Background
Methods
Aim
Design
Setting and participating primary care sites
Audit
Feedback and focus groups
Analysis
Findings
Description of the participants taking part in the focus groups
Site | 1011 | 1021 | 1031 | 1041 | 1053 | 1062 | 1074 | 1082 | Total |
---|---|---|---|---|---|---|---|---|---|
Family physicians | 15 | 4 | 2 | 3 | 1 | 4 | 3 | 2 | 34 |
Nurse practitioners | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 0 | 5 |
Nurses | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 7 |
Other healthcare professionals | 0 | 0 | 0 | 0 | 2 | 2 | 0 | 4 | 8 |
Managers | 1 | 0 | 0 | 0 | 2 | 0 | 0 | 1 | 4 |
Administrative staff | 0 | 0 | 0 | 1 | 0 | 3 | 0 | 1 | 5 |
Total | 18 | 6 | 2 | 6 | 7 | 11 | 4 | 9 | 63 |
First sub-objective: Describe what audit results elicited more discussion from the participants
101 | 102 | 103 | 104 | 105 | 106 | 107 | 108 | N of sites | |
---|---|---|---|---|---|---|---|---|---|
Referrals to external memory clinics | √ | √ | √ | √ | √ | √ | √ | √ | 8 |
Cognitive testing | √ | √ | √ | √ | √ | √ | √ | √ | 8 |
Caregiver’s needs | X | √ | √ | √ | √ | √ | √ | √ | 7 |
Diagnosis | X | X | √ | √ | √ | √ | √ | √ | 6 |
Number of contacts / visits | X | √ | √ | √ | √ | X | √ | √ | 6 |
Quality of follow-up | √ | √ | X | X | √ | √ | √ | √ | 6 |
Alzheimer’s society | X | √ | √ | √ | √ | √ | √ | X | 6 |
Dementia medications | √ | X | √ | √ | √ | X | √ | √ | 6 |
Functional status | √ | X | √ | X | √ | X | √ | √ | 5 |
Driving assessment | X | √ | √ | X | √ | X | √ | √ | 5 |
Weight assessment | X | √ | √ | X | √ | X | X | √ | 4 |
KAP scores | X | √ | X | X | X | √ | X | √ | 3 |
Prescription of antipsychotics | X | X | √ | √ | X | X | √ | X | 3 |
Prescription of anticholinergics | X | X | X | X | X | X | √ | √ | 2 |
Home care services | X | X | X | X | X | X | √ | X | 1 |
Evaluation of BPSD | X | X | X | X | X | X | X | X | 0 |
N of results | 5 | 9 | 11 | 8 | 11 | 7 | 13 | 12 |
Second sub-objective: Describe the participants’ insights on the factors that explain audit results
Organizational factors that explain the primary care sites’ audit results
Human resources and expansion of nurses and other health professionals’ role
In embedded-assessor sites, where a nurse or other healthcare professional performed cognitive assessments, the participants explained their audit results in general by the contribution these assessors made throughout the care process: from diagnosis to follow up. When discussing the diagnosis process, participants reported that the presence of the embedded assessors improved the timeliness of services and was perceived as an essential support for the adequate management of dementia:[The clinicians from the collaborative memory clinic] do all the heavy lifting and give me advice and it certainly changes the way. Whereas, before I referred them to [external resources]. […] The quality of information I'm getting is much better than what we've had previously, more timely, and more cognitively-based. - Site 107
Not all participants benefitted from human resources equally, especially in rural settings.Generally, most people come through. So, they'll have the cognitive testing with [the nurse], while the caregiver sits with the social worker to do that caregiver interview […] So, they're timed. And then, we come together as a group to discuss the results. – Site 107
Alternatively, participants, especially in multisite clinics (e.g., 105 and 106), explained that the presence of these human resources, especially dementia-specific resources such as the embedded-assessor or the collaborative memory clinic, also generated a high demand of referrals from family physicians, hindering the quality follow-up or their audit results in general. In consequence, they reported, the wait times for diagnosis or follow-up evaluation suffered. The participants added that this led some clinicians to make multiple competing referrals, to collaborative memory clinic, embedded-assessors, and to external memory clinics, to obtain timely access to services: “Some people [refer] to both [collaborative memory clinic or external memory clinic], and they’re hoping whichever is first. It becomes an issue.” – Site 106.Because of our [rural] location, I will say it to you: as a nurse practitioner in the office, I'm there three days a week, that's all the funding we have, our nurse is also there three days a week, so she's half-time, right? So, if we had her four days a week, you know, there would be more opportunity for her to take on some more projects. – Site 103
Clear and organized links with health and community services
However, participants from rural communities reported a lack of access to these community services resources and long waiting lists due to higher proportion of persons living alone: “[We have more people living alone in our region] because we’re so rural. There may be a lot of people who don’t have family around to help support […] Although we do have trouble with continuity and accountability.” - Site 107.The [Alzheimer Society] will fax [patient data] over to me and I will have to scan them into the EMR [electronic medical records]. They are using clinical judgement as to whether or not they feel that it is something that the physician should be made aware of. So, they won't always send it, but they do send it if they feel anything is pertinent and relevant. […] The social worker on our team is with the Alzheimer society.” – Site 105
Clear roles and support from external memory clinics
When discussing audit results as they relate specifically to referrals to external memory clinics, participants reported a lack of information and suboptimal communications:I think in that kind of situation, there is some assumptions that [the external memory clinic] is also connecting them with the Alzheimer's society. Patients are going from the country to the city to go to [the external memory clinic], the Alzheimer's society is in the city, you know. – Site 103
Alternatively, participants reported that the presence and proximity of well-established external memory clinics were driving higher referrals, prompted by the persons with dementia directly:I really didn't get as good information as I'd hoped from the [external memory clinic]. […] So, when we started up our [collaborative memory clinic], the quality of the information is just that much superior to the information I'd been getting previously. – Site 107
Often the patient or provider ask about it. They know that memory clinics are available in this area. They love the quality of them. I think it's fairly well-known in the community. And they ask [for it], as soon as they hear we are going toward the dementia diagnosis, [they say]: ‘I need to go there and get the best treatment’, you know. – Site 104
