Interprofessional partnerships in chronic illness care: a conceptual model for measuring partnership effectiveness

Building organizational and strategic interprofessional collaboration and partnerships: a case study

Developing organizational strategic partnerships is important to advance initiatives such as research, training/education, and interprofessional collaboration (IPC) with a global perspective. Commitments to collaborative leadership, intentional partnership, coordination, and progress, thematically represent the series of critical decisions and actions collectively required to achieve strategic alliance success. The purpose of this paper is to describe the evidenced-informed framework and systematic processes involved in building successful strategic organizational and collaborative partnerships for InterprofessionalResearch.Global to expand and enhance opportunities for IPC on mutually beneficial initiatives. The conceptual model for effective collaborative partnerships by Butt et al. (2008) provided a framework for InterprofessionalResearch.Global to develop two strategic organizational partnerships consistent with its mission, vision, and goals to explore interprofessional research and policy gaps through global research partnerships, grow and sustain communities of practice, and mobilize evidence-informed interprofessional education and collaborative practice across multiple and diverse contexts. These organizational partnerships are defined by a Memorandum of Understanding with clear expectations and mechanisms of communication, defined priority areas and timelines for collaborative efforts, mutual understanding of the purposes of each relationship, and timeline and expectations for periodic evaluation.

Is Project ECHO the transformational silver lining for interprofessional and interorganizational collaboration?

The globally disruptive impact of the COVID-19 pandemic on both healthcare systems and health profession education has created an opportunity for a reassessment of methods for delivering interprofessional practice education (IPE). A good candidate for consideration is Project ECHO (Extension for Community Healthcare Outcomes). Its unique combination of structural design in connecting specialist and community-based clinical sites, foundational education theories, and didactic and case-based learning methods present an innovative and promising new method of promoting both interprofessional and interorganizational collaboration. This paper first provides a description of Project ECHO, its major features, recent expansion during the pandemic, and IPE-related research history. Second, the educational concepts and theories underlying its use and their implications for interprofessional and interorganizational collaboration are reviewed. These include community of practice and single and double-loop learning. Third, the expression of these concepts in how key elements of ECHO are utilized - including the didactic presentation; the case study presentation, discussion, and tele-mentoring; and the power of community and tele-networking - will be explored. Finally, implications and applications for the expansion of ECHO into promoting competency-based education and innovative interprofessional and interorganizational collaboration will be presented.

Sustainability Planning for a Community Network to Increase Participation in Evidence-Based Lifestyle Change Programs: A Mixed-Methods Approach

Community-based chronic disease prevention programs can have long-term, broad public health benefits. Yet, only 40 to 60% of evidence-based health programs are sustained. Using established frameworks and evidence-based tools to characterize sustainability allows programs to develop structures and processes to leverage resources effectively to sustain effective program activities and systems. This study used a mixed-methods, partner-engaged approach to identify barriers and facilitators to sustaining a community network (the Alliance program) aimed to increase participation in evidence-based lifestyle change programs delivered in the community. Surveys and qualitative interviews were conducted with the Alliance partners based on the Program Sustainability Assessment Tool and Consolidated Framework for Implementation Research. Overall, partners felt Alliance had a high capacity for sustainability. Strategic planning, communication, and partnerships were areas partners prioritized to improve the potential for sustaining the program. Results informed the co-development of a sustainability action plan. This paper furthers our understanding of factors critical for the sustainability of community-based programs for chronic disease prevention and health equity and presents a process for developing action plans to build sustainability capacity.

Growing older with intellectual and developmental disabilities: Implementing and evaluating a project ECHO for dementia education

The needs of the rapidly expanding population of adults growing older with intellectual and developmental disabilities (IDD) and their families span both the IDD and the aging service systems. The use of Project ECHO (Extension for Community Healthcare Outcomes) for professional education can bridge gaps and span boundaries between them at the macro, meso, and micro levels. A series of 10 ECHO sessions over 12 months was developed, incorporating key content on IDD and AD/ADRD for 145 providers in over 20 agencies. Impacts were assessed by a follow-up survey sent to participants after each program. The evaluation included quantitative assessment of ECHO features and a retrospective pre- and posttest of knowledge acquisition; a separate item assessed intention to apply information. Qualitative data were collected from open-ended items. The case presentation and discussion were the most effective ECHO components. Knowledge acquisition was significant for all sessions; most important uses included providing better care to clients/patients, training staff, and educating family and/or caregivers. Participants were aligned with two distinct groups, one with a predominant knowledge focus, the other with an emphasis on networking. Project ECHO can bridge gaps and span boundaries between the IDD and aging care systems at multiple levels, improving interprofessional collaboration and care by addressing both knowledge and networking needs of providers.

Exploring Nursing Strategies to Engage Community in Cardiovascular Care

PURPOSE OF REVIEW

This review aims to highlight some of the strategies nurses use to engage community members in cardiovascular care. We also elaborate on opportunities for improving community engagement.

RECENT FINDINGS

Community engagement occurs across a continuum of progressive levels of community involvement, impact, trust, and flow of communication. Successful community engagement has been shown to improve both patient-centered care and intervention design, implementation, and dissemination. Nurse strategies used for engaging community in cardiovascular care included more examples of outreach, consult, and involvement than collaboration and shared leadership. More attention is needed toward strategies that embrace collaboration and enhance trusting relationships to advance to shared leadership. Nurses must intentionally work in partnership with communities to improve cardiovascular health for all. Furthermore, assessing meaningful community engagement is necessary to achieve the desired outcomes, including optimal cardiovascular health and thriving communities.

