Simone Dahrouge

Background: Patient portals (PPs) are digital healthcare programs providing patients with access to their electronic health records with features aiding patients in managing their care. Although PPs are now widely used in primary care (PC), the desirability of its features is less known. Aim: This study aims to describe the current and anticipated use of PP features and the socio-demographic profile of PP users accessing these features. Methods: A cross-sectional survey of patient and caregiver experiences with virtual care in PC in Ontario, Canada, was conducted from December 2022 to March 2023. A survey section captured use/anticipated use of PP features: ‘communicating with practice’, ‘viewing records’, ‘entering record information’, ‘receiving practice information’, and ‘scheduling appointments’. We report on respondents with/without PP access and their use/anticipated use of PP features, and analyzed associations between respondent socio-demographic data and the current use of a number of PP features using Pearson chi-square test. Findings: A total of 970 responses (743 patients (P) and 227 caregivers (C)) were obtained with respondents having PP access (P:57%; C:62%) and indicating using all (P: 43%; C:45%), some (P:55%; C:52%), or no (P: 2%; C:4%) PP features. For those with PP access, age (65+ years (14%) compared to <65 years (1%)), employment status (unemployed (6%) compared to employed (1%)), and language at home (non-English (9%) compared to English (1%)) were significantly associated with not using any PP features (percentages represent those not using any PP feature). Our findings provide insights into equity aspects to be considered for future PP implementation.

Individuals face multifaceted barriers to accessing community resources, which can significantly impact their ability to obtain necessary support and services. This study examines barriers and enablers to access community resources among primary care patients and explores the interplay between individual- and system-level factors that influence access to resources. In this qualitative study, we conducted 32 semi-structured interviews with primary care patients who participated in a social prescribing trial that compared two navigation services: ARC (patient-centered longitudinal support) vs. Ontario-211 (free 24-hour helpline service) in two regions, Ottawa and Sudbury, in the province of Ontario, Canada. We conducted thematic data analysis with a deductive/inductive hybrid approach, employing Levesque’s theoretical framework for access to health that examines the various system and individual level factors influencing access to healthcare services. At the system level, various systemic barriers encompassing broader organisational, structural, and policy-related elements influenced patients' access to community resources (outreach, availability, location, costs and accommodations for patient needs and preferences). These factors directly interacted with various patient-level factors (awareness of needs, ability to seek support, to reach resources and to pay for those, their physical and mental health, motivation, and confidence to engage in care) to determine access. Our findings highlight individual- and system-level barriers and enablers for accessing community resources among socially complex primary care patients with multiple unmet needs. As governments and organizations in Canada are increasingly investing in community-based services to address adverse social determinants of health (SDH), an upstream approach that reduces both systemic and individual-level barriers to access is warranted. ClinicalTrials.gov Identifier NCT03451552 registration date 15th Dec 2017.

Résumé La prescription sociale est une approche globale qui agit sur les déterminants sociaux de la santé. « Accès aux ressources communautaires » (ARC) est un programme de prescription sociale novateur aux services bilingues qui offre un point d’entrée unique pour les besoins en matière de santé et de services sociaux et qui permet d’apporter des changements dans les lieux de pratique dans le but d’aider les fournisseurs de soins primaires à mobiliser leurs patients, grâce à un intervenant-pivot non clinicien qui aide les patients à accéder aux ressources communautaires pertinentes. L’équipe du programme ARC a créé une trousse d’outils de prescription sociale qui contient des conseils pratiques sur l’établissement, la mise en oeuvre et l’évaluation de programmes de prescription sociale ainsi que sur le suivi des progrès. Les quatre guides du programme ARC sont facilement adaptables à divers milieux de pratique et de recherche.

Social prescribing (SP) embodies a comprehensive approach to addressing the social determinants of health. Access to Resources in the Community (ARC) is an innovative SP program offering bilingual services that involves a single point of entry for health and social needs and introduces practice changes to assist primary care providers in engaging patients, along with a nonclinical lay navigator who supports patients in accessing relevant community resources. The ARC team has created a SP toolkit offering practical guidance for setting up, implementing, monitoring the progress of and evaluating SP programs. The four ARC guides can be easily customized for application in diverse practice and research settings.

Background: Action on the social determinants of health is important to strengthen primary health care and promote access among underserved populations. We report on findings from stakeholder consultations undertaken at one of the Canadian sites of the Innovative Models Promoting Access-to-Care Transformation (IMPACT) program, as part of the development of a best practice intervention to improve access to primary health care. The overarching objective of this qualitative study was to understand the processes, barriers, and facilitators to connect patients to health enabling community resources (HERs) to inform a patient navigation model situated in primary care. Methods: Focus groups and interviews were conducted with primary care physicians, and community health and social service providers to understand their experiences in supporting patients in reaching HERs. Current gaps in access to primary health care and the potential of patient navigation were also explored. We applied Levesque et al., (2013) access framework to code the data and four themes emerged: (1) Approachability and Ability to Perceive, (2) Acceptability and Ability to Seek, (3) Availability and Accommodation, and Ability to Reach, and (4) Appropriateness. Results: Determinants of access included patient and provider awareness of HERs, the nature of the patient-provider relationship, funding of HERs, integration of primary and community care services, and continuity of information. Participants’ perspectives about the potential scope and role of a patient navigator provided valuable insight for the development of the Access to Resources in the Community (ARC) navigation model and how it could be embedded in a primary care setting. Conclusion: Additional consultation with key stakeholders in the health region is needed to gain a broader understanding of the challenges in caring for primary care patients with social barriers and how to support them in accessing community-based primary health care to inform the design of the ARC intervention.

