Measuring health outcomes of a multidisciplinary care approach in individuals with chronic environmental conditions using an abbreviated symptoms questionnaire

The Nova Scotia Environmental Health Centre is a treatment facility for individuals with chronic environmental conditions such as multiple chemical sensitivity, chronic fatigue syndrome, fibromyalgia, chronic respiratory conditions and in some cases chronic pain. The premise of care is to provide a patient-centred multidisciplinary care approach leading to self-management strategies. In order to measure the outcome of the treatment in these complex problems, with overlapping diagnoses, symptoms in many body systems and suspected environmental triggers, a detailed symptoms questionnaire was developed specifically for this patient population and validated. Results from a pilot study in which an abbreviated symptoms questionnaire based on the top reported symptoms captured in previous research was used to measure the efficacy of a multidisciplinary care approach in individuals with multiple chemical sensitivity are presented in this paper. The purpose of this study was to examine the extent, type and patterns of changes over time in the top reported symptoms with treatment measured using the abbreviated symptoms questionnaire. A total of 183 active and 109 discharged patients participated in the study where the health status was measured at different time periods of follow up since the commencement of treatment at the Centre. The findings from this study were successful in generating an initial picture of the nature and type of changes in these symptoms. For instance, symptoms such as difficulty concentrating, sinus conditions and tiredness showed early improvement, within the first 6 months of being in treatment, while others, such as fatigue, hoarseness or loss of voice, took longer while others showed inconsistent changes warranting further enquiry. A controlled longitudinal study is planned to confirm the findings of the pilot study

A controlled study of the effect of a mindfulness-based stress reduction technique in women with multiple chemical sensitivity, chronic fatigue syndrome, and fibromyalgia

Tara Sampalli1, Elizabeth Berlasso1, Roy Fox1, Mark Petter21Nova Scotia Environmental Health Centre, Fall River, Nova Scotia, Canada; 2Doctoral Candidate, Department of Psychology, Dalhousie University, Halifax, CanadaBackground: The objective of this study was to examine the effect of a mindfulness-based stress reduction (MBSR) program on women diagnosed with conditions such as multiple chemical sensitivity (MCS), chronic fatigue syndrome (CFS), and fibromyalgia (FM). Methods: The intervention group underwent a 10-week MBSR program. Symptoms Checklist Inventory (SCL-90R) was used as outcome measure and was administered before the start of the program (pre-), immediately upon completion (post-) and at three-month follow-up. Women on the wait list to receive treatment at the Nova Scotia Environmental Health Centre were used as control subjects for the study.Results: A total of 50 participants in the intervention group and 26 in the wait-list controls group were recruited for this study. Global scores in the intervention group reached statistical significance pre-post (<0.0001) and at pre-follow-up (<0.0001) while the global scores in the control group remained the same. Five of nine and eight of nine subscales of the SCL-90R showed improvement of statistical significance in MBSR group following treatment and at three-month follow-up.Conclusions: The study showed the importance of complementary interventions such as MBSR techniques in the reduction of psychological distress in women with chronic conditions.Keywords: chronic conditions, multiple chemical sensitivity, mindfulness-based stress reduction, chemical sensitivit

An evaluation of SNOMED CT® in the domain of complex chronic conditions

<p style="margin: 0pt; line-height: 200%; mso-layout-grid-align: none;"><strong>Objective</strong>: To determine the content coverage in SNOMED CT<strong style="mso-bidi-font-weight: normal;">®</strong> to represent the multidisciplinary terms and concepts in the domain for complex chronic conditions</p><p style="margin: 0pt; line-height: 200%; mso-layout-grid-align: none;"><strong>Methods</strong>: An evaluation of the coverage of multidisciplinary health factors in SNOMED CT<strong style="mso-bidi-font-weight: normal;">®</strong> for the complex and chronic condition, Multiple Chemical Sensitivity (MCS) is conducted in the study. The methodology included a retrospective audit of patient charts and feedback from multidisciplinary clinicians in the creation of a controlled vocabulary used in the generation of patient profiles for MCS. Clinicians and experts in the field reviewed and tested the vocabulary for its usefulness (scope, specificity and structure) by re-coding 3 patient profiles using the vocabulary. Cohen's kappa analysis was conducted to determine inter-rater reliability. Cronbach's alpha analysis was conducted to determine the internal reliability of the survey questionnaire.</p><p style="margin: 0pt; line-height: 200%; mso-layout-grid-align: none;"><strong>Results</strong>: One hundred patient charts and 9 clinicians from varying health disciplines participated in the study. SNOMED CT<strong style="mso-bidi-font-weight: normal;">®</strong> was shown to capture nearly 82% of the concepts spanning multidisciplinary areas of health focus. The nutrition area of health focus had the highest level of exact matches Furthermore post-coordination was applied in an attempt to improve coverage of concepts to 75% ( of 45 terms) of the missing terms in SNOMED CT ® . Seventy-five percent (n=9) of the clinicians agreed on the overall usefulness of the vocabulary.</p><p style="margin: 0pt; line-height: 200%; mso-layout-grid-align: none;"><strong>Conclusions</strong>: SNOMED CT® had a reasonable coverage of the multidisciplinary health concepts required to describe a complex and chronic condition. Standardizing the multidisciplinary vocabulary with reference tag to a widely used reference terminology such as SNOMED CT® to discuss the terms and concepts used may improve the understanding across disciplines and communities of practice. Overall, based on the availability of concepts in SNOMED CT® and the feedback from clinicians, the approach looks promising and should be further explored.</p

