Literature Collection

BACKGROUND: As healthcare systems transition toward person-centred integrated care (PC-IC), goal-oriented care (GOC) has gained prominence as a conceptual approach to aligning care with what matters most to patients. However, there is limited empirical insight of how GOC is enacted in daily practice and what competencies this requires from providers. This study explores how primary care providers enact GOC in daily practice to inform future training and competency development. METHODS: A focused, team-based ethnographic approach was used, combining non-participant observations with short reflective interviews. Primary care providers were purposively sampled from a cohort who completed interprofessional GOC training, ensuring disciplinary diversity. Data were analysed using thematic analysis to identify behaviours and competencies underpinning GOC in practice. RESULTS: Providing GOC requires competencies beyond knowledge or task-specific skills, and is enacted through contextual, relational, and reflective competencies. Providers showed contextual awareness by linking care actions to patients' lived experiences and personal goals. They built relational trust through open, authentic, and non-hierarchical communication to co-create care decisions with patients. Reflective competence was shown when providers reassessed care decisions in light of patient goals, assumptions, and team input. CONCLUSIONS: These findings highlight the importance of strengthening reflective competencies in training of primary care providers. In practice, this entails supporting providers to reflect on their professional responsibilities, alongside those of the other disciplines they work with in health and social care; and critically engage with assumptions. This reflective capacity is key to embedding GOC in daily practice and aligning care with what truly matters to patients.

BACKGROUND: An academic detailing model has improved self-efficacy of memory clinic clinicians to identify and manage complex behavioral and psychological symptoms in persons with dementia (BPSD). The purpose of this report is to describe a systematic approach to adapting a clinician education program previously delivered in two primary care integrated memory clinics for improving the management of BPSD to also be deliverable outside a memory clinic setting, in generalist primary care clinics. The RE-AIM/PRISM implementation framework guided the approach. METHODS: Application of the RE-AIM/PRISM framework to the academic detailing program for BPSD was mapped. Framework-guided qualitative interviews were completed with experienced (Champion) and inexperienced (Novice) program stakeholders including questions on perceived gaps in clinical care (BPSD management) and barriers and facilitators to the educational model. Inductive and deductive qualitative thematic analytic approaches were used, the latter organized by RE-AIM domains and multi-level context. Convergence or divergence in organized themes by stakeholder experience shaped examination of fit and interactions among domains, components and strategies of the model for pre-implementation adaptations planning for non-memory clinic primary care clinicians. RESULTS: A pragmatic application of the RE-AIM/PRISM framework was completed for collecting qualitative feedback from stakeholders, identifying multi-level contextual barriers and facilitators, and planning adaptations to our clinician education program. A description of the clinician stakeholders, the approach and one example of a clinician and intervention-level theme identified across RE-AIM domains for the program, self-efficacy in the management of BPSD, and resulting planned adaptations were shared. CONCLUSIONS: We provide a novel qualitative application of the RE-AIM/PRISM framework to inform adaptations for an intervention for primary care that incorporates feedback from both current experienced and future inexperienced program stakeholders. This approach can be used to identify multi-level contextual barriers and facilitators to reach, adoption, implementation, and effectiveness of this clinician education programs approach, academic detailing, for future primary care teams.

HealthySteps is an evidence-based, prevention program for families of children ages 0 to 3 integrated into pediatric primary care. Our objective was to synthesize feedback on local implementation of an enhanced HealthySteps+ program from various stakeholder viewpoints to improve implementation. Qualitative data were gathered from HealthySteps+ team members (n = 14), current clinic staff (n = 15), and a focus group of parents serving on the program's advisory committee (n = 7). Responses indicate that the core features of the HealthySteps+ program are consultations about typical and atypical child development, facilitated connections to resources, and parent mental health support. Key challenges to implementing the program include retention of skilled staff to sustain trusting relationships with parents and other providers. Based on these findings, the HealthySteps+ implementation team has increased communication with clinic staff at daily huddles, developed orientation materials for new pediatricians, and offered families additional peer support opportunities.

