and 19,082 PS-matched controls were identified from the NHIRD. The primary and secondary outcome measures were changes in 1-year emergency department visit rate, hospitalization rate, duration of hospital stay, and healthcare costs.

RESULTS

The number of emergency department visits in the Health+ group significantly reduced (0.8 to 0.6 per year vs. 0.8 to 0.9 per year, p < 0.0001) along with a significant decrease in hospitalization rate (43.7% to 21.3% vs. 42.7% to 35.3%, p < 0.001). The duration of hospital stay was also lower in the Health+ group (4.3 to 3.3 days vs. 5.3 to 6.5 days, p < 0.0001). The annual healthcare costs decreased more in the Health+ group (USD 1642 to 1169 vs. 1466 to 1393 per year, p < 0.001), compared with the controls. Subgroup analysis of the Health+ group revealed that the improvements in outcomes were significantly greater among those who were younger and had fewer comorbidities, especially without diabetes or hypertension.

CONCLUSIONS

A community-based integrated BPT program may improve patients' health outcomes and reduce healthcare costs.

A Home-Based Dyadic Music-with-Movement Intervention for People with Dementia and Caregivers: A Hybrid Type 2 Cluster-Randomized Effectiveness-Implementation Design

Background

Integrating evidence-based music-with-movement into routine practices for people with dementia requires effective implementation strategies. The objectives of this study were to evaluate the clinical efficacy of the intervention and to examine the effectiveness of the implementation strategies in promoting home-based adoption.

Methods

This was a cluster randomized controlled trial adopting a clinical effectiveness-implementation hybrid design. The 12-week music-with-movement intervention aims to promote the well-being of people with dementia and their caregivers. Clinical outcomes were assessed to evaluate the efficacy of the intervention. These included the symptoms of anxiety and depression of people with dementia; caregivers' perception of their stress and the positive aspects of caregiving; and the quality of the dyadic relationship. Caregivers, staff, and volunteers were interviewed and objective figures on reach and adoption were collected to reflect the outcomes of the implementation.

Results

Compared to the waitlist control, there was a significant reduction in the anxiety and the symptoms of depression of those in the intervention group. There was also a significant reduction in the perceived stress level of the caregivers. Six focus group interviews were conducted. The intervention and the appropriateness of the implementation strategies were perceived positively by the dyad participants, the staff of the centres, and volunteers. Of the collaborating centres, 57% continued to use the intervention and, after six months, served six times more people than were recruited in this study. Over half of the participating families continued to use the intervention for at least six more months.

Conclusion

Music-with-movement interventions showed promise for improving the well-being of people with dementia and their caregivers. Effective strategies facilitated the implementation process, such as integrating communication technology to provide instant support and involving volunteers in engaging the collaborating centres and families. This study sheds light on perceptions of the intervention, and on its scalability for a broader population.

Trial Registration

NCT03575026, Registered 2 July 2018.

Frontline connect: Evaluating a virtual technology program to enhance patient and provider communication during COVID-19

RATIONALE

Since the beginning of the COVID-19 pandemic, many hospitals have reduced in-hospital visitation. In these situations, virtual communication tools have helped maintain interaction between parties. The Frontline Connect program was designed to address communication and patient care challenges by providing data-enabled devices to clinical staff in hospitals.

OBJECTIVE

This study aimed to identify areas of improvement for the Frontline Connect program by: (a) evaluating communication needs, user experience, and program satisfaction; and (b) identifying potential barriers to device access or use.

METHODS

We administered pre-implementation needs assessment, post-use, and exit surveys to healthcare staff at a pilot hospital site in Ontario. Recruitment was through email lists and site champions using convenience sampling. We descriptively analysed survey responses and compared the initial need statements to post-implementation use-cases identified by users.

RESULTS

We received 139 needs assessments, 31 user experience assessments, and 47 exit survey responses. Most device use occurred in the emergency department and intensive care units and was facilitated by social workers, nurses, and physicians to connect patients, families, and care providers. Pre-implementation concerns were related to infection control, data security, and device privacy. In the exit survey, these were replaced by other concerns including Internet connectivity and time-intensiveness. Device utility and ease-of-use were rated 9.7/10 and 9.6/10 respectively in the user experience survey, though overall experience was rated 7.2/10 in the exit survey. Overall, respondents viewed the devices as useful and we agree with participants who suggested increased program promotion and training would likely improve adoption.

