Denis Prud'HOmme

Introduction: We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model.Methods: We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator.Results: Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s).Conclusion: The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients’ access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211).

Context: Access to Resources (ARC) navigation model is an innovative, whole-person, primary care integrated navigation service developed through a multi-stakeholder engagement process that aims to optimize equitable access to health enabling resources (HERs) for primary care patients. Objective: To examine the effectiveness of ARC model against navigation services from the provincial online and telephone Ontario-211 program. Study Design: Mixed method randomized controlled trial Setting: Ottawa and Sudbury. Population: 326 medically stable patients referred by the participating primary care providers, were randomized (1:1 allocation) to ARC/O-211 services. Intervention: ARC navigator offered bilingual services using the “active offer” approach to support patients overcome social barriers to accessing HERs. Patients allocated to the control arm received information on O-211 services. Main Outcome: Resouce/s accessed (defined as used/waitlist/appointment made) Results: 326 patients enrolled (32% Francophones), 237 (73%) completed 3-month questionnaire, and 29 patients were interviewed (28% Francophones). Participants were 62% female, 15% immigrants, 28% university educated, and patients who showed higher social complexity (56% tight/poor financially, 41% lived alone, 68% unmarried, 60% not working). ARC intervention was more effective in supporting patients’ access to resource, compared to O-211 (50% vs 36%; p =0.014) adjusted for patient factors (OR 1.8, 95% CI 1.1 – 2.8). Francophone patients achieved better access compared to Anglophones in both arms (OR 2.0; 95% CI =1.2-3.4). Language concordance between patient’s preferred language for receiving services and language of service received was greater for ARC compared to O-211 (91%/31%). Patients highly valued ARC’s patient-centered approach and reported higher satisfaction (91%/61%) and experience (94%/67%) with the ARC vs O-211 services. Patients expressed gratitude for the ARC navigation support they received, and expressed disappointment that ARC services were time bound. Conclusion: ARC may potentially reduce access gaps across social strata. It can readily be implemented in primary care, and is highly acceptable to patients and providers. We recommend direct referrals of patients to the O-211 services be implemented in primary care EMR systems, and that an ARC like service be integrated into existing O-211 services to support more complex patients achieve access.

Introduction: Soldiers work in various extreme environments, including the High Arctic, where energy requirements are increased compared with temperate climates. Soldiers often do not reach their energy needs with combat rations and face additional challenges to feeding in the Artic, which can hinder the performance. The purpose of this study is to document soldiers’ perception about individual, dietary, and environmental factors influencing intake of combat rations during Arctic field training.Materials and Methods: This qualitative phenomenological study included in-depth semi-structured individual interviews with 16 soldiers of the Canadian Armed Forces participating in the Arctic Operations Advisor training in Yellowknife (Northwest Territories) and Resolute Bay (Nunavut) from January to March 2019. Interviews were audio-recorded, transcribed verbatim, and then coded using a directed content analysis approach. Data were analyzed with NVivo qualitative data analysis software.Results: Five themes related to the individual (personal preferences; mood and morale), the diet (water availability; food variety), or the environment (meal preparation time) were identified. A sixth theme found was related to the diet and the environment (food/water temperature). Soldiers explained food and water were frozen, thus limiting water availability and greatly increasing meal preparation time. Food variety was deemed adequate by some, but others preferred more options. Individual food preferences and soldier mood and team morale could be barriers or facilitators to intake. Overall, the complexity of combat ration intake in the Arctic stemmed from the interaction of factors.Conclusions: Various factors related to the individual, diet, and environment were found to influence intake of combat rations by participating soldiers during Arctic training. Reducing barriers to combat ration consumption by enhancing operational suitability of rations for the Arctic environment could promote dietary intake. Bearing in mind many interrelated factors influenced intake of soldiers, the military would benefit from further assessing which challenges related to intake in the field could be addressed.

Background: Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. Objective: This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. Methods: We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. Results: Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. Conclusions: We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). Trial Registration: ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. International Registered Report Identifier (IRRID): DERR1-10.2196/16966

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Community based health and social resources can help individuals with complex health and social needs. However, there is often a discontinuation of patient care between primary care practices and community resources due to: a lack of physician or patient awareness of available resources; the presence of social barriers; the paucity of means to facilitate patients’ trajectory along the continuum of care; and more broadly, to the difficulties implementing organizational changes in primary care practices already busy providing health care services. Navigation services – where a person is tasked with helping connect patients to community resources – can strengthen continuity of care for patients. The implementation and study of the navigators’ impact is complex and warrants further investigation. Objective: Assess whether the ARC Model is feasible, including its potential to achieve its intended outcomes, and the viability of the evaluation approach. Methods: Describe the protocol of a single arm, prospective, explanatory mixed methods, pre-post design feasibility study, focusing on primary care practice settings with vulnerable populations. Participants include primary care providers, and patients. Results: Enrollment is closed with 82 patients. Navigation services have ended for 69 patients. Conclusions: Multilayered complex issues contribute to a high risk of failing to sustainably implement navigation services, thwarting randomized control trials’ effectiveness at assessing their impact. Undertaking a feasibility study from a conceptually clear and methodologically solid protocol will inform on the acceptability, ease of implementation, quality of integration, practicality and adaptation needs prior to initiating a randomized control trial. Clinical Trial: ClinicalTrials.gov, NCT03105635. Registered 10 April 2017

BACKGROUND Community-based health and social resources can help individuals with complex health and social needs achieve their health goals. However, there is often inadequate access to these resources due to a lack of physician and patient awareness of available resources and the presence of social barriers that limit an individual’s ability to reach these services. Navigation services, where a person is tasked with helping connect patients to community resources, embedded within primary care may facilitate access and strengthen the continuity of care for patients. OBJECTIVE This study aims to describe the protocol to assess whether the implementation of the Access to Resources in the Community (ARC) navigation model (an innovative approach to navigation services) is feasible, including its potential to achieve its intended outcomes, and to assess the viability of the evaluation approach. METHODS The study consists of a single-arm, prospective, explanatory, mixed-methods, pre-post design feasibility study focusing on primary care practice settings with vulnerable populations. Participants include primary care providers and patients. RESULTS Enrollment is closed with 82 patients. Navigation services have ended for 69 patients. CONCLUSIONS The study of an innovative complex intervention requires an adequate assessment of the feasibility of the intended approach during which the potential challenges of the planned intervention and need for its adaptation may be uncovered. Undertaking a feasibility study of the ARC navigation model from a conceptually clear and methodologically solid protocol will inform on the practicality and acceptability of the approach, demand for the services, ease of implementation, quality of integration of the new services within primary care, and practicality and potential for efficacy prior to initiating a randomized controlled trial. CLINICALTRIAL ClinicalTrials.gov NCT03105635; https://clinicaltrials.gov/ct2/show/NCT03105635 (Archived by WebCite at hhttp://www.webcitation.org/75FrwXORl) INTERNATIONAL REGISTERED REPOR RR1-10.2196/11022