Background
Methods
Study setting
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Blended care pathways for primary prevention and screening of chronic disease, including behavioural lifestyle risk factors, as well as cancer surveillance for breast, colorectal, and prostate cancer survivors;
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Screening for poverty, informed by a tool developed by the Centre for Effective Practice for use in diverse primary care settings in Canada [4],
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Visual representations of the care maps (referred to as the “Bubble Diagrams”), which can be used directly with patients as a teaching tool and to assist with agenda setting;
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A patient health survey to capture a detailed prevention and screening history, confidence and readiness to change lifestyle habits, and for cancer survivors, a detailed cancer surveillance history; and
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Prevention Prescription and Cancer Surveillance Prescription templates that summarize the patient’s health status. These prescriptions provide patients and clinicians with a personalized plan aimed at facilitating shared decision making and enabling patients to actively engage in their health.
Participants and recruitment
Data collection
Data analysis
Rigor of study methods
Results
Total # of participants (focus groups) | N = 124 |
Characteristic | No. (%) |
Gender | |
Male | 20 (16%) |
Female | 104 (84%) |
Profession | |
Primary Care Physician | 38 (31%) |
Admin/MOA/clerical staff | 29 (23%) |
Registered Nurse | 16 (13%) |
Clinic manager / coordinator / director | 14 (11%) |
Other clinicians (social worker, pharmacist, dieticians) | 10 (8%) |
Licensed Practical Nurse / Registered Practical Nurse | 9 (7%) |
Nurse Practitioner / Physician Assistant | 6 (5%) |
Family Medicine Residents | 2 (2%) |
Province | |
Alberta | 67 (54%) |
Ontario | 37 (30%) |
Newfoundland & Labrador | 20 (16%) |
Total # of participants (key informant interviews) | N = 17 |
(2 PPs completed a second interview when they left role) | |
Characteristic | |
Gender | |
Male | 2 |
Female | 15 |
Profession | |
Registered Nurse | 3 |
Licensed or Registered Practical Nurse | 5 |
Physician | 2 |
Nurse practitioner | 1 |
Dietician | 1 |
Pharmacist | 1 |
Clinic director | 1 |
Clinic coordinator | 1 |
Clinic medical assistant | 1 |
Kinesiologist | 1 |
Province | |
Alberta | 7 |
Ontario | 5 |
Newfoundland & Labrador | 5 |
Theme 1: Creating a safe environment and building trust with patients
It does take a time investment to do this properly. (…) The one thing about not being rushed is that first of all it allows for not just disclosures but it allows for people to feel comfortable like they are important and that their stories are important. (…) And it allows people the chance to explore their lives without being rushed out the door. Which is not something that we can always offer. [PP, KI008, AB]
- [PP] took the time to listen to what was going on in my life and I didn’t feel rushed. [PP] recognized that mental health is just as important as physical health [Patient, female, AB]- Pleasant, non-judgmental personality. No rush, patience, encouragement. Attainable suggestions [Patient, female, ON]- How open I was. Able to talk about my health issues and the information about myself that I did not realize might be an issue causing some of the problems going on in my life [Patient, male, AB]
We uncover things that even the physician, their primary care provider for years was not even aware of. It just speaks to how valuable it has to be to give the patient the time and to be heard and to explore what they feel is most important to them as opposed to, you know, just the tests that need to be done or just the results that need to be conveyed or just the routine sort of follow-up that is sometimes done in their general care. [PP, KI 012, ON]It’s totally different from the survey they filled out for me and what they’re actually telling me and when I actually met with patients, almost everybody has said: ‘I haven’t wanted to let my doctor down’. So, they haven’t been telling the truth. And specifically, regarding like the alcohol, how much physical activity, how much pain they’re in, (…) they felt like the doctor’s time was too valuable and they didn’t want to disappoint the doctor. [PP, KI007, AB]
Theme 2: Providing personalized health education
[Patients] don’t realize the benefits in having a FIT [fecal immunochemical test] (…) the people that I have met are not aware of the benefits of having the screening done. And I’m finding that I’m spending so much time on education and just talking to them about why. If you don’t want to have this done, it’s 100% the patient’s choice to decline treatment. But they need to be aware of what the benefits are and what the risks are of not having it or having it done. And I don’t think the docs just don’t have the time to do that because they’re trying to see so many patients. [PP, KI007, AB]
- Seeing my risk factors and actual condition on one sheet. Discussing how we will monitor the risk [Patient, female, ON]- Each visit prompts me to discuss and reassess my goals and keeps me up to date with when I need to have screening tests done [Patient, female, NL]
I think some of the things that stood out for me the most is patients that were in their earlier or mid 50s that have either have never gone for bloodwork, have never had their cancer screening done or even just some of those patients that just sometimes just end up falling through the cracks. [PP, KI 015, ON]
We've had a few instances in which we've diagnosed diabetes. Also, some people who have quit smoking. Some people have devised exercise plans which they followed through with. Which is huge, from my perspective anyway. [PP, KI 008, AB]We’ve caught actually three or four people [who] have been diagnosed with pre-diabetes just from BETTER WISE. I have started on actions to prevent diabetes. Catching it before it turns to diabetes. [PP, KI 014, ON]
