Introduction
Methods
Study intervention: rural primary health care memory clinic
Study design and setting
Participant | Focus Group Meetings (FG) | Workgroup Meetings (WG) | Total n FGs & WG | Individual Phone Interview | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
FG 1 | FG 2 | FG 3 | FG 4 | Total n FGs | WG 1 | WG 2 | WG 3 | Total n WGs | |||
Primary Health Care Team Members | |||||||||||
Family Physician | ✓ | ✓ | ✓ | 3 | 0 | 3 | |||||
Family Physician | ✓ | ✓ | ✓ | 3 | ✓ | 1 | 4 | ||||
Family Physician | ✓ | ✓ | ✓ | 3 | 0 | 3 | |||||
Nurse Practitioner | ✓ | ✓ | ✓ | ✓ | 4 | ✓ | ✓ | ✓ | 3 | 7 | |
Occupational Therapist & Regional Manager of Therapies | ✓ | ✓ | ✓ | ✓ | 4 | ✓ | ✓ | 2 | 6 | ✓ | |
Occupational Therapist 1 (Aug/14-Feb/16) | ✓ | 1 | 0 | 1 | |||||||
Occupational Therapist 2 (Sept/17-Jan/18) | 0 | ✓ | 1 | 1 | |||||||
Home Care Nurse 1 (Aug/14-Jan/18) | ✓ | ✓ | ✓ | 3 | ✓ | 1 | 4 | ||||
Home Care Nurse 2 (Aug/14-Feb/16) | ✓ | ✓ | 2 | 0 | 2 | ||||||
Alzheimer Society, Sun Country First Link Coordinator | ✓ | 1 | ✓ | ✓ | 2 | 3 | ✓ | ||||
Primary Health Care Team Facilitator 1 (Dec/15-Feb/16) | ✓ | 1 | 0 | 1 | ✓ | ||||||
Primary Health Care Team Facilitator 2 (Aug/14-Jan/18) | ✓ | 1 | ✓ | ✓ | ✓ | 3 | 4 | ||||
Regional Business Manager, Primary Health Care | ✓ | ✓ | ✓ | 3 | ✓ | ✓ | ✓ | 3 | 6 | ✓ | |
Managers | |||||||||||
Home Care Manager | ✓ | ✓ | 2 | 0 | 2 | ||||||
Manager Home Services | 0 | ✓ | 1 | 1 | |||||||
Alzheimer Society Manager | ✓ | 1 | 0 | 1 | |||||||
Community Health Services Manager | ✓ | ✓ | ✓ | 3 | 0 | 3 | |||||
Chronic Disease Management Coordinator | ✓ | 1 | 0 | 1 | |||||||
Regional Manager, Primary Health Care Teams | ✓ | ✓ | ✓ | ✓ | 4 | 0 | 4 | ||||
Regional Manager, Chronic Disease Management | ✓ | ✓ | 2 | 0 | 2 | ||||||
Regional Director, Mental Health and Addictions | ✓ | 1 | 0 | 1 | |||||||
Office Staff | |||||||||||
Medical Office Assistant/Office Staff | ✓ | 1 | ✓ | 1 | 2 | ||||||
Medical Office Assistant/Office Staff | ✓ | 1 | 0 | 1 | |||||||
Medical Office Assistant/Office Staff | ✓ | 1 | 0 | 1 | |||||||
Medical Office Assistant/Office Staff | ✓ | 1 | ✓ | 1 | 2 | ||||||
Totals | 16 | 13 | 11 | 7 | 47 | 8 | 4 | 7 | 19 | 66 |
Study participants
Data collection
Data analysis
Results
CFIR Domain and Constructs | Barrier | Facilitator |
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Innovation Characteristics
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Relative Advantage | Evidence-based flow sheets provided standardized assessment tool for all team members Team approach and standardized tools increased team members’ confidence in providing care without having to refer all patients Team members felt valued for their unique contribution to assessment and management Benefits to families including giving them a voice, providing direction, supporting future planning, connecting with services, avoiding crises | |
Trialability | Small-scale, iterative implementation and testing of the EMR flow sheets hampered by time intensiveness of modifying the EMR | Despite EMR challenges, the intervention could be implemented on a small scale to assess feasibility and iteratively test modifications to improve fit to context |
Complexity | Having the assessment flow sheets in the EMR was critical to implementation, but having multiple team members accessing the EMR created challenges that had to be resolved | The EMR created implementation challenges but it also reduced complexity by supporting team-based care and access to evidence-based decision support tools |
Outer Setting
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Needs and resources of those served by the innovation | Team members concerned about unmet needs of patients and families with usual care approach; late diagnosis and lack of support contributed to crisis situations Team approach and case conference facilitates discussion with family about services and planning for future needs Alzheimer Society participation in the memory clinics may increase use of supports by developing a relationship at time of diagnosis | |
External policy and incentives | Home care used a different EMR system that was not compatible with the PHC team EMR Policy of not funding licences for home care nurses to access the PHC team EMR Dementia not included in provincially funded incentive program for family physicians to use evidence-based tools with chronic disease patients | Improving access to primary health care teams is a priority for Ministry of Health |