Background: The expansion of the Patient-Centred Medical Home model presents a valuable opportunity to enhance the integration of team-based mental health services in primary care settings, thereby meeting the growing demand for such services. Understanding the organizational context of a Patient-Centred Medical Home is crucial for identifying the facilitators and barriers to integrating mental health care within primary care. The main objective of this paper is to present the findings related to the following research question: "What organizational features shape Family Health Teams’ capacity to provide mental health services for depression and anxiety across Ontario, Canada?" Methods: Adopting a constructivist grounded theory approach, we conducted interviews with various mental health care providers, and administrators within Ontario’s Family Health Teams, in addition to engaging provincial policy informants and community stakeholders. Data analysis involved a team-based approach, including code comparison and labelling, with a dedicated data analysis subcommittee convening monthly to explore coded concepts influencing contextual factors. Results: From the 96 interviews conducted, involving 82 participants, key insights emerged on the organizational contextual features considered vital in facilitating team-based mental health care in primary care settings. Five prominent themes were identified: i) mental health explicit in the organizational vision, ii) leadership driving mental health care, iii) developing a mature and stable team, iv) adequate physical space that facilitates team interaction, and v) electronic medical records to facilitate team communication. Conclusions: This study underscores the often-neglected organizational elements that influence primary care teams’ capacity to deliver quality mental health care services. It highlights the significance of strong leadership complemented by effective communication and collaboration within teams to enhance their ability to provide mental health care. Strengthening relationships within primary care teams lies at the core of effective healthcare delivery and should be leveraged to improve the integration of mental health care.

Objectives Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death. Methods We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit. Results Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both. Conclusions Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients’ preferences—emphasising the importance of NPs and physicians’ role in supporting people near the end of life.

BACKGROUND: Action on the social determinants of health is important to strengthen primary health care and promote access among underserved populations. We report on findings from stakeholder consultations undertaken at one of the Canadian sites of the Innovative Models Promoting Access-to-Care Transformation (IMPACT) program, as part of the development of a best practice intervention to improve access to primary health care. The overarching objective of this qualitative study was to understand the processes, barriers, and facilitators to connect patients to health enabling community resources (HERs) to inform a patient navigation model situated in primary care. METHODS: Focus groups and interviews were conducted with primary care physicians, and community health and social service providers to understand their experiences in supporting patients in reaching HERs. Current gaps in access to primary health care and the potential of patient navigation were also explored. We applied Levesque et al., (2013) access framework to code the data and four themes emerged: 1) Approachability and Ability to Perceive, 2) Acceptability and Ability to Seek, 3) Availability and Accommodation, and Ability to Reach, and 4) Appropriateness. RESULTS: Determinants of access included patient and provider awareness of HERs, the nature of the patient-provider relationship, funding of HERs, integration of primary and community care services, and continuity of information. Participants’ perspectives about the potential scope and role of a patient navigator provided valuable insight for the development of the Access to Resources in the Community (ARC) navigation model and how it could be embedded in a primary care setting. CONCLUSION: Additional consultation with key stakeholders in the health region is needed to gain a broader understanding of the challenges in caring for primary care patients with social barriers and how to support them in accessing community-based primary health care to inform the design of the ARC intervention.

There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents. To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations. A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening. We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the “reach” of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered. Realist reviews can help guide the development of locally adapted primary health care interventions.

Background: Electronic patient portals are online applications that allow patients access to their own health information, a form of asynchronous virtual care. The long-term impact of portals on the use of traditional primary care services is unclear, but it is an important question at this juncture, when portals are being incorporated into many primary care practices. Objective: We sought to investigate how an electronic patient portal affected the use of traditional, synchronous primary care services over a much longer time period than any existing studies and to assess the impact of portal messaging on clinicians’ workload. Methods: We conducted a propensity-score–matched, open-cohort, interrupted time-series evaluation of a primary care portal from its implementation in 2010. We extracted information from the electronic medical record regarding age, sex, education, income, family health team enrollment, diagnoses at index date, and number of medications prescribed in the previous year. We also extracted the annual number of encounters for up to 8 years before and after the index date and provider time spent on secure messaging through the portal. Results: A total of 7247 eligible portal patients and 7647 eligible potential controls were identified, with 3696 patients matched one to one. We found that portal registration was associated with an increase in the number of certain traditional encounters over the time period surrounding portal registration. Following the index year, there was a significant jump in annual number of visits to physicians in the portal arm (0.42 more visits/year vs control, P<.001) but not for visits to nurse practitioners and physician assistants. The annual number of calls to the practice triage nurses also showed a greater increase in the portal arm compared to the control arm after the index year (an additional 0.10 calls, P=.006). The average provider time spent on portal-related work was 5.7 minutes per patient per year. Conclusions: We found that portal registration was associated with a subsequent increase in the number of some traditional encounters and an increase in clerical workload for providers. Portals have enormous potential to truly engage patients as partners in their own health care, but their impact on use of traditional health care services and clerical burden must also be considered when they are incorporated into primary care.