A lot of patients are coming in and they had a PAP done, say in January. They came in to see their doctor for the results in February but then no one ever told them what the next step was, like, ‘so in how many years do I need it, what’s the recommendation? (…) The feedback I have gotten is this that [the program] is very proactive because they feel that they’re actually part of their healthcare team, not just the healthcare team looking at them. And that seems to be what people want is they want to be part of the health circles that they know, that they’re proactive and they know what’s required for them for care. [PP, KI007, AB]
Theme 3: Non-judgmental empowering of patients
Celebrating the good parts of people. (…) I think it’s common for us as human beings to feel like we’re not improving enough. So, this way we have a prevention project which doesn’t reinforce that feeling. That you are enough. And if you would like to make a plan as you are to move forward, that’s okay, too. [PP, KI 008, AB][This approach] doesn’t impose my ideas and it really helps these people come up with their own idea that they’re less likely to rebel against suggestions and I guess that really does increase compliance (…) The goal setting for me seems to be the biggest impact. [PP, KI 003, AB]
I said, ‘Look, this is no problem. The next time we meet in six months, if you think about something we can set a goal there or if there’s something that you think about later on in a couple of weeks or a month, just give me a call and we can set the goal over the phone.’ So, I’ve really kind of left it open ended that you know, ‘This is not something you have to do, but I am here to help you and support you’. [PP, KI 007, AB][If] they get stuck, I might say ‘can I make some suggestions that have worked for some other people in the past? Let’s make a menu of options and at the end say, maybe after hearing those things there’s something else that occurs to you?’ So, they still always have that option of adding their own idea into the mix. [PP, FG 001, AB]
I’ve had some people even say when they started looking at their goals, they’re all ‘well I can’t go to the new center for swimming but I could probably go to the one on top of the road’. Like they kind of work that out themselves. And again, not a conversation that you’re going to have time to have with your physician. You need somebody to be able to talk to about that. [PP, KI 001, NL]
- [PP] helped me make realistic goals [Patient, female, NL]- Thank you! I have found having someone to develop prevention goals and checking in on my progress to be both rewarding and holds me accountable. [Patient, female, AB]- Setting goals for my health with my prevention practitioner will go a long way for me. I feel like I’m doing this for myself but also have a coach motivating me in the background. (…) If I can maintain the goals I set for myself and confide in my practitioner to help me achieve good health, I will be very happy with myself. It could be a great mechanism for others who want to live healthier lifestyles as well. [Patient, male, ON]
Theme 4: Integrating care for patients
If [patients] haven't had their screening in so many years, whether it be a mammogram or a FIT test or whatever, when I send a note to the doctor, they say ‘Oh yeah, I haven't seen them in a while. That's, probably why’. But I think this is creating an awareness on both sides. You know, for the patient and for the physician [PP, KI 001, NL]
I had one gentleman he would come once a year and get a flu shot. And that was it. And he wouldn't come to the doctor for anything else. And he was very against screening, the fecal occult in particular. Not against it but just did not want to do it, right? So, he hadn't had bloodwork in a long time and he chose to go for some bloodwork after the BETTER WISE appointment. And he was diagnosed with prediabetes. So, he had come back in to have a visit with me as a family health team member for diabetes education. And during that visit he-, I explained to him the new FIT testing that just went live yesterday and now he wants to go, he wants to get that screening done now. So, without the BETTER WISE I don't think he would have ever done it. [PP, KI014, ON]Maybe [the doctors] didn't know the full extent of sort of the challenges that the patients are facing. And so sometimes you uncover a little bit more in terms of how things are, how they're coping at home or sort of their family dynamics or if there's you know maybe they're they've been hesitant about seeking help but they didn't want to tell anyone about their mental health concerns. And so sometimes when you have built that relationship with the client then they actually feel comfortable opening up to you. And so, you have to expand, and it enables me to explore and ask permission ‘Is it OK if I share this with your primary care provider so that we can see what supports are out there for you’? [PP, KI 012, ON]
- I appreciated the contact as I tend to ignore “timelines” – It made me think about where I am vis-à-vis health issues / prevention. The Prevention Practitioner told me about available resources which I found reassuring (and appreciated!) [Patient, female, AB]- [PP] presented plans to improve my well-being and ensured a follow-up visit with my doctor, given my complex conditions. [Patient, male, AB]- Covered a lot about health and what can be done to improve it. (…) It opened my eyes that there is help out there and I am not alone to get healthier [Patient, male, ON]
[PP] will message me if she identifies something that needs to be done, so someone that needs to do screening or is requiring follow-up that hasn’t happened yet. So, it’s been positive in that it takes some of that brain pressure off of me to remember and also drives the visit for a specific focus on that. And I would even say that [PP] is picking things up that I might otherwise have missed, when there is sometimes an exception to the screening. [Physician, KI 017, ON]
“In the seven people [PP] has done for me, already, she picked up on the poverty screen a couple that I had no idea (…) because there’s a space and time for when you’re asking the question and I would have never known to ask the question because they don’t tell you and you wouldn’t guess. And so actually that was tremendously helpful already because [PP] got them dialed into supports and has made a big difference” (Physician, FG 003, AB)