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BackgroundWith large volumes of longitudinal data in electronic medical records from diverse patients, primary care is primed for disruption by artificial intelligence (AI) technology. With AI applications in primary care still at an early stage in Canada and most countries, there is a unique opportunity to engage key stakeholders in exploring how AI would be used and what implementation would look like.ObjectiveTo identify the barriers that patients, providers, and health leaders perceive in relation to implementing AI in primary care and strategies to overcome them.Design12 virtual deliberative dialogues. Dialogue data were thematically analyzed using a combination of rapid ethnographic assessment and interpretive description techniques.SettingVirtual sessions.ParticipantsParticipants from eight provinces in Canada, including 22 primary care service users, 21 interprofessional providers, and 5 health system leaders.ResultsThe barriers that emerged from the deliberative dialogue sessions were grouped into four themes: (1) system and data readiness, (2) the potential for bias and inequity, (3) the regulation of AI and big data, and (4) the importance of people as technology enablers. Strategies to overcome the barriers in each of these themes were highlighted, where participatory co-design and iterative implementation were voiced most strongly by participants.LimitationsOnly five health system leaders were included in the study and no self-identifying Indigenous people. This is a limitation as both groups may have provided unique perspectives to the study objective.ConclusionsThese findings provide insight into the barriers and facilitators associated with implementing AI in primary care settings from different perspectives. This will be vital as decisions regarding the future of AI in this space is shaped.

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems. [ABSTRACT FROM AUTHOR]

Background: Although mobile health (mHealth) apps are increasingly being used to support patients with multiple chronic conditions (multimorbidity), most mHealth apps experience low interaction and eventual abandonment. To tackle this engagement issue, when developing an mHealth program, it is important to understand the social-behavioral factors that affect patients' use behavior. Objective: The aim of this study was to explore the social and behavioral factors contributing to patients' use behavior of an mHealth app called the electronic Patient-Reported Outcome (ePRO). The ePRO app supports goal-oriented care delivery in interdisciplinary primary care models. Methods: A descriptive qualitative study was used to analyze interview data collected for a larger mixed methods pragmatic trial. The original 15-month trial was conducted in 6 primary care teams across Ontario, Canada, between 2018 and 2019. The eligibility criteria for patients were being aged ≥60 years with ≥10 visits within the previous 12 months of study enrollment. For this analysis, patients were classified as long-term or short-term users based on their length of use of the ePRO app during the trial. The Social Cognitive Theory by Bandura was used to categorize social-behavioral factors that contributed to patients' decision to continue or discontinue using the app. Results: The patient-provider relationship emerged as a key factor that shaped patients' experiences with the app and subsequent decision to continue using the app. Other factors that contributed to patients' decision to continue using the app were personal and social circumstances, perceived usefulness, patients' previous experience with goal-related behaviors, and confidence in one's capability. There was an overlap of experience between long- and short-term app users but, in general, long-term users perceived the app to be more useful and their goals to be more meaningful than short-term app users. This observation was complicated by the fact that patient health-related goals were dynamic and changed over time. Conclusions: Complex patients' use behavior of a goal-supporting mHealth app is shaped by an array of sociobehavioral factors that can evolve. To tackle this dynamism, there should be an emphasis on creating adaptable health technologies that are easily customizable by patients and able to respond to their changing contexts and needs. [ABSTRACT FROM AUTHOR]

Background: Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions. Objective: To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions. Methods: This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1. Results: In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions. Conclusions: This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes. [ABSTRACT FROM AUTHOR]