Improving Wait Times to Care for Individuals with Multimorbidities and Complex Conditions Using Value Stream Mapping

Background: Recognizing the significant impact of wait times for care for individuals with complex chronic conditions, we applied a LEAN methodology, namely – an adaptation of Value Stream Mapping (VSM) to meet the needs of people with multiple chronic conditions and to improve wait times without additional resources or funding. Methods:Over an 18-month time period, staff applied a patient-centric approach that included LEAN methodology of VSM to improve wait times to care. Our framework of evaluation was grounded in the needs and perspectives of patients and individuals waiting to receive care. Patient centric views were obtained through surveys such as Patient Assessment of Chronic Illness Care (PACIC) and process engineering based questions. In addition, LEAN methodology, VSM was added to identify non-value added processes contributing to wait times. Results:The care team successfully reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction are also outcomes of this innovative initiative. In addition, successful transformations and implementation have resulted in resource efficiencies without increase in costs. Patients have shown significant improvements in functional health following Integrated Chronic Care Service (ICCS) intervention. The methodology will be applied to other chronic disease management areas in Capital Health and the province. Conclusion: Wait times to care in the management of multimoribidities and other complex conditions can add a significant burden not only on the affected individuals but also on the healthcare system. In this study, a novel and modified LEAN methodology has been applied to embed the voice of the patient in care delivery processes and to reduce wait times to care in the management of complex chronic conditions

Improving wait times to care for individuals with multimorbidities and complex conditions using value stream mapping

Background: Recognizing the significant impact of wait times for care for individuals with complex chronic conditions, we applied a LEAN methodology, namely – an adaptation of Value Stream Mapping (VSM) to meet the needs of people with multiple chronic conditions and to improve wait times without additional resources or funding. Methods: Over an 18-month time period, staff applied a patient-centric approach that included LEAN methodology of VSM to improve wait times to care. Our framework of evaluation was grounded in the needs and perspectives of patients and individuals waiting to receive care. Patient centric views were obtained through surveys such as Patient Assessment of Chronic Illness Care (PACIC) and process engineering based questions. In addition, LEAN methodology, VSM was added to identify non-value added processes contributing to wait times. Results: The care team successfully reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction are also outcomes of this innovative initiative. In addition, successful transformations and implementation have resulted in resource efficiencies without increase in costs. Patients have shown significant improvements in functional health following Integrated Chronic Care Service (ICCS) intervention. The methodology will be applied to other chronic disease management areas in Capital Health and the province. Conclusion: Wait times to care in the management of multimoribidities and other complex conditions can add a significant burden not only on the affected individuals but also on the healthcare system. In this study, a novel and modified LEAN methodology has been applied to embed the voice of the patient in care delivery processes and to reduce wait times to care in the management of complex chronic conditions

Evaluating the Implementation and Feasibility of a WebBased Tool to Support Timely Identification and Care for the Frail Population in Primary Healthcare Settings

Background: Understanding and addressing the needs of frail persons is an emerging health priority for Nova Scotia and internationally. Primary healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not standard practice and, in general, there is a lack of awareness about how to identify and respond to frailty. A web-based tool called the Frailty Portal was developed to aid in identifying, screening, and providing care for frail patients in PHC settings. In this study, we will assess the implementation feasibility and impact of the Frailty Portal to: (1) support increased awareness of frailty among providers and patients, (2) identify the degree of frailty within individual patients, and (3) develop and deliver actions to respond to frailtyl in community PHC practice. Methods: This study will be approached using a convergent mixed method design where quantitative and qualitative data are collected concurrently, in this case, over a 9-month period, analyzed separately, and then merged to summarize, interpret and produce a more comprehensive understanding of the initiative’s feasibility and scalability. Methods will be informed by the ‘Implementing the Frailty Portal in Community Primary Care Practice’ logic model and questions will be guided by domains and constructs from an implementation science framework, the Consolidated Framework for Implementation Research (CFIR). Discussion: The ‘Frailty Portal’ aims to improve access to, and coordination of, primary care services for persons experiencing frailty. It also aims to increase primary care providers’ ability to care for patients in the context of their frailty. Our goal is to help optimize care in the community by helping community providers gain the knowledge they may lack about frailty both in general and in their practice, support improved identification of frailty with the use of screening tools, offer evidence based severity-specific care goals and connect providers with local available community supports