CONCLUSIONS

We found that our virtual technology program for facilitating communication was positively perceived. Survey feedback indicates that a rapid rollout in response to urgent pandemic-related needs was feasible, though program logistics could be improved. The current work supports the need to improve, standardize, and sustain virtual communication programs in hospitals.

Implementation of interprofessional digital communication tools in primary care for frail older adults: An interview study

Communication and coordination between primary healthcare professionals and informal caregivers involved in the care for frail older adults is suboptimal and could benefit from interprofessional digital communication tools. Implementation in daily practice however frequently fails. We aim to identify generic barriers and facilitators experienced by healthcare professionals and informal caregivers during implementation of interprofessional communication tools to improve their long-term use. Qualitative content analysis using individual semi-structured interviews was used for evaluating three different digital communication tools used by interprofessional primary care networks for frail older adults by 28 professionals and 10 caregivers. After transcription and open coding, categories and themes were identified. Barriers and facilitators were related to: tool characteristics, context of use, involvement of professionals and caregivers. The tool improved availability, approachability and users' involvement. The large number of digital systems professionals simultaneously use, and different work agreements hampered tool use. The tools facilitated care coordination, and professionals declared to be better informed about patients' current situations. Overall, interprofessional digital communication tools can facilitate communication in networks for primary elderly care. However, integration between digital systems is needed to reduce the number of tools. Organizations and policy makers have an important role in realizing the tools' long-term use.

Lessons Learned Through Two Phases of Developing and Implementing a Technology Supporting Integrated Care: Case Study

BACKGROUND

As health care becomes more fragmented, it is even more important to focus on the provision of integrated, coordinated care between health and social care systems. With the aging population, this coordination is even more vital. Information and communication technology (ICT) can support integrated care if the form of technology follows and supports functional integration. Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a program centered on the health of older adults, supported by volunteers, primary care teams, community engagement and connections, and an ICT known as the Health TAPESTRY application (TAP-App), a web-based application that supports volunteers in completing client surveys, volunteer coordinators in managing the volunteer program, and primary care teams in requesting and receiving information.

OBJECTIVE

This paper describes the development, evolution, and implementation of the TAP-App ICT to share the lessons learned.

METHODS

A case study was conducted with the TAP-App as the case and the perspectives of end users and stakeholders as the units of analysis. The data consisted of researchers' perspectives on the TAP-App from their own experiences, as well as feedback from other stakeholders and end user groups. Data were collected through written retrospective reflection with the program manager, a specific interview with the technology lead, key emailed questions to the TAP-App developer, and viewpoints and feedback during paper drafting from other research team members. There were 2 iterations of Health TAPESTRY and the TAP-App and we focused on learnings from the second implementation (2018-2020) which was a pragmatic implementation scale-up trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework at 6 primary care sites across Ontario, Canada.

RESULTS

TAP-App (version 1.0), which was iteratively developed, was introduced as a tool to schedule volunteer and client visits and collect survey data using a tablet computer. TAP-App (version 2.0) was developed based on this initial experience and a desire for a program management tool that focused more on dual flow among users and provided better support for research. The themes of the lessons learned were as follows: iterative feedback is valuable; if ICT will be used for research, develop it with research in mind; prepare for challenges in the integration of ICT into the existing workflow; ask whether interoperability should be a goal; and know that technology cannot do it alone yet-the importance of human touch points.

CONCLUSIONS

Health TAPESTRY is human-centered. The TAP-App does not replace these elements but rather helps enable them. Despite this shift in supporting integrated care, barriers remained to the uptake of the TAP-App that would have allowed a full flow of information between health and social settings in supporting patient care. This indicates the need for an ongoing focus on the human use of ICT in similar programs.

Barriers and Benefits of Information Communication Technologies Used by Health Care Aides

BACKGROUND

Although information and communication technologies (ICT) are becoming more common among health care providers, there is little evidence on how ICT can support health care aides. Health care aides, also known as personal care workers, are unlicensed service providers who encompass the second largest workforce, next to nurses, that provide care to older adults in Canada.

OBJECTIVE

The purpose of this literature review is to examine the range and extent of barriers and benefits of ICT used by health care workers to manage and coordinate the care-delivery workflow for their clients.

METHODS

We conducted a literature review to examine the range and extent of ICT used by health care aides to manage and coordinate their care delivery, workflow, and activities. We identified 8,958 studies of which 40 were included for descriptive analyses.