Background: eHealth technologies for self-management can improve quality of life, but little is known about whether the benefits gained outweigh their costs. The electronic patient-reported outcome (ePRO) mobile app and portal system supports patients with multiple chronic conditions to collaborate with primary health care providers to set and monitor health-related goals. Objective: This study aims to estimate the cost of ePRO and the cost utility of the ePRO intervention compared with usual care provided to patients with multiple chronic conditions and complex needs living in the community, from the perspective of the publicly funded health care payer in Ontario, Canada. Methods: We developed a decision tree model to estimate the incremental cost per quality-adjusted life year (QALY) gained for the ePRO tool versus usual care over a time horizon of 15 months. Resource utilization and effectiveness of the ePRO tool were drawn from a randomized clinical trial with 6 family health teams involving 45 participants. Unit costs associated with health care utilization (adjusted to 2020 Canadian dollars) were drawn from literature and publicly available sources. A series of sensitivity analyses were conducted to assess the robustness of the findings. Results: The total cost of the ePRO tool was CAD $79,467 (~US $ 63,581; CAD $1733 [~US $1386] per person). Compared with standard care, the ePRO intervention was associated with higher costs (CAD $1710 [~US $1368]) and fewer QALYs (-0.03). The findings were consistent with the clinical evidence, suggesting no statistical difference in health-related quality of life between ePRO and usual care groups. However, the tool would be considered a cost-effective option if it could improve by at least 0.03 QALYs. The probability that the ePRO is cost-effective was 17.3% at a willingness-to-pay (WTP) threshold of CAD $50,000 (~US $40,000)/QALY. Conclusions: The ePRO tool is not a cost-effective technology at the commonly used WTP value of CAD $50,000 (~US $40,000)/QALY, but long-term and the societal impacts of ePRO were not included in this analysis. Further research is needed to better understand its impact on long-term outcomes and in real-world settings. The present findings add to the growing evidence about eHealth interventions' capacity to respond to complex aging populations within finite-resourced health systems. [ABSTRACT FROM AUTHOR]

Background: Digital health technologies have been proposed to support hospital-to-home transition for older adults. The COVID-19 pandemic and the associated physical distancing guidelines have propelled a shift toward digital health technologies. However, the characteristics of older adults who participated in digital health research interventions to support hospital-to-home transitions remain unclear. This information is needed to assess whether current digital health interventions are generalizable to the needs of the broader older adult population. Objective: This rapid review of the existing literature aimed to identify the characteristics of the populations targeted by studies testing the implementation of digital health interventions designed to support hospital-to-home transitions, identify the characteristics of the samples included in studies testing digital health interventions used to support hospital-to-home transitions, and create recommendations for enhancing the diversity of samples within future hospital-to-home digital health interventions. Methods: A rapid review methodology based on scoping review guidelines by Arksey and O'Malley was developed. A search for peer-reviewed literature published between 2010 and 2021 on digital health solutions that support hospital-to-home transitions for older adults was conducted using MEDLINE, Embase, and CINAHL databases. The data were analyzed using descriptive statistics and qualitative content analysis. The Sex- and Gender-Based Analysis Plus lens theoretically guided the study design, analysis, and interpretation. Results: A total of 34 studies met the inclusion criteria. Our findings indicate that many groups of older adults were excluded from these interventions and remain understudied. Specifically, the oldest old and those living with cognitive impairments were excluded from the studies included in this review. In addition, very few studies have described the characteristics related to gender diversity, education, race, ethnicity, and culture. None of the studies commented on the sexual orientation of the participants. Conclusions: This is the first review, to our knowledge, that has mapped the literature focusing on the inclusion of older adults in digital hospital-to-home interventions. The findings suggest that the literature on digital health interventions tends to operationalize older adults as a homogenous group, ignoring the heterogeneity in older age definitions. Inconsistency in the literature surrounding the characteristics of the included participants suggests a need for further study to better understand how digital technologies to support hospital-to-home transitions can be inclusive. [ABSTRACT FROM AUTHOR]

Martens and colleagues' paper "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study," offers an in-depth examination of integrated care policy efforts in Belgium. A key finding in this case study was that political fragmentation proved too great an obstacle for integration efforts. In this commentary, I draw on the organizational behaviour and integrated care literatures to suggest how meso-level mechanisms related to sensemaking, distributive leadership, and evaluation could help overcome policy (or macro) level challenges like those experienced in Belgium. The commentary also suggests we need to consider and address both the process and normative challenges in these transformation efforts. [ABSTRACT FROM AUTHOR]

