A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults

Detailed description of the intervention [57, 84–89]. (DOC 63 kb

Curricular Processes as Practice: The Emergence of Excellence in a Medical School

This thesis deals with two related questions. The first relates to a critical inquiry into the processes of curriculum creation and formation within a medical school which has undergone a significant curriculum revision. I explore the notion that such processes can be understood as a form of practice in which the relationship between content and process is held together by what is explored in the thesis as an indivisible, paradoxical tension. Exploring curriculum as a kind of process is a novel approach in a school steeped in the traditions of the natural sciences. The common metaphors for curriculum in this setting refer to blueprints, models, behavioural competencies and objective standards. These are all founded on the belief in an objective observer who can maintain some form of distance between themselves and the subject in question. Issues of method are, therefore, central to my explorations of how we might, instead, locate curriculum in social processes and acts of evaluation involving power relations, conflict and the continuous negotiation of how it is we work together. The paradox of process and content in this way of understanding is that participants in curricular practice are simultaneously forming and being formed by their participation. In this way of thinking, it makes no sense to say one can either “step back” to “reflect” on their participation or that there is a way to approach participation “objectively.” The other question I address in this thesis has to do with the emergence of excellence. By emergence, I refer to thinking in the complexity sciences which attempts to explain phenomena which have a coherence which cannot be planned for or known in advance. “Excellence” is a kind of idealization which has no meaning until it is taken up and “functionalized” within specific settings and situations. In the setting of participating in curriculum formation, excellence may be understood as one possible outcome of persisting engagement and continuous inquiry which itself influences the ongoing conversation of how excellence is recognized and understood. In other words, excellence emerges in social processes as a theme simultaneously shaping and being shaped by curricular practice. This research was initiated as a result of a mandate to establish a program which could demonstrate excellence in the area of relationships in health care. The magnitude of this mandate felt overwhelming at the time and raised a lot of anxiety. I found that the traditional thinking regarding participation in organizational change processes (which, within my setting, could be understood as “set your goal and work backwards”) did not satisfactorily account for the uncertainties and surprises of working with colleagues to create something new. The method of inquiry can be read as another example of a process / content paradox through which my findings regarding curriculum and excellence emerged. This method involved taking narratives from my experience as an educator and clinician and a participant in varied forms of curricular processes and inquiring into them further by both locating them within relevant discourses from sociology, medical education and organizational studies and also sharing them with peers in my doctoral program as well as colleagues from my local setting. This method led to an inquiry and series of findings which was substantively different from my starting point. This movement in thinking offers another demonstration of an emergent methodology in which original findings are “discovered” through the course of inquiry. These findings continue to affect my practice and my approach to inquiry within the setting of medical education. The original contributions to thinking in medical education occur in several ways. One is in the demonstration of a research method which takes my own original experience seriously and seeks to challenge taken for granted assumptions about a separation of process and content, instead exploring the implications of understanding these in a relation of paradox. By locating my work within social processes of engagement and recognition, I explore the possibility that excellence can also be understood as an emergent property of interaction which is under continuous negotiation which itself forms the basis for further recognition and exploration of “excellence.” The social processes which shape and are shaped by “excellence” are fundamental to the practice of curriculum itself. Both curricula and “excellence” emerge within the interactions of people with a stake in the desired outcomes as the product of continued involvement and consideration of ongoing experience. Finally, a process view of medical education is presented as a contribution to understanding the work of training physicians who are comfortable with the uncertainties and contingencies involved in the humane care of their patients

"Primary care is primary care": Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario.

BackgroundIn Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario.MethodsA qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered.ResultsUsing the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners' roles, and the need for more training and education in transgender care for practitioners.ConclusionsPrimary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals

A web-based social network tool (GENIE) for supporting self-management among high users of the health care system: feasibility and usability study

Background: primary care providers are well positioned to foster self-management through linking patients to community-based health and social services (HSSs). This study evaluated a web-based tool—GENIE (Generating Engagement in Network Involvement)—to support the self-management of adults. GENIE empowers patients to leverage their personal social networks and increase their access to HSSs. GENIE maps patients’ personal social networks, elicits preferences, and filters local HSSs from a community service directory based on patient’s interests. Trained volunteers (an extension of the primary care team) conducted home visits and conducted surveys related to life and health goals in the context of the Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) program, in which the GENIE tool was implemented. GENIE reports were uploaded to an electronic medical record for care planning by the team.Objective: this study aims to explore patients’, volunteers’, and clinicians’ perceptions of the feasibility, usability, and perceived outcomes of GENIE—a tool for community-dwelling adults who are high users of the health care system.Methods: this study involved 2 primary care clinician focus groups and 1 clinician interview (n=15), 1 volunteer focus group (n=3), patient telephone interviews (n=8), field observations that captured goal-action sequences to complete GENIE, and GENIE utilization statistics. The patients were enrolled in a primary care program—Health TAPESTRY—and Ontario’s Health Links Program, which coordinates care for the highest users of the health care system. NVivo 11 (QSR International) was used to support qualitative data analyses related to feasibility and perceived outcomes, and descriptive statistics were used for quantitative data.Results: most participants reported positive overall perceptions of GENIE. However, feasibility testing showed that participants had a partial understanding of the tool; volunteer facilitation was critical to support the implementation of GENIE; clinicians perceived their navigation ability as superior to that of GENIE supported by volunteers; and tool completion took 39 minutes, which made the home visit too long for some. Usability challenges included difficulties completing some sections of the tool related to medical terminology and unclear instructions, limitations in the quality and quantity of HSSs results, and minor technological challenges. Almost all patients identified a community program or activity of interest. Half of the patients (4/8, 50%) followed up on HSSs and added new members to their network, whereas 1 participant lost a member. Clinicians’ strengthened their understanding of patients’ personal social networks and needs, and patients felt less social isolation.Conclusions: this study demonstrated the potential of GENIE, when supported by volunteers, to expand patients’ social networks and link them to relevant HSSs. Volunteers require training to implement GENIE for self-management support, which may help overcome the time limitations faced by primary care clinicians. Refining the filtering capability of GENIE to address adults’ needs may improve primary care providers’ confidence in using such tools

A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults

Abstract Background Healthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person’s life that centers on meeting a person’s health goals and needs will result in optimal aging. Methods/design This is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person’s life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months. Discussion Evidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system’s transformation of person-focused, primary care for older adults. Trial registration ClinicalTrials.gov NCT0228372