Inner Setting
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Networks and Communications | Not all team members had EMR access initially Not all team members co-located Busy clinical schedules made it difficult to schedule meetings to develop and implement the clinic Researchers did not have direct communication with physicians | The team’s facilitator was critical to communication among team members and with the researchers. They could view calendars and book team members into meetings. Their formal role in team development benefited implementation by supporting communication. The memory clinic EMR was set up to accommodate access to the patient record by all team members |
Tension for change (Implementation Climate sub-construct) | Dissatisfaction with current approach to care; uncertainty about assessment process led to late diagnosis, often precipitated by a crisis situation Silo approach and lack of care coordination was less effective than a collaborative team approach Discussion about driving capacity in the team case conference removed the burden from one team member and reinforced the message to patients and families | |
Compatibility with existing workflows and processes (Implementation Climate sub-construct) | Team physicians perceived the team-based memory clinic model as inconsistent with their usual iterative approach to assessment Physicians’ involvement with other chronic disease case was less intensive; other team members managed most of the assessments and communication with patients and families. | Some team members were already experimenting with involving the Alzheimer Society and home care in a case conference when dementia suspected |
Leadership engagement (Readiness for Implementation sub-construct) | The support and active engagement of leaders was critical to ensuring adequate resources for the intervention, communicating the importance of the intervention, and giving permission to team members to participate | |
Available resources (Readiness for Implementation sub-construct) | Workload was a challenge to participation in the memory clinic for all team members Lack of personnel such as Dementia Care Managers to support the clinic and ease workload for team members Challenges in recruitment and retention of family physicians was a major barrier | The team facilitator and EMR manager were committed to the project and supported implementation despite workload issues The primary health care site had multiple allied health care providers linked to the site who could be accessed to participate in the memory clinic intervention |
Access to Knowledge and information (Readiness for Implementation sub-construct) | Few educational opportunities were available prior to the intervention; education by RaDAR specialists and PC-DATA™ developer helped build confidence in assessment and management Observing in the University-based interdisciplinary specialist memory clinic run by the RaDAR team inspired the rural PHC team to adopt the one-day clinic vs. the initial sequential approach Workgroup meetings with the researchers, RaDAR Handbooka, and tools embedded in the EMR were helpful | |
Characteristics of Individuals
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Self-efficacy | Team members’ self-efficacy and ownership of the intervention increased over the study. Growing confidence and feelings of contributing to improved outcomes for patients and families motivated continued involvement | |
Process
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Champions | Key individuals within the team who facilitated implementation were the nurse practitioner, PHC facilitator, and EMR manager | |
External change agents | Absence of a formally appointed internal facilitator | Participants identified the RaDAR researchers and PC-DATA™ developer as supporting implementation by providing education and working closely with the team at all stages to facilitate implementation and maintain momentum |
Innovation Sustainability
| Physician turnover Lack of process to engage and orient new team members, especially physicians, to the flow sheets and memory clinic processes | Continued contact with the researchers Consistent leadership in the region Increased community awareness of the memory clinic |
DOMAIN 1: innovation characteristics
Relative advantage
“We knew that the dementia part of our patients was important and assessment of that—we just didn’t quite know how to put all together and bring everybody together. So that’s been huge.” (Manager, Post-implementation, Focus Group 4)
“The providers did the best they could in their appointments … [but] they didn’t feel like it was very standardized so they wanted a process for when a patient complains of cognitive difficulties, what exactly do we do, what are the steps that we take.” (PHC Team Member, Post-implementation, Telephone Interview)
“As a provider I feel much more confident dealing with these people AND because I know there’s a team that backs me up too.” (PHC Team Member, Post-implementation, Focus Group 4)
“I think too the fact that we’re together and we all come from maybe a little bit of a different slant, but we were really speaking the same language to the family. I think they get a really good overall picture of what the issues are and what the plan could be. That’s part of it, that it looks like a really concerted effort as far as providing quality care for the clients.” (PHC Team Member, Post-implementation, Workgroup Meeting 3)
“And I think the family felt like they had a voice. And once they had that knowledge given to them, I mean you can just see it sink in and you can just see the wheels turning and I knew that they had questions and so before we’re over [case conference], we all went around the room and asked [the family] ‘what else do you have to say? Was there a question that you thought of?.... the family yesterday said ‘where’s the plan? What’s the first step that we do?’”(PHC Team Member, Post-implementation, Workgroup Meeting 3)
Trialability
“Instead of putting all three flow sheets in what if I try a small sampling of the flowsheets … I’m actually in [town] Friday, and so I can show the providers some of the templates I’ve developed, and some of the ways some of the things work … Kind of just put in a trial flowsheet with some of the information, see how it looks, and we can tweak it?” (Manager, Implementation, Focus Group 2)
Complexity
“There is another barrier. When it is scanned, what happens is that based on the label that is put on top, it ends up in the wrong place, so you are looking for something and you don’t find it … so when I’m going to review the past thing I may end up not finding the clock that the patient has done, and I think ‘okay it’s not done.’” (PHC Team Member, Implementation, Focus Group 2)
DOMAIN 2: outer setting
Needs and resources of those served by the innovation
“It’s just really exciting to think of the possibilities, and across the continuum of care, the early diagnosis is really important, and how we can help support our families as long as we can at home.” (PHC Team Member, Pre-implementation, Focus Group 1)
“The families were just so appreciative of getting together at the end of our all our testing and talking about it and including their family member … . they’re going home with something to think about and some ideas.” (PHC Team Member, Post-implementation, Workgroup Meeting 3)
External policy and incentives
Another policy barrier was the fact that dementia was not one of the few conditions included in the provincial chronic disease quality improvement program, which mandated implementation of assessment templates for four conditions and provided financial incentives for physicians to complete the templates.“I think what’s important to revisit as well is the ability to use our team to a comprehensive level … if somebody’s not a home care client, that shouldn’t preclude the team being able utilize someone like [home care nurse] to help with the assessment.” (Manager, Implementation, Focus Group 3)
DOMAIN 3: inner setting
Networks and communications
“They [PHC team members] are going about their daily work and daily duties and business which is seeing their patients. Time, scheduling, coordinating to get together for meetings is always a barrier but is overcome when everyone is aware of the benefits—that it will improve their seeing patients and the care they provide.” (PHC Team Member, Post-implementation, Telephone Interview)
Implementation climate
“I was all for it just because I had been seeing lots of people with pre-dementia or dementia and I had seen some less-than-desirable effects from people falling through the cracks because of … practitioners not knowing what to do, or where to go from here.” (PHC Team Member, Pre-implementation, Focus Group 1)