Using systems perspectives in evidence synthesis: A methodological mapping review

Reviewing complex interventions is challenging because they include many elements that can interact dynamically in a nonlinear manner. A systems perspective offers a way of thinking to help understand complex issues, but its application in evidence synthesis is not established. The aim of this project was to understand how and why systems perspectives have been applied in evidence synthesis. A methodological mapping review was conducted to identify papers using a systems perspective in evidence synthesis. A search was conducted in seven bibliographic databases and three search engines. A total of 101 papers (representing 98 reviews) met the eligibility criteria. Two categories of reviews were identified: (1) reviews using a "systems lens" to frame the topic, generate hypotheses, select studies, and guide the analysis and interpretation of findings (n = 76) and (2) reviews using systems methods to develop a systems model (n = 22). Several methods (e.g., systems dynamic modeling, soft systems approach) were identified, and they were used to identify, rank and select elements, analyze interactions, develop models, and forecast needs. The main reasons for using a systems perspective were to address complexity, view the problem as a whole, and understand the interrelationships between the elements. Several challenges for capturing the true nature and complexity of a problem were raised when performing these methods. This review is a useful starting point when designing evidence synthesis of complex interventions. It identifies different opportunities for applying a systems perspective in evidence synthesis, and highlights both commonplace and less familiar methods.

Activating Partnership Assets to Produce Synergy in Primary Health Care: A Mixed Methods Study

Partnerships are an important mechanism to tackle complex problems that extend beyond traditional organizational divides. Partnerships are widely endorsed, but there is a need to strengthen the evidence base relating to claims of their effectiveness. This article presents findings from a mixed methods study conducted with the aim of understanding partnership processes and how various partnership factors contribute to partnership effectiveness. The study involved five multi-stakeholder partnerships in Canada and Australia working towards improving accessibility to primary health care for vulnerable populations. Qualitative data were collected through the observation of 14 partnership meetings and individual semi-structured interviews (n = 16) and informed the adaptation of an existing Partnership Self-Assessment Tool. The instrument was administered to five partnerships (n = 54). The results highlight partnership complexity and the dynamic and contingent nature of partnership processes. Synergistic action among multiple stakeholders was achieved through enabling processes at the interpersonal, operational and system levels. Synergy was associated with partnership leadership, administration and management, decision-making, the ability of partnerships to optimize the involvement of partners and the sufficiency of non-financial resources. The Partnership Synergy framework was useful in assessing the intermediate outcomes of ongoing partnerships when it was too early to assess the achievement of long-term intended outcomes.

Measuring partnership synergy and functioning: Multi-stakeholder collaboration in primary health care

In primary health care, multi-stakeholder partnerships between clinicians, policy makers, academic representatives and other stakeholders to improve service delivery are becoming more common. Literature on processes and approaches that enhance partnership effectiveness is growing. However, evidence on the performance of the measures of partnership functioning and the achievement of desired outcomes is still limited, due to the field's definitional ambiguity and the challenges inherent in measuring complex and evolving collaborative processes. Reliable measures are needed for external or self-assessment of partnership functioning, as intermediate steps in the achievement of desired outcomes. We adapted the Partnership Self-Assessment Tool (PSAT) and distributed it to multiple stakeholders within five partnerships in Canada and Australia. The instrument contained a number of partnership functioning sub-scales. New sub-scales were developed for the domains of communication and external environment. Partnership synergy was assessed using modified Partnership Synergy Processes and Partnership Synergy Outcomes sub-scales, and a combined Partnership Synergy scale. Ranking by partnership scores was compared with independent ranks based on a qualitative evaluation of the partnerships' development. 55 (90%) questionnaires were returned. Our results indicate that the instrument was capable of discriminating between different levels of dimensions of partnership functioning and partnership synergy even in a limited sample. The sub-scales were sufficiently reliable to have the capacity to discriminate between individuals, and between partnerships. There was negligible difference in the correlations between different partnership functioning dimensions and Partnership Synergy sub-scales. The Communication and External Environment sub-scales did not perform well metrically. The adapted partnership assessment tool is suitable for assessing the achievement of partnership synergy and specific indicators of partnership functioning. Further development of Communication and External Environment sub-scales is warranted. The instrument could be applied to assess internal partnership performance on key indicators across settings, in order to determine if the collaborative process is working well.

Complexity in partnerships: A qualitative examination of collaborative depression care in primary care clinics and community-based organisations in California, United States

Partnering across health clinics and community organisations, while worthwhile for improving health and well-being, is challenging and time consuming. Even partnerships that have essential elements for success in place face inevitable challenges. To better understand how cross-organisational partnerships work in practice, this paper examines collaborations between six primary care clinics and community-based organisations in the United States that were part of an initiative to address late-life depression using an enhanced collaborative care model (Archstone Foundation Care Partners Project). As part of an evaluation of the Care Partners Project, 54 key informant interviews and 10 focus groups were conducted from 2015 to 2017. Additionally, more than 80 project-related documents were reviewed. Qualitative thematic analysis was used to code the transcripts and identify prominent themes in the data. Examining clinic and community organisation partnerships in practice highlighted their inherent complexity. The partnerships were fluid and constantly evolving, shaped by a multiplicity of perspectives and values, and vulnerable to unpredictability. Care Partners sites negotiated the complexity of their partnerships drawing upon three main strategies: adaptation (allowing for flexibility and rapid change); integration (providing opportunities for multi-level partnerships within and across organisations) and cultivation (fostering a commitment to the partnership and its value). These strategies provided opportunities for Care Partners collaborators to work with the inherent complexity of partnering. Intentionally acknowledging and embracing such complexity rather than trying to reduce or avoid it, may allow clinic and community collaborators to strengthen and sustain their partnerships.