Introduction: Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation. Description: This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels. Discussion: The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care. Lessons learned: By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift. [ABSTRACT FROM AUTHOR]

Introduction: In a world where the prevalence of chronic conditions is increasing, the importance of a strong primary care system cannot be underestimated. One of the suggested strategies for person-centered integration of care is to explicitly focus on the patients' goals; or in other words a focus on goal-oriented care (GOC). To make GOC more applicable, it is important to build an understanding on how it should be provided in practice. Therefore, it is vital to not only learn from literature, but foremost of primary healthcare professionals themselves on how they operationalize GOC. Aims, objectives, theory or methods: This study explored how primary healthcare professionals operationalize GOC in their practice. Therefore, professionals were recruited in different primary care settings in Ottawa (Canada), Vermont (USA), and Flanders (Belgium). A two-step approach of a deductive and inductive analysis was used to analyze the in-depth interviews. Firstly - with the aim to validate the literature - the theoretical framework that emerged from the concept analysis on GOC, was used as a lens for the deductive analysis. Secondly, an inductive thematic analyses following Sundler was performed to expand the theoretical knowledge with insights from practice. All interviews were audio taped and transcribed verbatim. Highlights or results or key findings: When looking at the data trough a deductive lens, the theoretical framework - presenting a stepwise approach of GOC with the phases of goal-elicitation, goal-setting, and goal-evaluation and the patients' needs and preferences as a common thread - could be confirmed. However such a linear approach in one-on-one interactions, as emerged from the literature, could not be determined. The dynamic and iterative character of GOC should be more emphasized. The inductive analysis revealed three main themes that were not described in the concept analysis: 1) involving the patients, 2) interprofessional collaboration, and 3) the use of tools or guidance. The participants involved their patients by communicating in a constructive dialogue and informing them about their health status. Interprofessional collaboration allowed the participants to bring all different expertise - who could support the patients to work towards their goals - together. Finally, participants used tools to support the process of eliciting and setting patients' personal goals. Conclusions:The findings validated the theoretical framework emerged from the literature. Besides this validation, we learn from practice that professionals made use of tools to support goalelicitation, goal-setting, and to prepare interprofessional meetings. All this with the overall aim to encourage patients to actively take part in their care. Implications for applicability/transferability, sustainability, and limitations: This study allowed us to go beyond the theoretical knowledge of GOC and build on experiences of primary healthcare professionals from different disciplines, settings, and countries. This is needed to gain a full understanding on GOC and explore the elements that go along with providing GOC. [ABSTRACT FROM AUTHOR]

AimThis qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows.BackgroundThe Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows.MethodsOver a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015.FindingsKey issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change. [ABSTRACT FROM PUBLISHER]