RESULTS

We distinguished the following five different purposes for the use and implementation of ICT by health care aides: (1) improve everyday work, (2) access electronic health records for home care, (3) facilitate client assessment and care planning, (4) enhance communication, and (5) provide care remotely. We identified 128 barriers and 130 benefits related to adopting ICT. Most of the barriers referred to incomplete hardware and software features, time-consuming ICT adoption, heavy or increased workloads, perceived lack of usefulness of ICT, cost or budget restrictions, security and privacy concerns, and lack of integration with technologies. The benefits for health care aides' adoption of ICT were improvements in communication, support to workflows and processes, improvements in resource planning and health care aides' services, and improvements in access to information and documentation.

CONCLUSION

Health care aides are an essential part of the health care system. They provide one-on-one care to their clients in everyday tasks. Despite the scarce information related to health care aides, we identified many benefits of ICT adoption.

Exploring the relationship between the usability of a goal-oriented mobile health application and non-usage attrition in patients with multimorbidity: A blended data analysis approach

Background

Mobile health applications are increasingly used to support the delivery of health care services to a variety of patients. Based on data obtained from a pragmatic trial of the electronic Patient Reported Outcome (ePRO) app designed to support goal-oriented care primary care, this study aims to (1) examine how patient-reported usability changed over the one-year intervention period, and (2) explore participant attrition rate of the electronic Patient Reported Outcome app over one year study period.

Methods

We performed a secondary analysis of 44 older adults with complex chronic needs enrolled in the electronic Patient Reported Outcome-digital health intervention. App usage and attrition were measured using device-generated usage logs; usability was measured using the patient-reported post-study system usability questionnaire collected at 3, 6, 9, and 12 months. Research memos were used to interpret potential contextual contributing factors to patients' overall usage and usability score pattern. A data triangulation method of both quantitative and qualitative data was used to analyze and interpret study findings.

Results

While there was gradual attrition in the use of the ePRO app, patients' usability scores remained consistent throughout the study period. Qualitative memos suggested patients' encounters with technical difficulties and relationship dynamics with primary providers influenced patients' adherence to the ePRO app.

Conclusion

This study highlights that the patient-provider relationship is a key determining factor that influences complex patients' continued engagement with a Mobile health app. The finding calls attention to the measurement of usability of a Mobile health app, its impact on attrition, and contributing factors that influence patients' attrition. Trial registration: Clinicaltrials.gov Identified NCT02917954.

Integrated Care's New Protagonist: The Expanding Role of Digital Health

Digital health technologies hold significant promise to advance both functional and normative health and social care integration. The COVID-19 pandemic has created a window of opportunity to rapidly advance the adoption of digital solutions which can improve activities that support integration at clinical, professional, organizational and system levels. Global examples demonstrate how the pandemic has also created opportunities to use technology to address core values of integrated care like person-centredness and coordination. However, rapid and reactive changes could lead to increased fragmentation and exacerbate health inequity. This perspective paper outlines some of the opportunities and threats to advancing integrated care presented by the rapid adoption of digital health tools, suggesting we maintain a long view to ensure the stage we set today will mean greater integration tomorrow.

ICT-based person-centered community care platform (IPC3P) to enhance shared decision-making for integrated health and social care services

BACKGROUND

Community care is a care model with the aim of shifting care services from being hospital based toward community-based care. Advances in platforms based on information and communications technology (ICT) with a person-centered approach provide the potential to improve the delivery of health and social care services toward community-based settings.

OBJECTIVES

The aims of this study were to describe the ICT-Based Person-Centered Community Care Platform (IPC3P) and to determine its impact on health- and social-care-related shared decision-making and quality of life among community residents.

METHODS

An online platform was developed with the aim of enhancing community care. The platform had four components: (1) comprehensive health and social needs assessment system, (2) personalized community care planning, (3) needs-based health and social care services delivery, and (4) health community engagement. Community residents were invited to use and evaluate the impact of the IPC3P on their quality of life and shared decision-making regarding health and social care services. They provided feedback about the platform by completing two surveys: at baseline (before using the platform) and 6 months after using the platform.

RESULTS

Data of 164 community residents were analyzed in this study. Between baseline and after using the platform, the quality of life reported by the participants increased significantly in all domains, with clear improvements also noted for shared decision-making about health and social care services. The IPC3P received positive feedback from the participants for its usability, familiarity, and ease of use. Some participants also reported their desire for the addition of more functions that support health communities.