Key dimensions of collaboration quality in mental health care service networks

Appropriate care delivery for patients with severe mental illness (SMI) requires a high level of collaboration quality between primary, mental health, and social care services. Few studies have addressed the interpersonal and inter-organizational components of collaboration within one unique study setting and it is unclear how these components contribute to overall collaboration quality. Using a comprehensive model that includes ten key indicators of collaboration in relation to both components, we evaluated how interpersonal and inter-organizational collaboration quality were associated in 19 networks that included 994 services across Belgium. Interpersonal collaboration was significantly higher than inter-organizational collaboration. Despite the internal consistency of the model, analysis showed that respondents perceived a conflict between client-centered care and leadership in the network. Our results reveal two approaches to collaborative service networks, one relying on interpersonal interactions and driven by client needs and another based on formalization and driven by governance procedures. The results reflect a lack of strategy on the part of network leaders for supporting client-centered care and hence, the persistence of the high level of fragmentation that networks were expected to address. Policy-makers should pay more attention to network formalization and governance mechanisms with a view to achieving effective client-centered outcomes.

Evaluating Program Integration and the Rise in Collaboration: Case study of A Palliative Care Network

Introduction: There is increasing global interest in using regional palliative care networks (PCNs) to integrate care and create systems that are more cost-effective and responsive. We examined a PCN that used a community development approach to build capacity for palliative care in each distinct community in a region of southern Ontario, Canada, with the goal of achieving a competent integrated system. Methods: Using a case study methodology, we examined a PCN at the structural level through a document review, a survey of 20 organizational administrators, and an interview with the network director. Results: The PCN identified 14 distinct communities at different stages of development within the region. Despite the lack of some key features that would facilitate efficient palliative care delivery across these communities, administrators largely viewed the network partnership as beneficial and collaborative. Conclusion: The PCN has attempted to recognize specific needs in each local area. Change is gradual but participatory. There remain structural issues that may negatively affect the functioning of the PCN.

Values of Integrated Care: A Systematic Review

INTRODUCTION

Although substantial generic knowledge about integrated care has been developed, better understanding of the factors that drive behaviour, decision-making, collaboration and governance processes in integrated care networks is needed to take integrated care forward. To gain more insight into these topics and to understand integrated care in more depth, a set of underlying values of integrated care has been developed and defined in this study.

THEORY AND METHODS

A systematic literature review was conducted to identify the underlying values of integrated care. Values theory was used as a theoretical framework for the analysis.

RESULTS

This study identified 23 values in the current body of knowledge. The most frequently identified values are 'collaborative', 'co-ordinated', 'transparent', 'empowering', 'comprehensive', 'co-produced' and 'shared responsibility and accountability'.

DISCUSSION AND CONCLUSION

The set of values is presented as a potential basis for a values-driven approach to integrated care. This approach enables better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area. The practical application of the values and their use at multiple levels is discussed. The consequences of different stakeholder perceptions on the values is explored and an agenda for future research is proposed.

Values of Integrated Care: A Systematic Review

INTRODUCTION

Although substantial generic knowledge about integrated care has been developed, better understanding of the factors that drive behaviour, decision-making, collaboration and governance processes in integrated care networks is needed to take integrated care forward. To gain more insight into these topics and to understand integrated care in more depth, a set of underlying values of integrated care has been developed and defined in this study.

THEORY AND METHODS

A systematic literature review was conducted to identify the underlying values of integrated care. Values theory was used as a theoretical framework for the analysis.

RESULTS

This study identified 23 values in the current body of knowledge. The most frequently identified values are 'collaborative', 'co-ordinated', 'transparent', 'empowering', 'comprehensive', 'co-produced' and 'shared responsibility and accountability'.

DISCUSSION AND CONCLUSION

The set of values is presented as a potential basis for a values-driven approach to integrated care. This approach enables better understanding of the behaviours and collaboration in integrated care and may also be used to develop guidance or governance in this area. The practical application of the values and their use at multiple levels is discussed. The consequences of different stakeholder perceptions on the values is explored and an agenda for future research is proposed.

Developing and Translating a New Model for Teaching Empowerment Into Routine Chronic Care Management: An International Patient-Centered Project

Background:

Health professional education has been criticized for not integrating patient expertise into professional curricula to develop professional skills in patient empowerment.

Objective:

To develop and translate a new expert patient-centered model for teaching empowerment into professional education about routine chronic care management.

Methods:

Eight Finnish patients (known as expert patients), 31 students, and 11 lecturers from 4 European countries participated in a new pilot intensive educational module. Thirteen focus groups, artefacts, and an online student evaluation were analyzed using a thematic analysis and triangulated using a meta-matrix.

Results:

A patient-centered pedagogical model is presented, which describes 3 phases of empowerment: (1) preliminary work, (2) the elements of empowerment, and (3) the expected outcomes. These 3 phases were bound by 2 cross-cutting themes “time” and “enabling resources.”

Conclusion:

Patient expertise was embedded into the new module curriculum. Using an example of care planning, and Pentland and Feldman’s theory of routine organization, the results are translated into a patient-centered educational model for teaching empowerment to health profession students.

Development of a tool for the evaluation of obesity prevention partnerships

ISSUE ADDRESSED

Working in partnership is advocated as a necessary process to achieve shared goals in complex policy areas, yet little effort is dedicated to evaluating how well partnerships are functioning. This study describes the development and psychometric properties of a partnership assessment tool and illustrates its use in an obesity prevention partnership.