Introduction: Information and communication technologies (ICTs) are recognized as a critical enablers of integrated primary care to support patients living with multiple chronic conditions. Although ICTenabled integrated primary care hold promises to support complex patients through team-based and continued care, critical implementation factors regarding what ICTs are available and how they enable the integrated model are yet to be mapped in the literature. This scoping review addresses this current knowledge gap in order to identify opportunities and gaps to help guide future implementation of the ICT-enabled integrated primary care model. Aims Objectives Theory or Methods: Objective: This study systematically scoped the literature on ICT-enabled integrated healthcare delivery models for patients with complex care needs to identify which technologies have been used in integrated primary care settings. Method: The Arksey and O'Malley method was used to guide this scoping review. Four electronic medical databases were accessed: MEDLINE, EMBASE, CINAHL, PsycINFO, collecting studies published between January 2000 - December 2020. Identified peer-reviewed articles were screened in two stages: 1) title and abstract screening; and 2) full-text review. Relevant studies were charted and analyzed using the Rainbow Model of Integrated Care and the eHealth enhanced Chronic Care model. Highlights or Results or Key Findings: A total of 46,736 articles were screened at the title and abstract level of which 37 met the eligibility criteria of the review. A large number of the studies originated from North America (62.5%) and used a quantitative method as a study design (51%). 70% of the studies used technology to enable professional and clinical level integration through clinical information sharing among a multidisciplinary team or across multiple organizations. There were fewer studies focused on the organization or system-level integration of care through technologies. A range of technologies was used in these models including web-based platforms, mobile applications, and telemonitoring being the most frequently used. Multiple implementation factors were identified that could enable or hinder the successful implementation of technologies including patient health/digital literacy and training; provider workload, attitudes, and beliefs; usability and interoperability of technologies; and system factors such as incentives, technical and human resource support. Conclusions: To maximize technological benefits in primary care, the literature suggests system-level support and favourable implementation climate are required. Future research is needed to explore how to integrate technologies at an organization and system level to create a health system that is wellprepared to optimize technologies to support patients. Implications for applicability/transferability sustainability and limitations: The study findings benefit system leaders in showing the implementation factors and the types of technologies they need to consider when applying technology to optimize their integrated care models. Due to time constraints, gray literature was excluded in the review which may limit the findings of the study. [ABSTRACT FROM AUTHOR]

Introduction: Discussions of integrated care have ranged in focus from large-scale health system transformations, to discrete interventions intended to enhance local continuity of care. Beyond these variations in scale and focus, literature on integrated care has used a variety of conceptual frameworks to explain various activities and elements necessary to achieve integrated care. Existing frameworks have helped to advance research and practice; yet the complexity of changing practice required to achieve integrated care across the policy, organizational, and clinical levels complicates efforts to represent or implement these innovations in straightforward ways. Aims Objectives Theory or Methods: In this paper, we present a novel strategy for conceptualizing integrated care as developing through a series of milestones observable at the organizational level. Based on analysis of four integrated care organizational case studies in Canada and New Zealand, we outline how this approach to conceptualizing integrated care both resolves the tension of crossing the macro, meso, and micro levels of analysis, and generates new practical insights to guide policy and practice. Methods consist of qualitative interviews, observation, and document analysis across cases, and qualitative data were analyzed temporally to identify milestones as indicated by participants over time. Highlights or Results or Key Findings: We define a milestone as the occurrence of a salient event that is perceived by respondents to facilitate or disrupt efforts towards the development of integrated care. We synthesize these events at the organizational level, suggesting that the organizational level of analysis is the most appropriate level to represent the significance of these milestones. Our analysis identified six categories of milestone: (1) Strategic relational milestones, referring to building relationships between stakeholders. (2) Strategic process change milestones, referring to efforts to improve quality in practice. (3) Structural (intra-organizational) milestones, referring to changes in organizational structure. (4) Structural (inter-organizational) milestones, referring to changes in the legal, operational, or leadership structures that facilitate relationships between organizations. (5) Environmental milestones, referring to changes in the social or natural environment. (6) Political milestones, referring to changes in the control and allocation of resources. Conclusions: Our results generate a new conceptual framework for understanding the achievement of integrated care as occurring through a series of milestones. This approach enhances the focus on achieving integrated care "in the wild", in the actual environments in which leaders, clinicians, policymakers, patients, and caregivers work to implement integrated care. Implications for applicability/transferability sustainability and limitations: Our model emphasizes two practical points. First, that there is no single series of sequential steps that must be taken to achieve integrated care. Second, that policy efforts to support integrated care ought to encourage organizations and their collaborators to work toward milestones that facilitate the development of integrated care. [ABSTRACT FROM AUTHOR]