Background: Shared medical appointments (SMAs) for buprenorphine prescribing are clinical encounters in which multiple patients with opioid problems receive treatment from providers in a group setting. Telehealth, the provision of clinical services remotely using telecommunications technology, is an essential modality for improving access to healthcare when combined with SMAs, especially since the COVID pandemic. Objectives: The current study specifically examined psychological components of telehealth SMAs for buprenorphine prescribing to learn about the benefits and drawbacks of this treatment model. Methods: Data was collected through qualitative interviews with patients (N=10) in a psychiatry addiction medicine clinic. Narrative synthesis using grounded theory was conducted to identify salient themes from the interviews. Results: Findings highlighted the advantages and downsides of telehealth SMA to treat addictive disorders in a digital age: (1) Shared group identity; (2) Decreased stigma around buprenorphine; (3) Benefits of telehealth; (4) Discomfort with group SMA format; (5) Strategies for managing medication side effects; and (6) Enhanced empathy for providers. Several themes corresponded to therapeutic factors identified in group therapy (i.e., installation of hope, universality, imparting information, altruism) and mechanisms theorized in previous SMA research (e.g., combating isolation, disease self-management, feeling inspired by others). Conclusion: Telehealth SMAs for buprenorphine prescribing may be a unique opportunity for patients to receive both ongoing medication management and psychosocial benefits that promote recovery and reduce stigma. The SMA group had shortcomings for some patients, including privacy concerns, fear of judgment from other patients and limited time to discuss individual concerns with providers.

The stepped care model aims to dynamically align the intensity of care with the patients' needs, adjusting mental health interventions accordingly. While stepped up care for mental illness has been widely researched, there is limited evidence on how stepped down care supports recovery after acute mental illness. This JBI qualitative systematic review sought to understand stakeholders' perspectives of stepped care in supporting patients' transitions from acute mental healthcare to community settings. CINAHL, Medline, Embase, PsycINFO and Web of Science were searched, and data were synthesized using the JBI meta-aggregation method. Fourteen studies were included. Themes were patient preference, emotional support, information and education, coordination, access to care, family and friends, continuity and transition, physical comfort, service delivery, health sector, and community setting. Patients expressed the importance of autonomy, with many stakeholders making assumptions about their care. Challenges with existing stepped care programs, include a lack of resources, strained patient relationships with providers, a lack of standardized care, and limited communication. Enhancing the design and delivery of stepped care following acute mental illness could support mental health recovery.

BACKGROUND AND OBJECTIVES: General practice is the most common source of healthcare for people who use methamphetamine. The aim of this study was to explore primary care providers' understandings of access to and service utilisation by this group. METHOD: Semi-structured interviews were conducted with general practitioners, practice nurses and alcohol and other drug service providers from two large towns in rural Victoria. RESULTS: Participants (n = 8) reported that availability (workforce shortages, time, complex clinician-client relationships), acceptability (stigma) and appropriateness of care (skill mix, referral networks, models of care) were associated with access to care for this population. Affordability of care was not perceived to be of concern. DISCUSSION: Availability of care is not enough to ensure utilisation and improved health outcomes among consumers who use methamphetamine. Provision of services to this group and to other substance-using populations requires the right 'skill mix' across and within healthcare organisations.

This paper highlights the need for nursing-sensitive indicators tailored to children and young people with complex and integrated care needs. While nursing plays a pivotal role in influencing care quality for this population, current measures predominantly focus on adult populations, creating gaps that hinder the evaluation of nursing contributions across diverse settings such as acute, community, and home care. We examine the importance of quality care measurement for children and young people with complex and integrated care needs and highlight deficiencies in international measurement systems. The discussion highlights the multidimensional care needs of this vulnerable population and advocates for nursing-sensitive indicators that capture broader outcomes including physical health, functional outcomes, family experience, and family well-being. Also highlighted is, the weak evidence linking process indicators to improved patient outcomes, a focus on negative outcomes, such as mortality, and the lack of theoretical foundations for nursing-sensitive indicators. There is a lack of consensus on what components to measure, definitions of indicators, and appropriate methodologies for the development of nursing sensitive indicators. Donabedian's (1988) structures, processes, and outcomes framework is discussed as well as an overview of adaptations used to improve the quality of indicator sets in a variety of settings. By situating the discussion within the context of children's and young people's nursing, this paper aims to direct future research towards the development of comprehensive indicators that capture the full contribution of nursing to the care of children and young people with complex and integrated care needs. Ultimately, this paper advocates for a standardised, holistic approach to nursing-sensitive indicators for this vulnerable population to improve care quality and overall health and wellbeing for children, young people, and their families.