METHODS

A literature scoping review was conducted on existing partnership assessment tools and used to develop a new tool, which was tested using the ACT whole-of-government Healthy Weight Initiative at two timepoints. The psychometric properties of the tool were evaluated using principal component analysis and Cronbach's alpha for internal consistency of domain subscales.

RESULTS

The review identified 11 partnership assessment tools, from which we identified five domains of partnership to develop the new tool. Factor analysis showed each domain yielded a single subscale. Cronbach's alpha for each of the domain subscales ranged between 0.88 and 0.94 at Timepoint 1 and 0.90 and 0.95 at Timepoint 2 demonstrating very high internal consistency. All subscales demonstrated high correlation with an overall partnership rating, good internal consistency and concordance with issues raised in open-ended questions.

CONCLUSION

This paper describes the development and implementation of a tool to evaluate partnership functioning, which was found to have high internal consistency and reliability. SO WHAT?: With increasing emphasis on working in partnership, using partnership assessment tools can provide useful evidence to assess whether partnerships are a successful strategy in complex programs evaluation.

Geriatric Cooperatives in Southwestern Ontario: A novel way of increasing inter-sectoral partnerships in the care of older adults with responsive behaviours

Established in 2010, Geriatric Cooperatives support the evolving Behavioural Supports Ontario (BSO) programme in the South West Local Health Integration Network. Geriatric Cooperatives bring together members representing relevant cross-sectoral services and are tasked with identifying system gaps associated with the BSO target population as well as developing work plans specific to their local area, leveraging local capacity, and co-ordinating and improving linkages between sectors and services. The purpose of this study was to evaluate the partnerships formed over time within these Cooperatives in order to inform their ongoing development and sustainability. In 2012 and in 2015, Geriatric Cooperative members were invited to complete the Partnership Self-Assessment Tool (PSAT), a valid and reliable tool for evaluating collaborative processes and identifying areas in need of improvement. Scoring the PSAT involves the calculation of mean scores (ranging from 1 to 5) for each of six dimensions describing effective collaboration; higher mean scores reflect better functioning. Two psychometrically sound versions of the PSAT exist; the shorter version (PSAT-S) scores fewer items in three dimensions. Survey response rates for the three Cooperatives that were evaluated in both 2012 and 2015 were 70% in 2012 and 36% in 2015; 57% of members who completed the survey in 2015 were new Cooperative members. Both years, more than 25% of respondents selected "don't know" for three of the nine items used to score the administration and management dimension. Both PSAT and PSAT-S mean dimension scores across both years reflected that more effort is needed to maximise collaborative potential. Use of the PSAT has promoted a better understanding of how partnerships are functioning. Knowledge of where more work is required along with effective strategies to overcome weak areas and gaps in functioning has the potential to ensure that these Cooperatives are successful.

Toward Advanced Nursing Practice along with People-Centered Care Partnership Model for Sustainable Universal Health Coverage and Universal Access to Health

Objective:

this study developed a people-centered care (PCC) partnership model for the aging society to address the challenges of social changes affecting people’s health and the new role of advanced practice nurses to sustain universal health coverage.

Method:

a people-centered care partnership model was developed on the basis of qualitative meta-synthesis of the literature and assessment of 14 related projects. The ongoing projects resulted in individual and social transformation by improving community health literacy and behaviors using people-centered care and enhancing partnership between healthcare providers and community members through advanced practice nurses.

Results:

people-centered care starts when community members and healthcare providers foreground health and social issues among community members and families. This model tackles these issues, creating new values concerning health and forming a social system that improves quality of life and social support to sustain universal health care through the process of building partnership with communities.

Conclusion:

a PCC partnership model addresses the challenges of social changes affecting general health and the new role of advanced practice nurses in sustaining UHC.

Engaging older adults in healthcare research and planning: a realist synthesis

PLAIN ENGLISH SUMMARY

The importance of citizen involvement in healthcare research and planning has been widely recognized. There is however, a lack of understanding of how best to engage older adults, Canada's fastest growing segment of the population and biggest users of the healthcare system. We aimed to address this gap by developing an understanding of the engagement of older adults and their caregivers in healthcare research and planning. We conducted a review of available knowledge on engagement in healthcare research and planning with a focus on older adults and their caregivers. A five stage engagement framework emerged from this study that can be used to guide engagement efforts. We are continuing to collaborate with older adults and decision makers to develop and test strategies based on the presented framework.

ABSTRACT

Background The importance of engaging the community in healthcare research and planning has been widely recognized. Currently however, there is a limited focus on older adults, Canada's fastest growing segment of the population and biggest users of the healthcare system. Objective This project aimed to develop an understanding of engagement of older adults and their caregivers in healthcare research and planning. Method A realist synthesis was conducted of the available knowledge on engagement in healthcare research and planning. The search methodology was informed by a framework for realist syntheses following five phases, including consultations with older adults. The synthesis included theoretical frameworks, and both peer-reviewed and grey literature. Results The search generated 15,683 articles, with 562 focusing on healthcare research and planning. The review lead to the development of a framework to engage older adults and their caregivers in healthcare research and planning. The 5 stages environment, plan, establish, build, and transition are accompanied with example context, mechanism, and outcomes to guide the use of this framework. Conclusion We have identified a framework that promotes meaningful engagement of older adults and their caregivers. We are continuing to collaborate with our community partners to further develop and evaluate engagement strategies that align with the presented framework.

What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review

Background

Group clinics are a form of delivering specialist-led care in groups rather than in individual consultations.

Objective

To examine the evidence for the use of group clinics for patients with chronic health conditions.

Design

A systematic review of evidence from randomised controlled trials (RCTs) supplemented by qualitative studies, cost studies and UK initiatives.

Data sources

We searched MEDLINE, EMBASE, The Cochrane Library, Web of Science and Cumulative Index to Nursing and Allied Health Literature from 1999 to 2014. Systematic reviews and RCTs were eligible for inclusion. Additional searches were performed to identify qualitative studies, studies reporting costs and evidence specific to UK settings.

Review methods

Data were extracted for all included systematic reviews, RCTs and qualitative studies using a standardised form. Quality assessment was performed for systematic reviews, RCTs and qualitative studies. UK studies were included regardless of the quality or level of reporting. Tabulation of the extracted data informed a narrative synthesis. We did not attempt to synthesise quantitative data through formal meta-analysis. However, given the predominance of studies of group clinics for diabetes, using common biomedical outcomes, this subset was subject to quantitative analysis.

Results

Thirteen systematic reviews and 22 RCT studies met the inclusion criteria. These were supplemented by 12 qualitative papers (10 studies), four surveys and eight papers examining costs. Thirteen papers reported on 12 UK initiatives. With 82 papers covering 69 different studies, this constituted the most comprehensive coverage of the evidence base to date. Disease-specific outcomes – the large majority of RCTs examined group clinic approaches to diabetes. Other conditions included hypertension/heart failure and neuromuscular conditions. The most commonly measured outcomes for diabetes were glycated haemoglobin A1c(HbA1c), blood pressure and cholesterol. Group clinic approaches improved HbA1cand improved systolic blood pressure but did not improve low-density lipoprotein cholesterol. A significant effect was found for disease-specific quality of life in a few studies. No other outcome measure showed a consistent effect in favour of group clinics. Recent RCTs largely confirm previous findings. Health services outcomes – the evidence on costs and feasibility was equivocal. No rigorous evaluation of group clinics has been conducted in a UK setting. A good-quality qualitative study from the UK highlighted factors such as the physical space and a flexible appointment system as being important to patients. The views and attitudes of those who dislike group clinic provision are poorly represented. Little attention has been directed at the needs of people from ethnic minorities. The review team identified significant weaknesses in the included research. Potential selection bias limits the generalisability of the results. Many patients who could potentially be included do not consent to the group approach. Attendance is often interpreted liberally.

Limitations

This telescoped review, conducted within half the time period of a conventional systematic review, sought breadth in covering feasibility, appropriateness and meaningfulness in addition to effectiveness and cost-effectiveness and utilised several rapid-review methods. It focused on the contribution of recently published evidence from RCTs to the existing evidence base. It did not reanalyse trials covered in previous reviews. Following rapid review methods, we did not perform independent double data extraction and quality assessment.

Conclusions

Although there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes. Much of the evidence was derived from the USA. It is important to engage with UK stakeholders to identify NHS considerations relating to the implementation of group clinic approaches.

Future work

The review team identified three research priorities: (1) more UK-centred evaluations using rigorous research designs and economic models with robust components; (2) clearer delineation of individual components within different models of group clinic delivery; and (3) clarification of the circumstances under which group clinics present an appropriate alternative to an individual consultation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Micro practices of coordination based on complex adaptive systems: user needs and strategies for coordinating public health in Denmark

INTRODUCTION

Many highly formalised approaches to coordination poorly fit public health and recent studies call for coordination based on complex adaptive systems. Our contribution is two-fold. Empirically, we focus on public health, and theoretically we build on the patient perspective and treat coordination as a process of contingent, two-level negotiations of user needs.

THEORY AND METHODS

The paper draws on the concept of user needs-based coordination and sees coordination as a process, whereby needs emerging from the life world of the user are made amenable to the health system through negotiations. The analysis is based on an explorative case study of a health promotion initiative in Denmark. It adopts an anthropological qualitative approach and uses a range of qualitative data.

RESULTS

The analysis identifies four strategies of coordination: the coordinator focusing on the individual user or on relations with other professionals; and the manager coaching the coordinator or providing structural support. Crucially, the coordination strategies by management remain weak as they do not directly relate to specific user needs.

DISCUSSION

In process of bottom-up negotiations user needs become blurred and this is especially a challenge for management. The study therefore calls for an increased focus on the level nature of negotiations to bridge the gap that currently weakens coordination strategies by management.

Interprofessional collaboration in primary health care: a review of facilitators and barriers perceived by involved actors

BACKGROUND

The epidemiological transition calls for redefining the roles of the various professionals involved in primary health care towards greater collaboration. We aimed to identify facilitators of, and barriers to, interprofessional collaboration in primary health care as perceived by the actors involved, other than nurses.

METHODS

Systematic review using synthetic thematic analysis of qualitative research. Articles were retrieved from Medline, Web of science, Psychinfo and The Cochrane library up to July 2013. Quality and relevance of the studies were assessed according to the Dixon-Woods criteria. The following stakeholders were targeted: general practitioners, pharmacists, mental health workers, midwives, physiotherapists, social workers and receptionists.

RESULTS

Forty-four articles were included. The principal facilitator of interprofessional collaboration in primary care was the different actors' common interest in collaboration, perceiving opportunities to improve quality of care and to develop new professional fields. The main barriers were the challenges of definition and awareness of one another's roles and competences, shared information, confidentiality and responsibility, team building and interprofessional training, long-term funding and joint monitoring.

CONCLUSIONS

Interprofessional organization and training based on appropriate models should support collaboration development. The active participation of the patient is required to go beyond professional boundaries and hierarchies. Multidisciplinary research projects are recommended.