Background: Goal-oriented care is being adopted to deliver person-centered primary care to older adults with multimorbidity and complex care needs. Although this model holds promise, its implementation remains a challenge. Digital health solutions may enable processes to improve adoption; however, they require evaluation to determine feasibility and impact.Objective: This study aims to evaluate the implementation and effectiveness of the electronic Patient-Reported Outcome (ePRO) mobile app and portal system, designed to enable goal-oriented care delivery in interprofessional primary care practices. The research questions driving this study are as follows: Does ePRO improve quality of life and self-management in older adults with complex needs? What mechanisms are likely driving observed outcomes?Methods: A multimethod, pragmatic randomized controlled trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrollment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the midpoint and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data were analyzed using qualitative description and framework analysis methods.Results: Recruitment challenges resulted in fewer sites and participants than expected; of the 176 target, only 142 (80.6%) patients were identified as eligible to participate because of lower-than-expected provider participation and fewer-than-expected patients willing to participate or perceived as ready to engage in goal-setting. Of the 142 patients approached, 45 (32%) participated. Patients set a variety of goals related to self-management, mental health, social health, and overall well-being. Owing to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however, the intervention group, ePRO plus usual care (mean 15.28, SD 18.60) demonstrated a nonsignificant decrease in quality of life (t24=-1.20; P=.24) when compared with usual care only (mean 21.76, SD 2.17). The ethnographic data reveal a complex implementation process in which the meaningfulness (or coherence) of the technology to individuals' lives and work acted as a key driver of adoption and tool appraisal.Conclusions: This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinical settings, dynamic goal-oriented care process, and readiness of provider and patient participants.Trial Registration: ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954. [ABSTRACT FROM AUTHOR]

Introduction: Community based primary health care (CBPHC) organizations are critical providers of integrated care for complex patients. Exemplar cases exist, but efforts to scale up and spread successful models continue to face major challenges. While scale and spread has become a popular topic, there are still significant gaps in our understanding of what components or activities of integrated care models should and can be spread from one locale or jurisdiction to the next, and to what degree we allow for local adaptation of those activities. Theory/Methods: To address this identified gap we developed a survey for managers and providers in CBPHC organizations that allows respondents to specify which activities require local adaptation for their scale up and spread and which need to be more standardized. The survey builds on learning from the iCOACH project, a study analyzing 9 integrated models of community-based primary health care (CBPHC) in Ontario, Quebec and New Zealand. To develop the survey we carried out 1) a targeted literature review identifying existing reviews of key activities of integrated CBPHC; 2) a workshop session with CBPHC managers and providers to validate the approach and aim of the survey; 3) mapping the findings of the literature review to coded qualitative data from the iCOACH study to validate identified activities; and 4) validation and initial testing of a pilot survey. Results: The literature review yielded 32activities of integrated CBPHC, each of which were found to be present in iCOACH case studies. The workshop session was run in January 2018 with 17 participants. from 3 case study sites. Participants identified all activities as important to models of integrated care; but reported varying needs for standardization or adaptation for specific elements. Discussion from the workshop was used to refine survey wording and structure. The draft survey was tested with managers and providers in CBPHC organizations using cognitive interviewing techniques to refine the instrument. Small scale testing of the survey will be undertaken with staff in 2 CBPHC sites. Discussion: Multiple methods were used to validate the key activities of integrated care; however, the ways in which these activities are implemented in scale and spread efforts are nuanced and context dependent. Conclusions: The survey tool developed will help us to unpack these nuances and contextual influences, with the aim of clarifying core versus peripheral activities of integrated care at different stages of the scale and spread process (e.g., whether early or later stages of adoption). Lessons learned: One critical finding from the symposium was that conceptualizations of fidelity and adaptation are widely varied and needs to be clearly stated in any assessment. Ensuring clarity of these terms was central to the development of this survey. Limitations: While the survey has strong content validity due to our development methodology, additional work will be required to test reliability and other components of validity prior to wider adoption of the survey. Suggestions for future research: Following testing in Canadian settings, we plan to deploy the survey to CBPHC organizations internationally. [ABSTRACT FROM AUTHOR]

