Stepping Up Telehealth: Using telehealth to support a new model of care for type 2 diabetes management in rural and regional primary care

Our proposal is to pilot the feasibility and acceptability of a telehealth intervention to enhance care in rural general practice for people with out-of-target Type 2 Diabetes (T2D). Our research program builds on the UK Medical Research Council framework in developing a model of care intervention that is well matched to the setting of General Practice and to the experiences and priorities of patients. We undertook an exploratory qualitative study, leading to the development of a practice-based intervention that we pilot tested for feasibility and acceptability before undertaking a larger pilot and a cluster RCT. We based our work on Normalisation Process Theory (NPT), a sociological theory of implementation, which describes how new practices become incorporated into routine clinical care as a result of individual and collective work. NPT suggested that our model of care intervention would need to be patient centred and include all members of the multidisciplinary diabetes team, including Endocrinologist, RN-CDE General Practitioners (GP), and generalist Practice Nurses (PNs). All of these groups are involved in the �work� of insulin initiation.The research reported in this paper is a project of the Australian Primary Health Care Research Institute which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research Evaluation and Development Strategy

Let's CHAT (community health approaches to) dementia in Aboriginal and Torres Strait Islander communities: protocol for a stepped wedge cluster randomised controlled trial

Background: Documented rates of dementia and cognitive impairment not dementia (CIND) in older Aboriginal and Torres Strait Islander Peoples is 3–5 times higher than the rest of the population, and current evidence suggests this condition is under-diagnosed and under-managed in a clinical primary care setting. This study aims to implement and evaluate a culturally responsive best practice model of care to optimise the detection and management of people with cognitive impairment and/or dementia, and to improve the quality of life of carers and older Aboriginal and Torres Islander Peoples with cognitive impairment. Methods/design: The prospective study will use a stepped-wedge cluster randomised controlled trial design working with 12 Aboriginal Community Controlled Health Services (ACCHSs) across four states of Australia. Utilising a co-design approach, health system adaptations will be implemented including (i) development of a best practice guide for cognitive impairment and dementia in Aboriginal and Torres Strait Islander communities (ii) education programs for health professionals supported by local champions and (iii) development of decision support systems for local medical software. In addition, the study will utilise a knowledge translation framework, the Integrated Promoting Action on Research Implementation in Health Services (iPARIHS) Framework, to promote long-term sustainable practice change. Process evaluation will also be undertaken to measure the quality, fidelity and contextual influences on the outcomes of the implementation. The primary outcome measures will be rates of documentation of dementia and CIND, and evidence of improved management of dementia and CIND among older Indigenous peoples attending Aboriginal and Torres Strait Islander primary care services through health system changes. The secondary outcomes will be improvements to the quality of life of older Indigenous peoples with dementia and CIND, as well as that of their carers and families. Discussion: The Let’s CHAT Dementia project will co-design, implement and evaluate a culturally responsive best practice model of care embedded within current Indigenous primary health care. The best practice model of care has the potential to optimise the timely detection (especially in the early stages) and improve the ongoing management of people with dementia or cognitive impairmentKate Bradley, Robyn Smith, Jo-anne Hughson, David Atkinson, Dawn Bessarab, Leon Flicker ... et al

Mobilities of Older Chinese Rural-Urban Migrants: A Case Study in Beijing.

Along with the rapid urbanization process in Beijing, China, the number of older rural-urban migrants is increasing. This study aims to understand how Chinese rural-urban migration in older age is influenced by, and impacts on the migrants' mobilities. This study draws on a new conceptual framework of mobile vulnerability, influenced by physical, economic, institutional, social and cultural mobility, to understand older people' experiences of migration from rural to urban areas. Forty-five structured in-depth interviews with older rural-urban migrants aged 55 and over were undertaken in four study sites in Beijing, using the constant comparative method. Results demonstrate that rural household registration (hukou) is an important factor that restricts rural older migrants' institutional mobility. As older migrants' physical mobility declines, their mobile vulnerability increases. Economic mobility is the key factor that influences their intention to stay in Beijing. Older migrants also described coping strategies to improve their socio-cultural mobility post-migration. These findings will inform service planning for older rural-urban migrants aimed at maintaining their health and wellbeing

Implementation of Shared Decision-Making in Australia

Shared decision-making (SDM) is the process of clinicians and patients participating jointly in making healthcare decisions, having discussed evidence-based treatment options and the potential risks and benefits of each option, taking into consideration the patient’s individual preferences and values. SDM is ubiquitous in Australian healthcare policy. While there is good evidence for utilising SDM, clinicians’ knowledge of SDM, the current uptake, effectiveness and acceptability of SDM in Australia is largely unknown. The challenges perceived by clinicians to implementing SDM in clinical practice and potential moral, legal and ethical dilemmas require further debate and consideration. Abbreviations: SDM – Shared Decision-Making

Optimizing care and outcomes for people with type 2 diabetes - lessons from a translational research program on insulin initiation in general practice.

BACKGROUND: Clinical inertia, failure to intensify treatment according to evidence-based guidelines, leads to prolonged, avoidable hyperglycemia in people with type 2 diabetes (T2D). This is a challenge for General Practice and Primary Care, where most people with T2D receive most of their care. Sustained, integrated translational research programs are needed to embed effective treatments in routine practice, yet many challenges exist for developing such programs. OBJECTIVES: To explore challenges and facilitators to implementing a translational research program focused on insulin initiation and titration among people with T2D in general practice and to identify key factors important to support and sustain such translation research in primary care. Operationalizing a program of translational work in primary care: We describe a series of studies on insulin initiation and titration in general practice including theory and qualitative work (Phase 1), a small feasibility and acceptability pilot (Phase 2), a large scale pilot (Phase 3), and a pragmatic cluster randomized trial currently under way (Phase 4). We used mixed methods to explore practice level implementation issues, and reflective investigator discussions to explore broader research program sustainability. Challenges for translational research in primary care: Key facilitators and barriers at practice and research program levels, include: Appropriate funding structures to secure long-term capacity building and people support; Building and maintaining linkages between communities of practice, primary and secondary/tertiary care researchers, institutions, and industry partners; Strategies for engagement and support for practitioners and participants. CONCLUSION: Building effective and sustainable translational research programs are critical for developing evidence-based policy that drives improved outcomes at a population level. Diverse sources of funding that support extensive and sustained trans-mural collaboration as well as engagement with practitioners, patients, and policymakers in the field are crucial

Evidence for a prolonged postimplantation period in the Australian sea lion (Neophoca cinerea)

Concentrations of circulating progesterone and oestradiol were measured in 96 free-ranging, female Australian sea lions Neophoca cinerea from Kangaroo Island, South Australia. There was a marked increase in the concentrations of both hormones (progesterone from approximately 12 ng ml -1 to approximately 24 ng ml -1; oestradiol from approximately 1.5 pg ml -1 to approximately 14 pg ml -1) about 3.5 months after the probable date of mating, reaching peak values in the 5 months after parturition. Progesterone concentrations remained at peak concentrations for about 2 months, decreasing at approximately 8 months to concentrations approximating those of the first 3 months after parturition. Oestradiol concentrations decreased, after reaching a peak, to 3-4 pg ml -1 at about 8 months after parturition. The timing of the increase in the concentrations of circulating progesterone and oestradiol provides evidence that the blastocyst reactivates and implants between 3.5 and 5 months of pregnancy in Australian sea lions, indicating an embryonic diapause of similar duration to that of other pinnipeds. This would suggest a prolonged postimplantation period of up to 14 months (to fit with the gestation period of 18 months reported for this species) the longest postimplantation period recorded for pregnancy in any pinniped