The effect of interprofessional education on interprofessional performance and diabetes care knowledge of health care teams at the level one of health service providing

Background:

The increase in life expectancy and changes in lifestyle have led to prevalence of non-communicable diseases including diabetes whose treatment and care requires effective teamwork. This study was conducted to examine the effect of inter-professional education on performance and diabetes care knowledge of health care teams.

Materials and Methods:

This quasi-experimental study was performed as an inter-professional education on 6 healthcare teams (34 people) based on Kolb's Learning Cycle and consisted of a set of training activities to improve individual, group, and inter-professional capabilities of members of the health care team. The pre- and post-tests included Team Climate Inventory (TCI) and a knowledge assessment tool performed before the workshop and 3 months later.

Results:

Mean scores for knowledge of health care team before intervention and 3 months later were 7.06 ± 1.04 and 7.97 ± 0.97 out of 10, respectively, that showed a significant difference (P < 0.0001). Mean score of the pre-test and post-test for inter-professional performance comprised 47.03 ± 6.7 and 49.44 ± 5.54 out of 70, respectively, which did not show any significant difference. However, these mean scores had a significant difference for the domains of knowledge and exercising objectives of the teamwork (10.62 ± 1.37 and 11.41 ± 1.76 out of 15, respectively) (P = 0.013).

Conclusion:

It seems that inter-professional education can improve the quality of health care to some extent through influencing knowledge and collaborative performance of health care teams. It also can make the health-related messages provided to the covered population more consistent in addition to enhancing self-confidence of the personnel.

The use of memoranda of understanding in fostering inter-agency collaboration: A qualitative study of health services agencies serving vulnerable populations in Baltimore, USA

Introduction:

We examined whether mandated collaboration reflected in memoranda of understanding (MOUs) developed by health agencies to meet funder expectations is effective in fostering inter-agency collaboration.

Methods:

We conducted 22 semi-structured interviews from late 2010 to early 2012 in Baltimore, USA, with representatives of 17 HIV service agencies, three local health department units, and one agency that closed in 2008 (two interviews).

Results:

While there was no consensus, most respondents perceived MOUs negatively, mainly because the process of obtaining signed MOUs was time consuming; frontline staff was mostly unaware of MOUs, agencies did not necessarily work with agencies they signed MOUs with and MOUs were rarely evaluated after being signed. A few agencies reported that MOUs could keep agencies focused and set mutual expectations. The local health department acknowledged shortcomings in MOUs but emphasized that MOUs could help agencies plan for referring clients when their own capacity was full.

Conclusions:

Although many agencies acknowledged the importance of collaboration, most respondents found that MOUs lacked practical utility. Grant-makers should consult sub-grantees to develop alternative means of fostering collaboration that would be perceived as relevant by both parties.

Multidisciplinary integrated Parent and Child Centres in Amsterdam: a qualitative study

BACKGROUND

In several countries centres for the integrated delivery of services to the parent and child have been established. In the Netherlands family health care service centres, called Parent and Child Centres (PCCs) involve multidisciplinary teams. Here doctors, nurses, midwives, maternity help professionals and educationists are integrated into multidisciplinary teams in neighbourhood-based centres. To date there has been little research on the implementation of service delivery in these centres.

STUDY DESIGN

A SWOT analysis was performed by use of triangulation data; this took place by integrating all relevant published documents on the origin and organization of the PCCs and the results from interviews with PCC experts and with PCC professionals (n=91). Structured interviews were performed with PCC-professionals [health care professionals (n=67) and PCC managers n=12)] and PCC-experts (n=12) in Amsterdam and qualitatively analysed thematically. The interview themes were based on a pre-set list of codes, derived from a prior documentation study and a focus group with PCC experts.

RESULTS

Perceived advantages of PCCs were more continuity of care, shorter communication lines, low-threshold contact between professionals and promising future perspectives. Perceived challenges included the absence of uniform multidisciplinary guidelines, delays in communication with hospitals and midwives, inappropriate accommodation for effective professional integration, differing expectations regarding the PCC-manager role among PCC-partners and the danger of professionals' needs dominating clients' needs.

CONCLUSIONS

Professionals perceive PCCs as a promising development in the integration of services. Remaining challenges involved improvements at the managerial and organizational level. Quantitative research into the improvements in quality of care and child health is recommended.

The role of partnership functioning and synergy in achieving sustainability of innovative programmes in community care

This cross-sectional study (conducted in April-May 2011) explored associations between partnership functioning synergy and sustainability of innovative programmes in community care. The study sample consisted of 106 professionals (of 244 individuals contacted) participating in 21 partnerships that implemented different innovative community care programmes in Rotterdam, The Netherlands. Partnership functioning was evaluated by assessing leadership, resources administration and efficiency. Synergy was considered the proximal outcome of partnership functioning, which, in turn, influenced the achievement of programme sustainability. On a 5-point scale of increasing sustainability, mean sustainability scores ranged from 1.9 to 4.9. The results of the regression analysis demonstrated that sustainability was positively influenced by leadership (standardised regression coefficient β = 0.32; P < 0.001) and non-financial resources (β = 0.25; P = 0.008). No significant relationship was found between administration or efficiency and programme sustainability. Partnership synergy acted as a mediator for partnership functioning and significantly affected sustainability (β = 0.39; P < 0.001). These findings suggest that the sustainability of innovative programmes in community care is achieved more readily when synergy is created between partners. Synergy was more likely to emerge with boundary-spanning leaders, who understood and appreciated partners' different perspectives, and could bridge their diverse cultures and were comfortable sharing ideas, resources and power. In addition, the acknowledgement of and ability to use members' resources were found to be valuable in engaging partners' involvement and achieving synergy in community care partnerships.