CONCLUSION

The IPC3P has the potential to enhance the involvement of community residents in their own care. The findings of this study can be used to support the wider implementation of the IPC3P to promote person-centered community care.

Data-sharing practices in publications funded by the Canadian Institutes of Health Research: a descriptive analysis

BACKGROUND

As Canada increases requirements for research data management and sharing, there is value in identifying how research data are shared and what has been done to make them findable and reusable. This study aimed to understand Canada's data-sharing landscape by reviewing how data funded by the Canadian Institutes of Health Research (CIHR) are shared and comparing researchers' data-sharing practices to best practices for research data management and sharing.

METHODS

We performed a descriptive analysis of CIHR-funded publications from PubMed and PubMed Central published between 1946 and Dec. 31, 2019, that indicated that the research data underlying the results of the publication were shared. We analyzed each publication to identify how and where data were shared, who shared data and what documentation was included to support data reuse.

RESULTS

Of 4144 CIHR-funded publications identified, 1876 (45.2%) included accessible data, 935 (22.6%) stated that data were available via request or application, and 300 (7.2%) stated that data sharing was not applicable or possible; we found no evidence of data sharing in 1558 publications (37.6%). Frequent data-sharing methods included via a repository (1549 [37.4%]), within supplementary files (1048 [25.3%]) and via request or application (935 [22.6%]). Overall, 554 publications (13.4%) included documentation that would facilitate data reuse.

INTERPRETATION

Publications funded by the CIHR largely lack the metadata, access instructions and documentation to facilitate data discovery and reuse. Without measures to address these concerns and enhanced support for researchers seeking to implement best practices for research data management and sharing, much CIHR-funded research data will remain hidden, inaccessible and unusable.

Improving performance intelligence for governing an integrated health and social care delivery network: a case study on the Amsterdam Noord district

BACKGROUND

A guiding principle of a successful integrated health and social care delivery network is to establish a governance approach based on learning, grounded in a data and knowledge infrastructure. The 'Krijtmolen Alliantie' is a network of health and social care providers with the ambition to realize such a performance intelligence driven governance model in line with the Triple Aim. This study seeks to identify what performance intelligence is available and how it can be improved.

METHODS

This case study was conducted in the district of Amsterdam Noord, the Netherlands, and employed 23 semi-structured interviews with stakeholders in health and social care, a feasibility analysis of available administrative data, and a reflection meeting with board members of the 'Krijtmolen Alliantie'. Information needs for performance intelligence by the stakeholders were mapped and a data landscape of the district covered by the network was drafted. Finally, in the reflection meeting with board members of the 'Krijtmolen Alliantie' the information needs and data landscape were aligned with governing needs, resulting in priority domains around which to strengthen the data infrastructure for governance of the integrated health and social care delivery network.

RESULTS

The 'Krijtmolen Alliantie' encompasses a network of providers with a diverse range of catchment areas. There are indicators on population health and welfare, however they have limited actionability for providers due to a misalignment with their respective catchment areas. There is a barrier in data exchange between health and social care providers. It is difficult to construct one indicator for per capita cost in the Dutch health data infrastructure as health and social care are subdivided in financing siloes. Priority domains for improvement of performance intelligence for the 'Krijtmolen Alliantie' are: 1) Per capita and per patient cost data integration that would allow combined accountability through aligning financial incentives to facilitate integrated care, and 2) combined patient experience and outcome measures to reflect network quality of care and patient experience performance.

CONCLUSION

Available performance intelligence lacks actionability for the governance of integrated care networks. Our recommendation is to align performance intelligence with the regional governance responsibilities of stakeholders for health and social care delivery.

Do Collaborative Care Managers and Technology Enhance Primary Care Satisfaction with Care from Embedded Mental Health Providers?

BACKGROUND

To improve mental health care access, the Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) in clinics nationally. Primary care clinical leader satisfaction can inform model implementation and may be facilitated by collaborative care managers and technology supporting cross-specialty collaboration.

OBJECTIVE

(1) To determine primary care clinical leaders' overall satisfaction with care from embedded mental health providers for a range of conditions and (2) to examine the association between overall satisfaction and two program features (care managers, technology).

DESIGN

Cross-sectional organizational survey in one VA region (Southern California, Arizona, and New Mexico), 2018.

PARTICIPANTS

Sixty-nine physicians or other designated clinical leaders in each VA primary care clinic (94% response rate).

MAIN MEASURES

We assessed primary care clinical leader satisfaction with embedded mental health care on four groups of conditions: target, non-target mental health, behavioral health, suicide risk management. They additionally responded about the availability of mental health care managers and the sufficiency of information technology (telemental health, e-consult, instant messaging). We examined relationships between satisfaction and the two program features using χ² tests and multivariable regressions.

KEY RESULTS

Most primary care clinical leaders were "very satisfied" with care for targeted anxiety (71%) and depression (69%), but not for other common conditions (37% alcohol misuse, 19% pain). Care manager availability was significantly associated with "very satisfied" responses for depression (p = .02) and anxiety care by embedded mental health providers (p = .02). Highly rated sufficiency of communication technology (only 19%) was associated with "very satisfied" responses to suicide risk management (p = .002).

CONCLUSIONS

Care from embedded mental health providers for depression and anxiety was highly satisfactory, which may guide improvement among less satisfactory conditions (alcohol misuse, pain). Observed associations between overall satisfaction and collaborative care features may inform clinics on how to optimize staffing and technology based on priority conditions.

Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

BACKGROUND

Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.

OBJECTIVE

This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology.

METHODS

The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure-3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs.

RESULTS

This project is underway and expected to be complete by Spring 2024.

CONCLUSIONS

Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/20220.

A critical exploration of professional jurisdictions and role boundaries in inter-professional end-of-life care in the community

This article critically examines how professional boundaries and hierarchies influence how end-of-life care is managed and negotiated between health and social care professionals. Our findings suggest there is uncertainty and lack of clarity amongst health and social care professionals regarding whose responsibility it is to engage, and document, the wishes of patients who are dying, which can lead to ambiguity in treatment decisions. We go on to explore the potential role of a new electronic system, designed to facilitate information sharing across professional boundaries, in shaping and bridging professional boundaries in the delivery of end-of-life care. We highlight potential negative impacts that may arise when health and social care groups are permitted varying levels of access to the system, and how this may be seen to reflect the value placed on their role in end-of-life care.

Effectiveness of the integrated care model Salut+Social in patients with chronic conditions: A mixed methods study protocol

INTRODUCTION

Integrated care models aim to provide solutions to fragmentation of care by improving coordination. This study will evaluate the effectiveness of a new integrated care model (Salut + Social), which will promote the coordination and communication between social and healthcare services in southern Catalonia (Spain) to improve quality of life, adherence to treatment and access to medical services for patients with chronic conditions, and also to reduce caregiver burden. Additionally, we will evaluate the experience of caregivers, health professionals and social workers with the new model implemented.

METHODS AND ANALYSIS

A clinical trial using mixed methodology will be carried out. The intervention consists of improving the coordination between the social and healthcare sectors during a 6-month period, by means of information and communication technology (ICT) tools that operate as an interface for the integrated care model. The study subjects are primary care patients with chronic health and social conditions that can benefit from a collaborative and coordinated approach. A sample size of 141 patients was estimated. Questionnaires that assess quality of life, treatment adherence, medical service and caregiver burden will be used at baseline and at 6, 9, and 12 months after the beginning of the study. The principal variable is quality of life. For statistical analysis, comparisons of means and proportions at different time points will be performed. A discussion group and semi-structured interviews will be conducted with the aim of improving the care model taking into account the opinions of professionals and caregivers. A thematic content analysis will be carried out.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P17/100). Articles will be published in international, peer-reviewed scientific journals.

TRIAL REGISTRATION

Clinical-Trials.gov: NCT04164160.

Integrated Care Programs for People with Multimorbidity in European Countries: eHealth Adoption in Health Systems

INTRODUCTION

eHealth applications have the potential to provide new integrated care services to patients with multimorbidity (MM), also supporting multidisciplinary care. The aim of this paper is to explore how widely eHealth tools have been currently adopted in integrated care programs for (older) people with MM in European countries, including benefits and barriers concerning their adoption, according to some basic health system characteristics.

MATERIALS AND METHODS

In 2014, in the framework of the ICARE4EU project, expert organizations in 24 European countries identified 101 integrated care programs. Managers of the selected programs completed an online questionnaire on several dimensions, including the use of eHealth. We analyzed data from this questionnaire, in addition to qualitative information from six innovative programs which were studied in depth through case study methodology, according to characteristics of national health systems: a national health model (financing system), overall strength of primary care (PC) (structure/service delivery process), and level of (de)centralization of health system (executive powers in a country).