Introduction: Digital solutions are increasingly central in the delivery of integrated care models. Adopting co-design methods is one means to ensure usability of solutions. Although user-centered co-design is routinely embraced during software design, the challenges of eliciting needs from users with complex continuing health conditions is not well addressed by existing methodologies. We develop an approach to user-engagement for patients with complex care needs resulting in the creation of the electronic Patient-Reported Outcomes (ePRO) tool to support interprofessional primary care delivery. Theory/Methods: User-centered co-design principles were integrated with interpretive descriptive qualitative research methods to capture user priorities, experiences, feedback and expectations. Phase 1 involved a needs assessment conducted through user focus groups and interviews. Phase 2 engaged user groups to iteratively design a prototype, and Phase 3 undertook a usability study prior to evaluation (currently underway). Iterative analysis consistent with qualitative interpretive description were used to generate findings at each phase. Results: In Phase 1, 14 patients and caregivers participated in focus groups, followed by interviews with primary care providers, and experts in the field of primary care, complex care, and digital health solutions. Findings analyzed through interpretive descriptive methods linked user needs to technology solutions, generating a prototype with four key features (symptom monitoring, medication management, educational materials, hospital access notification). Modified cognitive walk-throughs with patients, caregivers and providers were used in Phase 2 to refined the prototype, resulting in the removal of education and medication management features, and revisions to the symptom monitoring and hospital access notification features. The Phase 3 usability assessment included in-depth focus groups and interviews with 11 patients and 6 providers who used the tool for four weeks. Qualitative data yielded surprising results regarding the feasibility and usefulness of ePRO resulting in a significant pivot in functionality from a tool that monitored symptoms, to one that supported personalized goal-setting and monitoring. Discussion: Adopting rigorous qualitative methods alongside iterative technology development resulted in a tool that was very different than initially anticipated, but more useful and meaningful to end-users. While many critique user-centered co-design for resulting in status quo solutions, our application of qualitative analysis techniques with a team of multi-disciplinary researchers and developers allowed us to be purposively disruptive and innovative, while still ensuring meaningfulness to users. Conclusions: End users adopt technology that is perceived as valuable and meaningful. Working with unique populations required adoption of rigorous qualitative methods alongside designthinking approaches as a means to effectively elicit user needs. Lessons learned: True user-centred co-design means setting aside pre-conceived notions about what a technology solution should look like so we can really hear the challenges of users and innovate meaningful solutions. Limitations: Each phase of the study had its own set of limitations. Small user groups and participants were engaged in each phase which may limit generalizability. Adoption of theoretical frameworks at each phase helps address this gap. Suggestions for future research: Bringing forth foundational theoretical frameworks like interactionism can help inform design through better understand how users derive meaning from interacting with technology. [ABSTRACT FROM AUTHOR]

Background: Health systems globally are still struggling to roll out system-wide models of integrated health and social care. While pockets of innovation exist they often remain stuck within single jurisdictions, or, worse yet, never expand beyond the pilot phase. Researchers, providers, managers and health system leaders could learn from the experiences of other countries facing similar challenges, however lack a standardized comparative method to take findings from different contexts and relate them back to their own. Aims and Objectives: This workshop will walk participants through one approach to conducting comparative program summaries originally developed by the Commonwealth Fund in the United States and applied to cases of integrated care across three different countries. The template captures key components of integrate care including client access and eligibility, care coordination and transition processes, information management systems, self-management and caregiver supports, program maturity, measures of success, and evaluation. Audience members will learn about the strengths, weaknesses, opportunities and challenges of adopting this type of comparative work, drawing on the examples presented by a panel of international researchers who have applied the Commonwealth Fund template on integrated care to their original studies SUSTAIN (Netherlands) and iCOACH (Canada, New Zealand). Participants will have the opportunity to go through the exercise of adopting the approach. Participants will be broken up into small groups and given short-form templates that can be applied to their own models of integrated care. Groups will go through the exercise and engage in a facilitated discussion on: 1) whether it can be applied to their contexts; 2) what they can learn from this type of exercise to improve and build on existing or new models; and 3) what is missing and what are the challenges when we try to learn across borders. Target audience: This workshop will be of interest to providers, manager and decision-makers seeking to learn from other examples as they adopt, grow, or spread their own models of care. Researchers will also benefit from this workshop as we tackle the methodological and conceptual challenges of complex comparative case analysis, using a case summary templates as a starting point. Learnings/Take away: Participants of this workshop will learn: How to apply a standardized template to analyze their local contexts. Methods to share knowledge across international borders as a means to further their programs and models of care The values and challenges in engaging in cross-national comparative case analysis. [ABSTRACT FROM AUTHOR]

Introduction: While integrated care programs are proliferating around the world, rigorous measurement and evaluation of the intended and unintended effects of these programs are rare outside of the context of specific research programs. There are a number of reasons for the lack of evaluation including implementation without regard to measurement and evaluation, a lack of funding for evaluation activity, and challenges associated with measurement and evaluation in complex interventions. As a result, most research on integrated care is descriptive including case studies that most often summarize what was implemented, in some cases how it was implemented, but far less often what outcomes were achieved. Approach: We describe an evaluation framework for integrated care. It includes multiple components of evaluation (implementation, reporting and feedback, methods and measures) and a host of supplementary tools for measuring successful implementation of integrated care. The broad approach is to use rapid-cycle realist-informed evaluation methodology inclusive of implementation science, person-centred evaluation and comparative-effectiveness methodology. The approach to evaluation adds value and must be adaptable to local variations in models and organizational approaches to integrating care. Evaluation is framed into four components: Implementation: The evaluation of integrated care must first assess the implementation of new models of delivery, including description of the policy and organizational context of providers. Drawing from approaches taken including the Consolidated Framework for Implementation Research, evaluation is best begun parallel with the implementation of new models of integrated care allowing for early successes and challenges or barriers to be identified. Program operational monitoring: Second, programs themselves need to set out key measure of performance. A logic model for program implementation may be a particularly useful way to ensure that the program design will enable desired outcomes and ensure the essential component of the logic model are measured. Patient-centred assessment: The third major component of evaluation is patient-centred measurement including patient reported outcome and patient reported experience measures. Ultimately, patients themselves are the best target for measurement of integrated care. We will address essential domains for measurement of patient and caregiver outcomes and patient and caregiver experience. Outcome evaluation: Finally outcome evaluation is an essential activity. While the most rigorous form of outcome evaluation might involve experimental designs, the focus here is primarily on quasi-experimental approaches. Conclusion: This presentation describes a comprehensive framework for realist-informed rapidcycle evaluations for integrated care programs. The framework is used to evaluate integrated care. Requirements for Implementation of Evaluation will also be discussed. [ABSTRACT FROM AUTHOR]