Should I stay or should I go? Understanding families' decisions regarding initiating, continuing, and terminating health services for managing pediatric obesity: the protocol for a multi-center, qualitative study

BACKGROUND

At least two million Canadian children meet established criteria for weight management. Due to the adverse health consequences of obesity, most pediatric weight management research has examined the efficacy and effectiveness of interventions to improve lifestyle behaviors, reduce co-morbidities, and enable weight management. However, little information is available on families' decisions to initiate, continue, and terminate weight management care. This is an important knowledge gap since a substantial number of families fail to initiate care after being referred for weight management while many families who initiate care discontinue it after a brief period of time. This research aims to understand the interplay between individual, family, environmental, and systemic factors that influence families' decisions regarding the management of pediatric obesity.

METHODS/DESIGN

Individual interviews will be conducted with children and youth with obesity (n = 100) and their parents (n = 100) for a total number of 200 interviews with 100 families. Families will be recruited from four Canadian multi-disciplinary pediatric weight management centers in Vancouver, Edmonton, Hamilton, and Montreal. Participants will be purposefully-sampled into the following groups: (i) Non-Initiators (5 families/site): referred for weight management within the past 6 months and did not follow-up the referral; (ii) Initiators (10 families/site): referred for weight management within the past 6 months and did follow-up the referral with at least one clinic appointment; and (iii) Continuers (10 families/site): participated in a formal weight management intervention within the past 12 months and did continue with follow-up care for at least 6 months. Interviews will be digitally recorded and analyzed using an ecological framework, which will enable a multi-level evaluation of proximal and distal factors that underlie families' decisions regarding initiation, continuation, and termination of care. Demographic and anthropometric/clinical data will also be collected.

DISCUSSION

A better understanding of family involvement in pediatric weight management care will help to improve existing health services in this area. Study data will be used in future research to develop a validated survey that clinicians working in pediatric obesity management can use to understand and enhance their own health services delivery.

The diagnosis less traveled: NPs' role in recognizing adult ADHD

PURPOSE

To stimulate critical thought about sociocultural implications of unrecognized and undiagnosed attention deficit hyperactivity disorder (ADHD), and how these factors interface with healthcare delivery models and care that nurse practitioners (NPs) provide.

DATA SOURCES

Health science databases--Psych Info, Proquest, Sage, PubMed, and authors' professional experiences.

CONCLUSIONS

NPs, often the main healthcare provider for underserved populations in community practice settings, have little training in assessing adult ADHD. ADHD, often unrecognized and undiagnosed among adults, contributes to global impairments adversely affecting individuals' social, behavioral, academic, and cognitive functioning. Increased insight and awareness about adult ADHD is warranted to facilitate appropriate diagnosis.

IMPLICATIONS FOR PRACTICE

ADHD is found in all sectors of our society; however, assessment and diagnosis among those whose socioeconomic status limits access to resources is a problem. Working in integrated care clinical settings facilitates recognition of patient problems and colocates resources required to manage the ADHD patient effectively. While this practice model may not be the norm, it is critical for NPs to have: (a) heightened awareness of the presentation of adult ADHD; (b) skills and/or resources to facilitate proper diagnosis of adult ADHD, and (c) models of practice that support optimal NP care delivery.

Providers' perspectives on collaboration

OBJECTIVE

Changes in models of health care are required to better meet the needs of diverse, underserved patient populations. Collaboration among providers is one way to promote accessible, comprehensive and continuous care in healthcare organizations. This paper describes the quantitative findings from two time points that examined providers' views of collaboration among a sample of diverse personnel (e.g. clinical nurses, social workers, dental providers, mental health providers, clerical staff, medical assistants, public health staff, and administrators) within a federally qualified nurse managed health care centre in the United States.

METHODS

The quantitative arm of a mixed-method study is presented in this paper. Two instruments, the Collaboration and Satisfaction About Care Decisions Scale and the University of the West of England Interprofessional Questionnaire (comprised of 4 subscales-Communication and Teamwork Scale, Interprofessional Learning Scale, Interprofessional Interaction Scale, and Interprofessional Relationships Scale) were administered to providers at baseline and three to eight months following six same discipline focus group discussions on collaboration, in order to evaluate whether participating in the focus group discussions changed providers' views of collaboration. A summary of the focus group data which were published elsewhere is additionally summarized to help provide insight to the quantitative findings. Thirty-nine staff participated.

RESULTS

Paired t-tests revealed that only one scale out of the five, Collaboration and Satisfaction About Care Decisions Scale (33.97 at time one and 37.45 at time two), significantly and positively changed after the focus group discussion (p=0.046). Providers' views on collaboration ranged from positive to moderate views of collaboration; most measures revealed a non-significant improvement after the focus group discussions. Staff with some graduate school reported the greatest satisfaction with decisions for the patient, and those with high school reported the lowest satisfaction with decisions for the patient. Respondents with a graduate degree had the most positive views of interprofessional relationships, whilst those with either a high school degree or bachelor's degree had the most negative views of interprofessional relationships. ANOVAs by professional role revealed the least positive views of collaboration for provider groups with lower levels of education, with upper administration reporting the most positive views on collaboration.

CONCLUSION

Although the discussion generated by the focus groups was expected to facilitate communication, and research has suggested that communication between providers facilitates collaboration, only one subscale evaluating providers' views of collaboration positively and significantly changed after the focus group discussion. The wide range of views on collaboration suggests there are diverse perspectives on collaboration among the staff based on professional roles and levels of education, with upper administration and those with higher levels of education reporting the most positive views of collaboration and staff with lower levels of education reporting more negative views of collaboration. A major limitation of this study was a low time two return among support staff, comprised of primarily African American women. Due to their marginalized professional and racial status, future research needs to explore the perspectives of this important and often overlooked group of staff.

Development and validation of a short version of the Partnership Self-Assessment Tool (PSAT) among professionals in Dutch disease-management partnerships

BACKGROUND

The extent to which partnership synergy is created within quality improvement programmes in the Netherlands is unknown. In this article, we describe the psychometric testing of the Partnership Self-Assessment Tool (PSAT) among professionals in twenty-two disease-management partnerships participating in quality improvement projects focused on chronic care in the Netherlands. Our objectives are to validate the PSAT in the Netherlands and to reduce the number of items of the original PSAT while maintaining validity and reliability.

METHODS

The Dutch version of the PSAT was tested in twenty-two disease-management partnerships with 218 professionals. We tested the instrument by means of structural equation modelling, and examined its validity and reliability.

RESULTS

After eliminating 14 items, the confirmatory factor analyses revealed good indices of fit with the resulting 15-item PSAT-Short version (PSAT-S). Internal consistency as represented by Cronbach's alpha ranged from acceptable (0.75) for the 'efficiency' subscale to excellent for the 'leadership' subscale (0.87). Convergent validity was provided with high correlations of the partnership dimensions and partnership synergy (ranged from 0.512 to 0.609) and high correlations with chronic illness care (ranged from 0.447 to 0.329).

CONCLUSION

The psychometric properties and convergent validity of the PSAT-S were satisfactory rendering it a valid and reliable instrument for assessing partnership synergy and its dimensions of partnership functioning.

A 4-year sequential assessment of the Families First Edmonton partnership: challenges to synergy in the implementation stage

This article assesses the partnership functioning of Families First Edmonton, a multisectored collaborative effort formed to determine the best health and recreation service delivery model for families with low income. Partners' evaluations of the collaborative process are examined across the formation, implementation, and maintenance stages of development. Statistical analyses of questionnaire data reveal a significant decrease in the partnership's capacity to maximize synergy-a main indicator of a successful collaborative process-in the implementation stage of the partnership. Implications for partnership practice are addressed.

A proposed systems approach to the evaluation of integrated palliative care

BACKGROUND

There is increasing global interest in regional palliative care networks (PCN) to integrate care, creating systems that are more cost-effective and responsive in multi-agency settings. Networks are particularly relevant where different professional skill sets are required to serve the broad spectrum of end-of-life needs. We propose a comprehensive framework for evaluating PCNs, focusing on the nature and extent of inter-professional collaboration, community readiness, and client-centred care.

METHODS

In the absence of an overarching structure for examining PCNs, a framework was developed based on previous models of health system evaluation, explicit theory, and the research literature relevant to PCN functioning. This research evidence was used to substantiate the choice of model factors.

RESULTS

The proposed framework takes a systems approach with system structure, process of care, and patient outcomes levels of consideration. Each factor represented makes an independent contribution to the description and assessment of the network.

CONCLUSIONS

Realizing palliative patients' needs for complex packages of treatment and social support, in a seamless, cost-effective manner, are major drivers of the impetus for network-integrated care. The framework proposed is a first step to guide evaluation to inform the development of appropriate strategies to further promote collaboration within the PCN and, ultimately, optimal palliative care that meets patients' needs and expectations.

An interprofessional team approach to fall prevention for older home care clients 'at risk' of falling: health care providers share their experiences

Background

Providing care for older home care clients ‘at risk’ of falling requires the services of many health care providers due to predisposing chronic, complex conditions. One strategy to ensure that quality care is delivered is described in the integrated care literature; interprofessional collaboration. Engaging in an interprofessional team approach to fall prevention for this group of clients seems to make sense. However, whether or not this approach is feasible and realistic is not well described in the literature. As well, little is known about how teams function in the community when an interprofessional approach is engaged in. The barriers and facilitators of such an approach are also not known.

Purpose

The purpose of this qualitative study was to describe the experiences of five different health care professionals as they participated in an interprofessional team approach to care for the frail older adult living at home and at risk of falling.

Methodology

This study took place in Hamilton, ON, Canada and was part of a randomized controlled trial, the aim of which was to determine the effects and costs of a multifactorial and interdisciplinary team approach to fall prevention for older home care clients ‘at risk’ of falling. The current study utilized an exploratory descriptive design to answer the following research questions: how do interprofessional teams describe their experiences when involved in a research intervention requiring collaboration for a 9-month period of time? What are the barriers and facilitators to teamwork? Four focus groups were conducted with the care-provider teams (n=9) 6 and 9 months following group formation.

Results

This study revealed several themes which included, team capacity, practitioner competencies, perceived outcomes, support and time. Overall, care providers were positive about their experiences and felt that through an interprofessional approach benefits could be experienced by both the provider and the patient and his/her family. Findings from this study suggest that research needs to be conducted to further explore the issues faced by this group of care providers and potential client outcomes.

A double-edged sword: lactation consultants' perceptions of the impact of breast pumps on the practice of breastfeeding

This qualitative descriptive study examined the beliefs and experiences of 12 lactation consultants regarding the impact of breast pumps on breastfeeding practices. Interview topics on breast pumps included types and patterns of use, mothers' experiences, and advantages and risks. The lactation consultants reported an increase in the use of breast pumps due to improved marketing, a change in society's view of pumps as a necessity rather than a luxury, and the impact of birthing technology. Reasons given for this increased use were mothers' need to have greater control over the breastfeeding process and to quantify the amount of breastmilk. Concerns were expressed regarding an overdependency on breastfeeding technology by some lactation consultants and mothers.