“We’re seeing people in silos; we get a referral, we write a report, we send it back and there is never any discussion between the different people and the family on what we should do.” (PHC Team, Implementation, Focus Group 2)
“The whole driving thing, that’s much better … it’s definitely something we can talk about now, rather than just me having to send that in to [insurance company]. It’s better if we can make a group decision.” (PHC Team Member, Post-implementation, Focus Group 4)
“When these forms were not there, what we did was this. We started to do the physical, history, asking for bloodwork. I waited for the results of the bloodwork and then if there was any imaging needed … . [it took] two to three visits.” (PHC Team Member, Implementation, Focus Group 3)
“I think for multidisciplinary team, I think we’re pretty strong with that; there’s many people that can be involved, that we can pull in. We have OT, we have home care, we have practitioners.” (PHC Team Member, Pre-Implementation, Focus Group 1)
Readiness for implementation
“These meetings do take time from the day, so just to have the support from managers and supervisors you know, to attend the meetings, to be part of the team, and to help develop [the intervention] would definitely [help] them to continue.” (Manager, Post-implementation, Telephone Interview)
“When we don’t have the luxury of something like [specialist Rural and Remote Memory Clinic] and that’s all your focus is, which is awesome, where this team is all trying to put the bits together as a team for the patient. I think we need to reach out and think outside the box and think how can we do this.” (Manager, Implementation, Focus Group 3)
“You have to have somebody that says ‘yes we are willing to do that.’ Or else your project is dead in the water.” (PHC Team Member, Post-implementation, Telephone Interview)
“The facilitators … are all phenomenal at what they do and really they do a lot of the background work that I don’t think a lot of people even recognize.” (PHC Team Member, Post-implementation, Telephone Interview)
“The researchers have been awesome the whole time. And they were great at the beginning, great support, great in communicating, a nice balance of visiting in person and over the phone, in communicating, so they were there, and then … the providers could identify [RaDAR specialists] to help them network and to be able to provide better care … somebody that’s not providing the care but was involved in all the meetings so I think that was good.” (PHC Team Member, Post-implementation, Telephone Interview)
“A lot of the education that we’ve had over the couple of years has been really, really good … I was able to spend a day at the [specialist Rural & Remote] dementia clinic and that was really good. So you take little bits of all that you learn and you can apply them to your setting.” (PHC Team Member, Post-implementation, Focus Group 4)
DOMAIN 4: characteristics of individuals
Self-efficacy
“I think it’s influenced it [care] huge, just to have those tools, and the kind of process by which to follow … we had the misconception that everybody had to have a scan and everybody had to see a neurologist … I think it’s accomplished what I think the initial thing was about -- building capacity. It’s helped you know give us the tools and give us the confidence that yeah, we can do that.” (PHC Team Member, Post-implementation, Telephone Interview)
“We don’t have the capabilities you have at the Rural and Remote Memory Clinic. We just have what we have.” (PHC Team Member, Implementation, Focus Group 2)
“Very beneficial. I loved it. It was a good day.” (PHC Team Member, Post-implementation, Workgroup Meeting 2)
“So I think it’s going very well and it’s just really positive.” (PHC Team Member, Post-implementation, Workgroup Meeting 3)
DOMAIN 5: process
Engaging
“She [nurse practitioner] was really instrumental after [PC-DATA™ developer] gave us the [flow sheet] document and we were kind of living with it and she would be the one who could say ‘can we make these changes with this, I think it would work better if we did this.’ And then she was the one who would go to the other team members and say ‘okay we need to use this, this is how it’s working’ … . definitely the champion right in the clinic.” (Manager, Post-implementation, Telephone Interview)
“She [PHC team facilitator] has been very valuable … she helps organize things, she helps write things up … I think if you didn’t have that then it would be very daunting.” (PHC Team Member, Post-implementation, Telephone Interview)