Background: Care coordination is central in models of integrated care. Goal-oriented care is one approach that supports care coordination for multimorbid and complex patients by tailoring shared care plans to patient-identified goals rather than disease-specific targets. However, providers struggle with the adoption of goal-oriented care. Personal values have been found to influence provider behaviour in care delivery. It is possible that personal values may be a mechanism to drive the adoption of goal-oriented care. This work aims to understand the personal values of providers in the adoption of goal-oriented care. Methods: This is a sub-study of an international comparative case study of three primary healthcare sites that have implemented goal-oriented care in Ghent (Belgium), Ottawa, (Canada), and Vermont, (United States). A secondary analysis of 17 semi-structured interviews from the Vermont case site was conducted using inductive thematic analysis. The Vermont case study is situated within an integrated care setting. At this site, providers come from various disciplines and work in collaboration across organizations. Findings: Preliminary findings demonstrated that providers delivering goal-oriented care valued 'putting the patient at the centre', providing care in a holistic manner to understand the 'whole person', which could best be supported through team-based care. These values were often linked to beliefs around the importance of addressing the social determinants of health to improve health outcomes of patients. While most providers shared these values, they told different stories regarding how they came to these beliefs, which related to their education and training experiences. Community-based providers including social workers and mental health providers were introduced to the concepts of social determinants early in their professional training and reported personcentredness to be a core value of their profession. Alternatively, physicians and providers trained in medical models reported a shift in their values from problem-oriented towards personcentredness. Specific team-based training supported the adoption of core values like personcentredness. Discussion: Despite differences in disciplines and organizations, participants demonstrated similar values. These perceived difference in values appear to trace back to the model of training in postsecondary education that providers were trained under. However, with additional training on goal oriented care, shifts in values appear to be possible as participants were aligned in the values they held that support goal-oriented care. Another value that supported the adoption was a belief in team-based care for their patients. In practice, this was reinforced by working with interdisciplinary teams and an increasing presence of integration in their work environment. Conclusion: Across different disciplines and organizations, participants strongly valued personcenteredness, understanding the whole person, and team-based care. There is an opportunity to utilize structured training in goal-oriented care for providers to have aligned values to support its adoption. Lessons learned: Common values among interdisciplinary teams seem to support the adoption of goal-oriented care. Structured training in goal-oriented care appears to lead to providers having common values. Future research: The analysis will expand to other case study sites to compare and contrast the provider values working in other primary healthcare settings in different contexts. [ABSTRACT FROM AUTHOR]

Introduction: There are currently multiple integrated care IC models and pilots developed to enhance collaborative care delivery for older adults living with complex health and social needs. Technology innovations are increasingly embedded in the delivery of IC for this population. These include, electronically-delivered: information communication, shared-care planning, early risk identification, decision support, self-management support and remote monitoring. However, at various stages of implementation, there are common setbacks that influence the adoption and spread of these technologies and overall IC delivery. The objective of this systematic review is to examine the following questions: 1 Across different implementation stages of IC for older adults with complex needs, what are the key enablers of technology adoption; 2 how do these factors interact to influence successful technology adoption across various levels of IC including at the: individual, provider, team, organizational and across care settings. Theory/Methods: A detailed search strategy was developed, and conducted in following databases: Medline/PubMed, EMBASE, PsychINFO, CINAHL and Scopus. When articles described barriers or challenges that emerged from the implementation of technology in IC, they were systematically recorded. Following a multilevel thematic analysis, these statements were mapped against a combination of two frameworks: 1- the Consolidating Framework for Research Implementation CFIR; 2- the Fit between Individuals Task and Technology framework FITT Results: Preliminary results of this systematic review found that technologies were predominantly implemented to enhance integration at the provider-teams level, followed by at the organizational level. The most frequently reported influencers of adoption were related to the providers' knowledge and perceptions of the technology, and how it impacted their ability to perform their responsibilities. This was followed by the technology characteristics; particularly its seamlessness or disruptiveness to the existing systems of work. As well as how adaptive and responsive the technology was to the goals and needs of the: older adults, providers, organization and the system. Factors such as organizational and system leadership, environmental culture and the ability to engage key players in the co-design and implementation of technologies were also key influencers. Conclusions key findings: These early findings highlight the need to tailor technological innovations to the IC setting, as well as the importance of considering change management strategies to enhance the system readiness and responsiveness to change. Supporting stakeholders before and during the processes of implementing IC technologies will increase their effectiveness in being flexible and adaptive to system changes. Limitations: The results presented are based on preliminary findings, however, an extensive systematic review is underway. A significant limitation is that the review did not deeply examine older adult and caregiver factors that could influence the implementation of technology in IC. A comprehensive systematic review and qualitative analysis will further examine this necessary dimension of technology implementation. Suggestions for future research: Results of the review will be used to inform the development of a tool that assesses the cross-sectoral capability of adopting technologies that support IC for older adults living with complex needs. [ABSTRACT FROM AUTHOR]