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Context: At onset of the COVID-19 pandemic, primary care quickly transitioned to the use of virtual care. Although much is known about the challenges and opportunities of virtual care for providers and practices, little remains known about the patient experience with virtual care in primary care. The involvement of patients and other key stakeholders as partners in the research process is crucial to generate relevant findings to guide policy and decision-makers in a way that enhances quality of care and patient outcomes. Objective: Describe a multi-pronged approach to inform a population based, mixed-methods research study investigating patients' experiences with virtual care in Ontario, Canada. Study Design: Mixed-methods--a province-wide survey and descriptive qualitative interviews running in parallel. Our multi-pronged approach engaged Patients, Researchers, Policy makers and other data users throughout the study. I) Patients: We recruited a Patient Advisory Committee through patient advocacy groups and health-oriented organizations, and selected individuals to maximize geographical, gender, and sociocultural variation. II) Professional Organizations: We integrated the Association of Family Health Teams of Ontario, Alliance for Healthier Communities, and Ontario College of Family Physicians as key members of the research team. III) Primary Care Practices: We partnered with primary care practices who were data users. Practices disseminated the survey to their patients. IV) Policy and Decision-Makers: We conducted ongoing consultations with stakeholders from Ontario Health and Ontario Ministry of Health for a reciprocal dynamic that informed the research process and enabled rapid uptake of research findings by key stakeholders. Our multi-pronged process used a mixture of involvement and collaboration models of engagement. Results: 55 interviews were conducted with patients and 534 survey respondents met eligibility criteria. The multi-pronged approach provided success with rapid dissemination of results to inform immediate system and practice-level decisions on the use of virtual care. We produced a comprehensive report for provincial policy and decision-makers, conducted 3 presentations to provincial policy and decisionmakers, provided each participating practice with detailed practice-specific reports, and participated in an invited panel. Conclusions: Patient and stakeholder engagement is a key component to primary care research., Presenters Rachelle Ashcroft, PhD, Simone Dahrouge, PhD, Kiran Saluja, PhD, Simon Lam, BA, [...]

Context: Home visits at the end of life decrease hospitalizations and hospital deaths, which reduces healthcare costs and aligns with most patients' wishes. In addition to family physicians, nurse practitioners (NPs) play a critical role in meeting the rising demand for home and community-based palliative care. However, very few population-level studies have examined practice patterns of NPs delivering home-based end-of-life care and the collaboration between physicians and NPs. Objective: To describe the characteristics and outcomes of patients receiving home-based palliative care provided by physicians and NPs in the last 90 days of life. Study Design and Analysis: Retrospective population-based study with a descriptive analysis of patient characteristics and multivariate logistic regression analyses of end-of- life outcomes controlling for patients' demographics, health, and healthcare use. Setting or Dataset: Healthcare administrative data in Ontario, Canada. Population Studied: Adults 19 years and older who died between January 1, 2018, and December 31, 2019, and received home care in their last 90 days of life (N=103,664). Intervention/Instrument: Receipt of home visits by an NP, physician, or both. Outcome Measures: Receipt of medications for symptoms (e.g., pain, delirium/agitation, and terminal secretion) in the last 3 weeks of life, acute care use in the last 3 weeks of life, and location of death. Results: Over half (56.9%) of the decedents did not receive any visits from an NP or physician; 3.8% received at least 1 visit from an NP (and no physician visits), 34.5% received at least 1 visit from a physician (but no NP visits), and 4.9% received at least 1 visit from each. NP visits were more prevalent among patients living in rural areas. Patients who received at least 1 home visit were less likely to be hospitalized, more likely to have received medications for symptom management, and more likely to experience a community-based death. These associations were strongest when patients received home visits from both NPs and physicians. Results from multivariable regression are forthcoming. Conclusions: The receipt of at least 1 NP or physician home visit at the end of life can significantly reduce acute care use, improve access to symptom management medications, and mitigate hospital-based deaths. Collaboration between NPs and physicians was associated with greater benefits to patients' outcomes., Presenters Amy Ramzy, BHSc, Mary Scott, MSc, Sarina Isenberg, Colleen Webber, Carrie Heer, NP-PHC, MN, Maya Murmann, MSc, HBA, Jennifer Rayner, PhD, Roshanak Mahdavi, Peter Tanuseputro, David Ponka, MD, CCFP, [...]