Engaging family caregivers and health system partners in exploring how multi-level contexts in primary care practices affect case management functions and outcomes of patients and family caregivers at end of life: A realist synthesis

From Springer Nature via Jisc Publications RouterBrendan McCormack - ORCID: 0000-0001-8525-8905 https://orcid.org/0000-0001-8525-8905Background: An upstream approach to palliative care in the last 12 months of life delivered by primary care practices is often referred to as Primary Palliative Care (PPC). Implementing case management functions can support delivery of PPC and help patients and their families navigate health, social and fiscal environments that become more complex at end-of-life. A realist synthesis was conducted to understand how multi-level contexts affect case management functions related to initiating end-of-life conversations, assessing patient and caregiver needs, and patient/family centred planning in primary care practices to improve outcomes. The synthesis also explored how these functions aligned with critical community resources identified by patients/families dealing with end-of-life. Methods: A realist synthesis is theory driven and iterative, involving the investigation of proposed program theories of how particular contexts catalyze mechanisms (program resources and individual reactions to resources) to generate improved outcomes. To assess whether program theories were supported and plausible, two librarian-assisted and several researcher-initiated purposive searches of the literature were conducted, then extracted data were analyzed and synthesized. To assess relevancy, health system partners and family advisors informed the review process. Results: Twenty-eight articles were identified as being relevant and evidence was consolidated into two final program theories: 1) Making end-of-life discussions comfortable, and 2) Creating plans that reflect needs and values. Theories were explored in depth to assess the effect of multi-level contexts on primary care practices implementing tools or frameworks, strategies for improving end-of-life communications, or facilitators that could improve advance care planning by primary care practitioners. Conclusions: Primary care practitioners’ use of tools to assess patients/families’ needs facilitated discussions and planning for end-of-life issues without specifically discussing death. Also, receiving training on how to better communicate increased practitioner confidence for initiating end-of-life discussions. Practitioner attitudes toward death and prior education or training in end-of-life care affected their ability to initiate end-of-life conversations and plan with patients/families. Recognizing and seizing opportunities when patients are aware of the need to plan for their end-of-life care, such as in contexts when patients experience transitions can increase readiness for end-of-life discussions and planning. Ultimately conversations and planning can improve patients/families’ outcomes.2

Patient-centred innovation for multimorbidity care : mixed-methods, randomized trial and qualitative study of the patients’ experience

Background Patient-centred interventions to help patients with multimorbidity have had mixed results. Aim To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand underwhal circumstances it worked. and did not work Design and setting Mixed-methods design with a pragmatic randomised trial and qualitative study. involving nine urban primary care sites in Ontario, Canada. Method Patients aged 18-80 years with >= 3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients' experiences of the intervention. Results A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of >= C$50 000 [beta-coefficient 11.003, P= 0.006]. More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported. receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes. Conclusion Overall, the intervention showed improvements only for patients who had an annual income of >= C$50 000, implying a need to address the Wsis of intervention components not covered by existing health policies. Findings suggest a need to optimise learn composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference's recommendations

The Newcomer Health Clinic in Nova Scotia: A Beacon Clinic to Support the Health Needs of the Refugee Population

Abstract Refugees tend to have greater vulnerability compared to the general population reporting greater need for physical, emotional, or dental problems compared to the general population. Despite the importance of creating strong primary care supports for these patients, it has been demonstrated that there is a significant gap in accessing primary care providers who are willing to accept the refugee population. These have resulted in bottlenecks in the transition or bridge clinics and have left patients orphaned without a primary care provider. This in turn results in higher use of emergency service and other unnecessary costs to the healthcare system. Currently there are few studies that have explored these challenges from primary care provider perspectives and very few to none from patient perspectives. A novel collaborative implementation initiative in primary healthcare (PHC) is seeking to improve primary medical care for the refugee population by creating a globally recommended transition or beacon clinic to support care needs of new arrivals and transitions to primary care providers. We discuss the innovative elements of the clinic model in this paper