Clinicians’ factors that explain the primary care sites’ audit results
Perceived competency and practices with regards to the care of persons with dementia in primary care
However, when discussing their audit results as it relates to managing dementia medications, participants expressed doubts and felt inadequately supported and uncomfortable doing it themselves and preferred referring patients to external memory clinics:Especially because we have a big senior's population and many of our physicians also work in long term care, or complex continuous care, or the rehab unit, the hospital. That is a really big part of their practice and they have probably developed competencies around those areas. And so they feel comfortable managing that piece, like making the diagnosis. – Site 105
When discussing making the diagnosis and managing dementia medications, the participants also reported that this could be influenced by an aging population in their clinical practice or changed due to patients moving from their practice to another one. Participants also reported how this could lower their confidence in making diagnosis and managing dementia medications:Each drug, you think, they might have all kinds of side effects and so it was very difficult to make a decision. And to be honest, I very rarely know because of quality of back-up that we have locally. I just find it much easier to sit back long enough […] Sitting back, letting the experts carry on is a good idea. – Site 104
When participants discussed their audits results as they relate to referrals to external memory clinics, they reported referring to obtain additional clinical guidance, where doubts persisted after their assessment or for more complex cases, reflecting good practice: “That must have been like: ‘I think this person has dementia, do you agree?’. It wasn’t like: ‘what’s going on with this person?’ […] It was confirming the diagnosis.” – Site 107.I was practicing outside of [the region], I didn't have the numbers of geriatric patients that I have out here. So, my practice now is very geriatric-heavy and so I am starting […] doing like the testing and stuff for us. So, I'm starting to start prescribing but I must say that, even me, I have been referring a fair amount to the [external memory clinic] because I just haven't prescribed any of those meds for years […]. – Site 104
Attitudes toward dementia care in primary care
In addition, participants reported negative attitudes toward making a diagnosis as in they perceived a diagnosis had more dramatic consequences due to their rural situation:I have hesitation with the medicine because the effect of this is not so great: side effects are great, and the evidence that it's going to stop the process is very small. So, if a person in my practice is put on medication, it's because the [external memory clinic] says “Yes, they qualify”. So, I kind of let them manage the meds although I always ask question because face it, we need better drugs for it. – Site 103
Finally, when discussing their audit results on referrals to community services and external memory clinics, participants reported that some family physicians in their site kept referring to external memory services because they did not see the added value of the collaborative memory clinic and kept referring to well established and trusted external memory clinics: “I feel like some of our physicians […] don’t feel the [collaborative memory clinic] people are specialists per se. They don’t feel that, perhaps, they are any more trained than they are.” – Site 105.And to be quite honest, because Alzheimer's and dementia is such a devastating diagnosis in the rural area: you have to move, you have to sell your car, you have to sell your house, your family has to come picking at your fortune, right? It's such a devastating diagnosis. I tend to not make that diagnosis myself. […] I have a big problem telling people they have Alzheimer's. […] Because it's a big game changer out where we live. There is no coming back. […]. – Site 103
Third sub-objective: Describe the solutions proposed by the participants to improve dementia care in primary care
Financial incentives to support dementia care in primary care in general (organizational solution)
So, if a nurse does a cognitive test because her salary comes from the family health team, but she does cognitive tests and does care on one of my patients, I can’t bill any funding to that because the government already paid her salary to do that. – Site 102
Clear pathway across dementia care services, including within their primary care site as well as with external memory clinics and community services (organizational solution)
This idea has been already implemented successfully in some sites where many services are already available and referred to it as a “triage system” (Site 105) in a referral form. These pathways, the participants suggested, would support links with community services and external memory clinics to improve quality of follow-up and referrals to memory clinics.So, why couldn't each of the clinics, so the [collaborative memory clinic], the [external memory clinics], give a criterion to the physicians and nurse practitioners to say like an algorithm. So, if your patient presents with A, B and C, they go to the [28] memory clinic. If they present [with E, D, and F], they go to [external memory clinic]. – Site 106
Improve chart documentation and use of prompts in patients’ charts (organizational solution)
Training for dementia in primary care, especially for management of dementia medications (clinician solution)
In addition, the participants suggested that training could happen through the exchange of expertise among family physicians within their site, akin to the idea of a community of practice.For me, it would probably be more around the medications, and you know, what to follow-up on and how often we have to. […] The medication monitoring - to get me more comfortable dealing with that. Like I don't think it's the diagnosis part. – Site 104
The other issue is if you have a physician champion, you know, how do you find someone who’s going to be engage in each group, who has the time to do that, because they also have their own practice usually and I would think that that would be, that could be a challenge in a lot of groups, there may be some groups where they’re fortunate and have a particular physician who has a keen interest in doing that but I think there’s going to be a lot of groups where you’re going to have trouble finding someone who’s going to take on that role. – Site 102Or another way to do that is to raise the knowledge and the capacity, the competency of all physicians and nurses, and NPs. – Site 101