An Expanded Paradigm of Primary Care Diabetes Chronic Disease Management

The ability to address the comprehensive needs of diabetes chronic disease management is seriously challenged by staffing and time constraints within primary care visits. The purpose of this article is to outline the evidence for the use of community referrals to diabetes education, medical nutrition therapy, and mental health care providers. These referrals can expand the reach of achievable diabetes chronic care management to mitigate barriers to care and to improve outcomes. There is a strong evidence base to support these referrals, as well as the added benefits of patient safety and satisfaction, and decrease constraints on the workflow of busy primary care practices.     

Diabetes medical nutrition therapy: practical tips to improve outcomes

PURPOSE: To describe the evolving and expanding role of nurse practitioners (NPs) in providing diabetes medical nutrition therapy (MNT) as the United States faces epidemics of diabetes and obesity. DATA SOURCES: Scientific literature and reports from the public health, diabetes, and nutrition fields. CONCLUSIONS: Although clinically effective for both prevention and treatment of diabetes, MNT is often underutilized. The majority of people with diabetes are cared for by primary care providers; the role of NPs as primary care providers is evolving and expanding. NPs are recognized as leaders who creatively adapt to the rapidly changing health care delivery system. IMPLICATIONS FOR PRACTICE: NPs can serve as role models by presenting accurate, basic nutrition messages, referring patients to registered dietitians for MNT, reinforcing nutrition and the importance of lifestyle change as primary treatments for their disease, and following up on their patients' progress with nutrition interventions.     

Books Received

Practice guidelines include recommendations for collaboration between primary care (PC) and mental health (MH) to improve the quality of depression management within primary care. There is little research, however, assessing usual care relationships between PC and MH providers, or providers' perceptions regarding collaboration. Based on the literature, we conceptualize a continuum of collaborative activities and strategies. We describe the extent of collaboration and perceived barriers in selected outpatient clinics. We conducted semi-structured interviews with 22 PC and MH clinical leaders from 10 outpatient facilities. Topics included existing referral, consultation, and collaboration practices between PC and MH, beliefs and barriers related to collaboration. Informants generally described good relationships between providers, and PC providers reported satisfaction with referrals to MH. Informal consultation also occurred, although it was not universal. There was little evidence of collaboration beyond this basic level. The leaders identified several potential barriers to collaboration, including inadequate staffing and resources for both services. In contrast with practice guidelines, the clinics we studied incorporated little collaboration with MH providers into PC management of depression. We identify strategies that can help overcome the barriers to collaboration that our informants most commonly identified.     

Primary care - mental health collaboration: an example of assessing usual practice and potential barriers

Practice guidelines include recommendations for collaboration between primary care (PC) and mental health (MH) to improve the quality of depression management within primary care. There is little research, however, assessing usual care relationships between PC and MH providers, or providers' perceptions regarding collaboration. Based on the literature, we conceptualize a continuum of collaborative activities and strategies. We describe the extent of collaboration and perceived barriers in selected outpatient clinics. We conducted semi-structured interviews with 22 PC and MH clinical leaders from 10 outpatient facilities. Topics included existing referral, consultation, and collaboration practices between PC and MH, beliefs and barriers related to collaboration. Informants generally described good relationships between providers, and PC providers reported satisfaction with referrals to MH. Informal consultation also occurred, although it was not universal. There was little evidence of collaboration beyond this basic level. The leaders identified several potential barriers to collaboration, including inadequate staffing and resources for both services. In contrast with practice guidelines, the clinics we studied incorporated little collaboration with MH providers into PC management of depression. We identify strategies that can help overcome the barriers to collaboration that our informants most commonly identified.     

Healthcare provider perceptions of the role of interprofessional care in access to and outcomes of primary care in an underserved area

To meet the needs of an aging population who often have multiple chronic conditions, interprofessional care is increasingly adopted by patient-centred medical homes and Accountable Care Organisations to improve patient care coordination and decrease costs in the United States, especially in underserved areas with primary care workforce shortages. In this cross-sectional survey across multiple clinical settings in an underserved area, healthcare providers perceived overall outcomes associated with interprofessional care teams as positive. This included healthcare providers’ beliefs that interprofessional care teams improved patient outcomes, increased clinic efficiency, and enhanced care coordination and patient follow-up. Teams with primary care physician available each day were perceived as better able to coordinate care and follow up with patients (p = .031), while teams that included clinical pharmacists were perceived as preventing medication-associated problems (p < .0001). Healthcare providers perceived the interprofessional care model as a useful strategy to improve various outcomes across different clinical settings in the context of a shortage of primary care physicians.     

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives

Background  Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. Objectives  The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. Methods  We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. Results  Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1–38) years and had used an electronic medical record for 7.0 (1–20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers'' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). Conclusion  Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.     

Minority workers: educational models for workers, health providers, and planners

1. The Labor Occupational Health Program's (LOHP) experience with occupational health problems in minority communities demonstrates that information on a client's past work history and occupational exposures is essential in providing comprehensive health care. Occupational health histories are an excellent tool to utilize in community health. 2. Community clinics and primary health care professionals are integral components in health care delivery services. 3. The occupational health professional has a unique opportunity to provide leadership in educating community health providers about the basics of occupational health.     

Supportive and palliative care needs of families of children with life-threatening illnesses in Western Australia: evidence to guide the development of a palliative care service

OBJECTIVE: To obtain feedback from families of children receiving palliative and supportive care about their care needs in hospital and in community settings. DESIGN: A two-phase combined quantitative and qualitative study. SETTING: Western Australia. PARTICIPANTS: 134 parents and 20 service providers. RESULTS: Analysis indicated the concept of palliative care is poorly understood by health professionals and by parents. Many families are affected emotionally, financially and physically by the burden of caring for children with life threatening or chronic conditions requiring complex care at home. Parents indicated the need for clear and honest information about their child's condition and prognosis throughout the trajectory of illness and perceived this had been lacking. Families required financial and practical assistance with providing care from their children at home. Parents also wanted more practical resources and information to assist with the management of their child's nutrition and pain, as well as support for their other children. The level of respite (in home and residential) was perceived to be insufficient and inequitable. Parents also required access to, and advice from, multidisciplinary health professionals when caring for their child at home. There was a perceived lack of coordination between community services and the hospital. CONCLUSION: Education of health professionals and parents regarding the concepts and introduction of palliative and supportive care is required. Care for children and their families should be coordinated by a multidisciplinary team in consultation with children and their families, and linked and integrated with the treating hospital in collaboration with community services. More inclusive criteria are required for community services including practical aids and respite care.     

Patient safety culture in Norwegian primary care: A study in out-of-hours casualty clinics and GP practices

Objective. This study aimed to investigate patient safety attitudes amongst health care providers in Norwegian primary care by using the Safety Attitudes Questionnaire, in both out-of-hours (OOH) casualty clinics and GP practices. The questionnaire identifies five major patient safety factors: Teamwork climate, Safety climate, Job satisfaction, Perceptions of management, and Working conditions. Design. Cross-sectional study. Statistical analysis included multiple linear regression and independent samples t-tests. Setting. Seven OOH casualty clinics and 17 GP practices in Norway. Subjects. In October and November 2012, 510 primary health care providers working in OOH casualty clinics and GP practices (316 doctors and 194 nurses) were invited to participate anonymously. Main outcome measures. To study whether patterns in patient safety attitudes were related to professional background, gender, age, and clinical setting. Results. The overall response rate was 52%; 72% of the nurses and 39% of the doctors answered the questionnaire. In the OOH clinics, nurses scored significantly higher than doctors on Safety climate and Job satisfaction. Older health care providers scored significantly higher than younger on Safety climate and Working conditions. In GP practices, male health professionals scored significantly higher than female on Teamwork climate, Safety climate, Perceptions of management and Working conditions. Health care providers in GP practices had significant higher mean scores on the factors Safety climate and Working conditions, compared with those working in the OOH clinics. Conclusion. Our study showed that nurses scored higher than doctors, older health professionals scored higher than younger, male GPs scored higher than female GPs, and health professionals in GP practices scored higher than those in OOH clinics – on several patient safety factors.Key Words: Adverse events, general practice, medical errors, Norway, out-of-hours, patient safety culture, primary care, Safety Attitudes QuestionnairePatient safety culture is how leader and staff interaction, attitudes, routines, and practices in a group setting may protect patients from adverse events.

• In out-of-hours clinics, nurses scored higher than doctors, and older health professionals scored higher than younger on patient safety factors.
• Male professionals in GP practices scored significantly higher than female on four of the patient safety factors.
• Health care providers in GP practices had higher patient safety factor scores than those working in out-of-hours clinics.

     

Providing for the health needs of migrant children

Migrant children frequently have health needs that go unmet due to fragmented care caused by their mobility, poverty, lack of medical and financial resources, language barriers, superstitions and poor education. Their common health problems primarily fall into four categories: 1) Diseases and conditions caused by overcrowded and poor living conditions and frequent moves to new climatic areas with different water supplies and native viruses; 2) nutritional problems; 3) congenital anomalies, inherited conditions and allergies; and 4) neglect and lack of adequate medical treatment. Migrant children present nurse practitioners with a unique challenge to provide the children and their families with comprehensive health care which includes 1) diagnosis and treatment of common illnesses, infections and infestations within the family's meager economic means; 2) referrals for congenital anomalies, chronic conditions and those conditions requiring additional or specialized health services; and 3) the adaptation of teaching programs for the child and his/her parents (including health education in hygiene, immunization status, growth and development, stimulation, nutrition, etc.). This article discusses migrant health problems and makes recommendations for providing health care and referrals for migrant children.     

The “elephant in the room”: using emotion management to uncover hidden discourses in interprofessional collaboration and teamwork

Abstract

Shared decision-making and interprofessional collaboration are important approaches to achieving consumer-centered care. The concept of shared decision-making has been expanded recently to include the interprofessional healthcare team. This study explored healthcare providers’ perceptions of barriers and facilitators to both shared decision-making and interprofessional collaboration in mental healthcare. Semi-structured interviews were conducted with 31 healthcare providers, including medical practitioners (psychiatrists, general practitioners), pharmacists, nurses, occupational therapists, psychologists and social workers. Healthcare providers identified several factors as barriers to, and facilitators of shared decision-making that could be categorized into three major themes: factors associated with mental health consumers, factors associated with healthcare providers and factors associated with healthcare service delivery. Consumers’ lack of competence to participate was frequently perceived by mental health specialty providers to be a primary barrier to shared decision-making, while information provision on illness and treatment to consumers was cited by healthcare providers from all professions to be an important facilitator of shared decision-making. Whilst healthcare providers perceived interprofessional collaboration to be influenced by healthcare provider, environmental and systemic factors, emphasis of the factors differed among healthcare providers. To facilitate interprofessional collaboration, mental health specialty providers emphasized the importance of improving mental health expertise among general practitioners and community pharmacists, whereas general health providers were of the opinion that information sharing between providers and healthcare settings was the key. The findings of this study suggest that changes may be necessary at several levels (i.e. consumer, provider and environment) to implement effective shared decision-making and interprofessional collaboration in mental healthcare.     

PS1-62: Assessing Readiness for Team Care in Community-based Clinics: Barriers and Facilitators to Implementing an Evidence-based Intervention to Improve BP Control

Background/Aims Understanding the barriers and facilitators to implementing evidence-based models of care in typical community settings is critical to the successful translation of research-tested interventions into practice. The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP), implemented in a large, integrated group practice, demonstrated that team-care and incorporating a pharmacist to manage hypertension via secure e-mail communications in an existing patient-shared electronic health record (EHR) resulted in almost twice the rate of BP control compared to usual care. We sought to assess whether e-BP could be implemented in community-based primary care clinics with very different contextual features (e.g. inexperience with pharmacist team members, limited IT infrastructure, and vulnerable patient populations). Methods We conducted interviews with purposive samples of health care providers, pharmacists and patients associated with four community-based, primary care clinics. Using template analysis incorporating a priori codes drawn from the Chronic Care Model and the Consolidated Framework for Implementation Research, we identified themes illuminating contextual barriers and facilitators, as well as strategies for adapting core components of e-BP for implementation to control hypertension in community practice settings. Results Community-based patients, pharmacists, providers and staff expressed eagerness to participate in an intervention like e-BP. They characterized its approach to healthcare as "the right thing to do" and expressed hope that participation would yield enough evidence about the benefits of this care model to support significant reimbursement reform. The intervention's sustainability was of paramount importance to stakeholders and needs to be considered in planning for implementation. Stakeholders were more concerned about being able to overcome barriers related to regulations and reimbursement than to clinic-level factors. Discussion Community-based clinic stakeholders would like to improve hypertension control and the care of other chronic conditions using team care and communications outside of office visits. However, ensuring a business case for implementation and sustainability of these models was a persistent theme. Using this case study, we will discuss methods and models for adaptation and implementation of evidence-based interventions into community practice.     

Nurse practitioners in Ontario primary healthcare: Referral patterns and collaboration with other healthcare professionals

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.     

Utilization of a mobile medical van for delivering pediatric care in the bateys of the Dominican Republic

Background

Bateys are impoverished areas of housing for migrant Haitian sugar cane workers in the Dominican Republic (DR). In these regions, preventative health care is almost non-existent, public service accessibility is limited, and geographic isolation prevents utilization of care even by those families with resources. Consequently, the development of a viable mobile system is vital to the delivery of acute and preventative health care in this region.

Aims

This study evaluated an existing mobile medical system. The primary goal was to describe the population served, diseases treated, and resources utilized. A secondary goal was to determine qualitatively an optimal infrastructure for sustainable health care delivery within the bateys.

Methods

Information on basic demographic data, diagnosis, chronicity of disease, and medications dispensed was collected on all pediatric patients seen in conjunction with an existing mobile medical system over a 3-month period in the DR. Health statistics for the region were collected and interviews were conducted with health care workers (HCWs) and community members on existing and optimal health care infrastructure.

Results

Five hundred eighty-four pediatric patients were evaluated and treated. Median age was 5 years (range 2 weeks to 20 years), and 53.7% of patients seen were 5 years of age or younger. The mean number of complaints per patient was 2.8 (range 0 to 6). Thirty-six percent (373) of all diagnoses were for acute complaints, and 64% (657) were chronic medical problems. The most common pediatric illnesses diagnosed clinically were gastrointestinal parasitic infection (56.6%), skin/fungal infection (46.2%), upper respiratory tract infections (URIs) (22.8%), previously undiagnosed asthma and allergies (8.2%), and symptomatic anemia (7.2%). Thirty HCWs and community members were interviewed, and all cited the need for similar resources: a community clinic and hospital referral site, health promoters within each community, and the initiation of pediatric training for community HCWs.

Conclusion

A mobile medical system is a sustainable, efficient mechanism for delivering acute and preventive care in the Haitian bateys of the Dominican Republic. The majority of patients served were 8 years of age or younger with multiple presenting symptoms. A pediatric protocol for identifying the most appropriate drugs and supplies for mobile units in the DR can be created based upon diseases evaluated. Qualitative data from HCWs and community members identified the need for an integrative health care delivery infrastructure and community health promoters versed in pediatric care who can aid in education of batey members and monitor chronic and acute illnesses. We are planning follow-up visits to implement these programs.     

Primary care providers and medical homes for individuals with spina bifida

The contributions of primary care providers to the successful care of children with spina bifida cannot be underestimated. Overcoming systemic barriers to their integration into a comprehensive care system is essential. By providing routine and disability specific care through the structure of a Medical Home, they are often the first line resource and support for individuals and their families. The Medical Home model encourages primary care providers to facilitate discussions on topics as varied as education and employment. Knowledge of specific medical issues unique to this population allows the primary care provider to complement the efforts of other specialty clinics and providers in often neglected areas such as sexual health, obesity and latex sensitization. As individuals with spina bifida live into adulthood, and access to traditional multidisciplinary care models evolves, these skills will take on increasing importance within the scope of providing comprehensive and coordinated care.     

Facilitating an integrated approach to primary health care in Saskatchewan

It is unlikely that truly integrated primary health care will become a reality unless health professionals actively strive to foster integration. Dialogue about integration barriers and opportunities has begun between the nursing, pharmacy, social work, emergency medical services, and medical professions. This dialogue should be expanded to include all of the professions with a potential role in an integrated system. The dialogue will also need to include government leaders as key public policy decisions will significantly influence the success or failure of integrated primary health service delivery strategies. As well, dialogue needs to occur with communities so that citizens can understand, value and help shape and maintain this kind of service delivery. Public education needs to emphasize that an integrated approach to primary health care in Saskatchewan is the best kind of service that can be provided. The Integrated Primary Health Care Working Group believes that the principles of primary health care require health professionals in Saskatchewan to develop an integrated approach to health services delivery in Saskatchewan. An exploration of possible barriers to this integrated approach is an important first step in eliminating barriers and facilitating effective health care service delivery to meet population health needs.     

Nurse practitioners in Ontario primary healthcare: referral patterns and collaboration with other healthcare professionals

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.