RESULTS

85 programs (out of 101) adopted at least one eHealth tool, and 42 of these targeted explicitly older people. In most cases, Electronic Health Records (EHRs) were used and some benefits emerged like improved care management and integration, although inadequate funding mechanisms represented a major barrier. The analysis by health system characteristics showed a greater adoption of eHealth applications in decentralized countries, in countries with a National Health Service (NHS) model, and in countries with a strong/medium level of PC development.

CONCLUSIONS

Although in the light of some limitations, findings indicate a relation between implementation of care programs using eHealth tools and basic characteristics of health systems, with decentralization of a health system, NHS model, and strong/medium PC having a key role. However adaptations of European health systems seem necessary, in order to provide a more innovative and integrated care.

Comparing International Models of Integrated Care: How Can We Learn Across Borders?

Introduction:

Providers, managers, health system leaders, and researchers could learn across countries implementing system-wide models of integrated care, but require accessible methods to do so. This study assesses if a common framework could describe and compare key components of international models of integrated care.

Theory and methods:

A framework developed for an international study of programs that address high needs high cost patients was used to describe and compare 11 case studies analyzed in two international research projects; the Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH) study in Canada and New Zealand, and the Vilans research group exploring models in the Netherlands. Comparative summaries were generated, with findings discussed at a 2019 International Conference on Integrated Care workshop.

Results:

The template was found to be useful to compare integrated case analyses in different contexts, and stands apart from other case comparison approaches as it is easily applied and can provide practical guidance for frontline staff and managers. Areas of improvement for the template are identified and two updated versions are presented.

Conclusions and discussion:

There is value to using a common template to provide guidance in international comparison of models of integrated care. We discuss the applicability of the approach to support scale and spread of integrated care internationally.

Integrating health care in Australia: a qualitative evaluation

BACKGROUND

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses.

METHODS

We aimed to investigate the WSICP's effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement.

RESULTS

Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors.

CONCLUSIONS

The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.

Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams

The objectives of this paper are to: (1) identify contextual factors such as policy that impacted the implementation of community-based primary health care (CBPHC) innovations among 12 Canadian research teams and (2) describe strategies used by the teams to address contextual factors influencing implementation of CBPHC innovations. In primary care settings, consideration of contextual factors when implementing change has been recognized as critically important to success. However, contextual factors are rarely recorded, analyzed or considered when implementing change. The lack of consideration of contextual factors has negative implications not only for successfully implementing primary health care (PHC) innovations, but also for their sustainability and scalability. For this evaluation, data collection was conducted using self-administered questionnaires and follow-up telephone interviews with team representatives. We used a combination of directed and conventional content analysis approaches to analyze the questionnaire and interview data. Representatives from all 12 teams completed the questionnaire and 11 teams participated in the interviews; 40 individuals participated in this evaluation. Four themes representing contextual factors that impacted the implementation of CBPHC innovations were identified: (I) diversity of jurisdictions (II) complexity of interactions and collaborations (III) policy, and (IV) the multifaceted nature of PHC. The teams used six strategies to address these contextual factors including: (1) conduct an environmental scan at the beginning (2) maintaining engagement among partners and stakeholders by encouraging open and inclusive communication; (3) contextualizing the innovation for different settings; (4) anticipating and addressing changes, delays, and the need for additional resources; (5) fostering a culture of research and innovation among partners and stakeholders; and (6) ensuring information about the innovation is widely available. Implementing CBPHC innovations across jurisdictions is complex and involves navigating through multiple contextual factors. Awareness of the dynamic nature of context should be considered when implementing innovations.

Triphasic waves in cerebral carcinomatosis. Another nonmetabolic cause

A 59-year-old woman with a metastatic adenocarcinoma of unknown origin and no metabolic abnormalities developed a diffuse encephalopathy, with generalized triphasic waves seen on the electroencephalogram. Postmortem examination revealed widespread, multifocal perivascular carcinomatosis of the cerebral cortices. Triphasic waves have been described with dementing processes, subdural hematomas, and cerebrovascular disease, but they are more commonly seen with metabolic encephalopathies. This case demonstrates an additional nonmetabolic cause of triphasic waves.