Context: Community resources are often required in addition to primary care to effectively address a variety of health and social needs. However, access to these resources is influenced by various system and individual level factors. Little is known about the factors that enhance and prevent access to community resources. Objective: To investigate the facilitators and barriers to accessing community resources. Study Design, Intervention, Setting, and Population: A randomized control trial of 326 primary care patients compared the Access to Resources in the Community (ARC) navigation model to the Ontario 211 Community and Social Services Help line in supporting individuals' access to community resources in Ottawa and Sudbury, Ontario (Canada). The patient experience was captured through 32 interviews (24 conducted in English and 8 in French) using a semi-structured approach. Purposeful sampling was used to maximize participant variability. Interviews were recorded, transcribed and analyzed applying a deductive approach with a uniquely developed coding scheme adapted from Levesque et al's 2013 Access to Primary Health Care Framework. Data was coded in QSR NVivo® 9 by two independent coders to ensure reliability and consensus. This analysis focuses exclusively on the facilitators and barriers that patients reported experiencing and does not include the impact of the navigation services on these factors. Results: System level facilitators to access included resources making themselves known through outreach activities, provision of whole-person care, high quality of care, and good follow-up. Individual level facilitators involved patients' autonomy in seeking resources, adequate social support, access to insurance, feeling empowered to access resources and high selfefficacy. System level barriers faced by patients included inadequate advertising of available resources, lack of cultural sensitivity, distance from resources, long wait times, and resources not meeting patient health and social needs. Individual level barriers included limited access and knowledge of technology, poor mental and physical health, lack of transportation, inability to pay, lack of adherence, and low motivation. Conclusion: Strategies to enhance facilitators and address barriers are required to achieve equitable access to community resources. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the relationship between the number of patients under a primary care physician's care (panel size) and primary care quality indicators.Methods: We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management.Results: The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P <.001), 5.9% (P = .01), and 4.6% (P <.001), respectively, with increasing panel size (from 1,200 to 3,900). Eight chronic care indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P <.001) with higher panel size. Increasing panel size was also associated with a 10.8% relative increase in hospitalization rates for ambulatory-care-sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P <.001), and comprehensiveness had a small decrease (P = .03) with increasing panel size.Conclusions: Increasing panel size was associated with small decreases in cancer screening, continuity, and comprehensiveness, but showed no consistent relationships with chronic disease management or access indicators. We found no panel size threshold above which quality of care suffered. [ABSTRACT FROM AUTHOR]

Context: The onset of COVID-19 has required the rapid adoption of virtual services in primary care (PC) practices, and virtual care delivery is likely to continue to some extent post-pandemic. Objective: To understand patient experience with synchronous virtual (telephone (Tel)/Video) appointments and elicit recommendations for its future use. Design: Mixed method, including patient survey co-developed with stakeholders and implemented online Feb-Mar 2021 with large promotional efforts through social media, patient and caregiver organizations, and other networks. We report on the survey results. Eligibility: 1+ virtual encounter in PC. Outcome measures: A) Patient experience scale (12/17 questions for Tel/Video) covering 4 sub-dimensions; B) Access related questions. Questions had 5-point Likert scale items (strongly disagree (-2) to strongly agree (+2)) and were converted into percentage (potential range -100%, +100%) Setting : Ontario, Canada which offers universal coverage for PC visits with no co-payment. Results: 534 eligible respondents (402/18/114 had Tel/Video/both): Females (78%), < 55 years (61%), white (75%), employed (61%), bachelor's degree (74%), family income > 100k (52%). Encounters evaluated were with family physicians (vs other health professionals) for 75%/46% of Tel/Video encounters. A) Patient Experience (Tel/Video) overall score: 75%/78%; Sub-dimensions: technology: 92%/84%, patient-provider relationship: 83%/86%, quality of care: 66%/66%, whole-person care: 43%/53%. Factors associated with a statistically significant(*) > 10% higher overall score in tel and/or video were: non-females: (8%*/14%*), French speaking (13%*/16%*), patient-provider relationship >1 year (16%*/7%), provider age < 50 (5%/15%*), having the choice of appointment time (15%*/21%*). Wanting to show problem to the provider was associated with a lower scores (-23%*/NA). B) Access Respondents overwhelmingly reported that Tel/Video visits reduced time (97%/97%), costs (81%/85%), and was more convenient (91%/91%). The majority wanted Tel (69%) and Video (71%) visits at least as often as in person visits post-covid. Only 5% did not want any future virtual care. Conclusions: Patient experience was largely positive and is influenced by patient/provider factors. Patients and providers may benefit from support/training to optimize care experience. We are now evaluating whether the reasons for visits influences care experience., Competing Interests: Authors report none., (2021 Annals of Family Medicine, Inc.)

Purpose: New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care., Methods: We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management., Results: Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians., Conclusions: The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario's CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality.