Health Teams Advancing Patient Experience Research Articles

Health TAPESTRY Ontario: protocol for a randomized controlled trial to test reproducibility and implementation

BackgroundHealth TAPESTRY (Health Teams Advancing Patient Experience: STRengthening qualitY) aims to help people stay healthier for longer where they live by providing person-focused care through the integration of four key program components: (1) trained volunteers who visit clients in their homes, (2) an interprofessional primary health care team, (3) use of technology to collect and share information, and (4) improved connections to community health and social services. The initial randomized controlled trial of Health TAPESTRY found promising results in terms of health care use and patient outcomes, indicating a shift from reactive to preventive care. The trial was based on one clinical academic center, thus limiting generalizability. The study objectives are (1) to test reproducibility of the established effectiveness of Health TAPESTRY on physical activity and hospitalizations, (2) to test the feasibility of, and understand the contributing factors to, the implementation of Health TAPESTRY in six diverse communities across Ontario, Canada, and (3) to determine the value for money of implementing Health TAPESTRY.MethodsThis planned study is a pragmatic parallel randomized controlled trial with a delayed intervention for control participants at 6 months. This trial will simultaneously assess effectiveness and implementation in a real-world setting (type II hybrid) in six diverse communities across Ontario. Participants 70 years of age and older will be randomized into the Health TAPESTRY intervention or the control group (usual care). Intervention clients will receive an individualized plan of care from an interprofessional care team. The plan will be based on a client’s goals and current health risks identified through volunteer visits. The study’s outcomes are mapped onto the RE-AIM framework, with levels of physical activity and number of hospitalizations as the co-primary outcomes. The main analysis will be a comparison at 6 months.DiscussionIt is important to evaluate the effectiveness and implementation of Health TAPESTRY in multiple communities prior to scaling or widespread adoption.Trial registrationClinicalTrials.gov NCT03397836. Registered on 12 January 2018

Experiences of integrating community volunteers as extensions of the primary care team to help support older adults at home: a qualitative study

BackgroundIncreasing the integration of community volunteers into primary health care delivery has the potential to improve person-focused, coordinated care, yet the use of volunteers in primary care is largely unexplored. Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) is a multi-component intervention involving trained community volunteers functioning as extensions of primary care teams, supporting care based on older adults’ health goals and needs. This study aimed to gain an understanding of volunteer experiences within the program and client and health care provider perspectives on the volunteer role.MethodsThis study used a qualitative descriptive approach embedded in a pragmatic randomized controlled trial. Participants included Health TAPESTRY volunteers, health care providers, volunteer coordinator, and program clients, all connected to two primary care practice sites in a large urban setting in Ontario, Canada. Data collection included semi-structured focus groups and interviews with all participants, and the completion of a measure of attitudes toward older adults and self-efficacy for volunteers. Qualitative data were inductively coded and analyzed using a constant comparative approach. Quantitative data were summarized using descriptive statistics.ResultsOverall, 30 volunteers and 64 other participants (clients, providers, volunteer coordinator) were included. Themes included: 1. Volunteer training: “An investment in volunteers”; 2. Intergenerational volunteer pairing: “The best of both worlds”; 3. Understanding the volunteer role and its scope: “Lay people involved in care”; 4. Volunteers as extensions of primary care teams: “Being the eyes where they live”; 5. The disconnect between volunteers and the clinical team: “Is something being done?”; 6. “Learning… all the time”: Impacts on volunteers; and 7. Clients’ acceptance of volunteers.ConclusionsThis study showed that it is possible to integrate community volunteers into the primary care setting, adding human connections to deepen the primary care team’s understanding of their patients. Program implementation suggestions that emerged included: using role play in training, making volunteer role boundaries and specifications clear, and making efforts to connect volunteers and the primary care team they are supporting. This exploration of stakeholder voices has the potential to help improve volunteer program uptake and acceptability, as well as volunteer recruitment, retention, and training.Trial registrationFor RCT: https://clinicaltrials.gov/ct2/show/NCT02283723, November 5, 2014.

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory

BackgroundMany countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers.MethodsThis study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4 months (June–July 2015) and 12 months (February–March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings.ResultsOverall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program’s purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes.ConclusionsThis study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams.Trial registrationClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered.

Exploration of volunteers as health connectors within a multicomponent primary care-based program supporting self-management of diabetes and hypertension.

Volunteers support health and social care worldwide, yet there is little research on integrating these unpaid community members into primary care. 'Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management' (Health TAPESTRY-HC-DM) integrates volunteer 'health connectors' into a community- and primary care-based program supporting client self-management in Hamilton, Canada. Volunteers supported clients through goal setting, motivation, education and connections to community resources and primary care. This study aimed to create and apply a volunteer program evaluation framework to explore: (a) volunteer training effectiveness (learning online content, in-person training, self-efficacy in role tasks, training overall); (b) feasibility of program implementation (process measures, reflections on client encounters, understanding of volunteer roles/responsibilities, client perspectives on volunteer program); and (c) effects of volunteering on volunteers (health outcomes, self-efficacy, value of volunteering). A concurrent triangulation, mixed-methods design was used. Data were collected in 2016, sources included: volunteer online training quizzes, focus groups, self-efficacy survey, Veterans RAND 12-Item (VR-12) survey, in-person training feedback forms and narratives of client visits; client interviews; and quantitative implementation data. Quantitative data analysis included descriptive statistics, paired samples t tests, and effect size (Cohen's d). Qualitative data used descriptive thematic analysis. Nineteen volunteers and 12 clients participated in this evaluation. Findings demonstrate the volunteer program evaluation framework in action. Online training increased knowledge. In-person training received largely positive evaluations. Self-efficacy was high post-training and higher after volunteering. VR-12 sub-scale means increased descriptively. Volunteers understood themselves as healthcare system connectors, feeling fulfilled with their contributions and learning new skills. They identified barriers including not having the resources and skills of healthcare professionals. Clients found volunteers were a major program strength, appreciating their company and regular goals follow-up. Using a volunteer program evaluation framework generated rich and comprehensive data demonstrating the feasibility of bringing volunteers into primary care.

Pilot randomized controlled trial of a complex intervention for diabetes self-management supported by volunteers, technology, and interprofessional primary health care teams

BackgroundMost health care for people with diabetes occurs in family practice, yet balancing the time and resources to help these patients can be difficult. An intervention empowering patients, leveraging community resources, and assisting self-management could benefit patients and providers. Thus, the feasibility and potential for effectiveness of “Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management” (Health TAPESTRY-HC-DM) as an approach supporting diabetes self-management was explored to inform development of a future large-scale trial.MethodsFour-month pilot randomized controlled trial (RCT), sequential explanatory qualitative component. Participants—patients of an interprofessional primary care team—were over age 18 years, diagnosed with diabetes and hypertension, and had Internet access and one of the following: uncontrolled HbA1c, recent diabetes diagnosis, end-stage/secondary organ damage, or provider referral. The Health TAPESTRY-HC-DM intervention focused on patient health goals/needs, integrating community volunteers, eHealth technologies, interprofessional primary care teams, and system navigation. Pilot outcomes included process measures (recruitment, retention, program participation), perceived program feasibility, benefits and areas for improvement, and risks or safety issues. The primary trial outcome was self-efficacy for managing diabetes. There were a number of secondary trial outcomes.ResultsOf 425 eligible patients invited, 50 signed consent (11.8%) and 35 completed the program (15 intervention, 20 control). Volunteers (n = 20) met 28 clients in 234 client encounters (home visits, phone calls, electronic messages); 27 reports were sent to the interprofessional team. At 4 months, controlling for baseline, most outcomes were better in the intervention compared to control group; physical activity notably better. The most common goal domains set were physical activity, diet/nutrition, and social connection. Clients felt the biggest impact was motivation toward goal achievement. They struggled with some of the technologies. Several participants perceived that the program was not a good fit, mostly those that felt they were already well-managing their diabetes.ConclusionsHealth TAPESTRY-HC-DM was feasible; a large-scale randomized controlled trial seems possible. However, further attention needs to be paid to improving recruitment and retention. The intervention was well received, though was a better fit for some participants than others.Trial registrationClinicalTrials.gov, NCT02715791. Registered 22 March 2016—retrospectively registered.

Perceptions of older adults in Ontario, Canada on the implementation and impact of a primary care programme, Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY): a descriptive qualitative study

ObjectivesThe aim of the study was to explore the perceptions of older adults on the implementation and impact of Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY), a multicomponent...

Combining volunteers and primary care teamwork to support health goals and needs of older adults: a pragmatic randomized controlled trial.

The Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes. We conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY (n = 158) or control (n = 154). Trained community volunteers gathered information on people's goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. There were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation [SD] 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 [95% confidence interval (CI) 0.84 to 2.19]). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio [OR] 0.44 [95% CI 0.20 to 0.95]). Health TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration: ClinicalTrials.gov, no. NCT02283723.

Managing multimorbidity in primary care.

[See related article at [www.cmaj.ca/lookup/doi/10.1503/cmaj.181173][2]][2] KEY POINTS In linked research, Dolovich and colleagues present the results of a pragmatic randomized controlled trial examining the Health TAPESTRY (Health Teams Advancing Patient Experience: Strengthening Quality)

A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults.

BackgroundHealthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person’s life that centers on meeting a person’s health goals and needs will result in optimal aging.Methods/designThis is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person’s life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months.DiscussionEvidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system’s transformation of person-focused, primary care for older adults.Trial registrationClinicalTrials.gov NCT02283723 Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0407-5) contains supplementary material, which is available to authorized users.