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BackgroundPatient-centred interventions to help patients with multimorbidity have had mixed results.AimTo assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.Design and settingMixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.MethodPatients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention.ResultsA total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.ConclusionOverall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.

OBJECTIVE The purpose of this review is to describe how health service and delivery systems support health equity and to identify strategies and indicators being used to measure health equity. INTRODUCTION It is widely acknowledged that a population health and equity approach is needed to improve the overall health of the population. The health service and delivery system plays an important role in this approach. Despite this, system transformation to address health inequities has been slow. This is due, in part, to the lack of evidence-based guidance on how health service and delivery systems can address and measure health equity integration. Most studies focus on health equity integration in the public health sector at a provincial or national level, but less is known about integration within the health service and delivery system. More information is needed to understand how that transformation is occurring, or could occur, to make a meaningful contribution toward improving population health outcomes. INCLUSION CRITERIA This scoping review will identify studies that describe the strategies and indicators that health service and delivery systems are using to integrate health equity and how progress is measured. Evidence from qualitative, quantitative, mixed method studies, and gray literature will be included. METHODS This review will be conducted in accordance with JBI methodology for scoping reviews. A comprehensive search strategy, developed with a librarian scientist, will be used to identify relevant sources. Titles, abstracts, and full texts will be evaluated against inclusion criteria. Information will be extracted by two independent reviewers. Data will be synthesized and presented narratively, with tables and figures where appropriate.

Canadian and other healthcare systems are adopting primary care models founded on multidisciplinary, team-based care. This paper describes the development and use of a new tool, the Team Assessment of Self-Management Support (TASMS), designed to understand and improve the self-management support teams provide to patients with chronic conditions. Team Assessment of Self-Management Support captures the time providers spend supporting seven different types of self-management support (process strategies, resources strategies, disease controlling strategies, activities strategies, internal strategies, social interactions strategies, and healthy behaviours strategies), their referral patterns and perceived gaps in care. Four unique features make TASMS user-friendly: it is patient-centred, it uses provider-level data to create a team profile, it has the ability to be tailored to needs (diagnosis and visit type), and visual presentation of results are quickly and intuitively understood by both providers and planners. Currently being used by providers and planners in Nova Scotia, scaling up will allow more widespread use.

IntroductionAssessing and measuring patients’ chronic condition self-management needs are critical to quality health care and to related research. One in three adults around the world live with multiple chronic conditions. While many patient-reported measures of self-management have been developed, none has emerged as the gold standard, and all have one or more of the following limitations: (1) they fail to measure the different domains of self-management important to patients, (2) they lack sufficient specificity to support patient-centred care or identify the specific components of self-management interventions that work and/or (3) they lack suitability for patients with multiple chronic conditions.Methods and analysisThe Patient-Reported Inventory of Self-Management of Chronic Conditions (PRISM-CC) is being developed to overcome these shortcomings. It will measure respondents’ perceived success (or difficulty) in self-managing seven domains important to patients. The protocol has three phases. Phase 1 is conceptual model development and item generation. Phase 2 is assessment of the relevance and understanding of items by people with chronic conditions. Phase 3 is item analysis, dimensionality assessment, scaling and preliminary validation of the PRISM-CC using an online survey of people with chronic conditions (n~750). The expected completion date is early 2021.Ethics and disseminationThis study will adhere to the Canadian Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans. Ethics approval for all phases has been obtained from the Nova Scotia Health Authority Research Ethics Board. Once completed, the PRISM-CC will be made available for research and healthcare at minimal to no cost.

Objectives There is an urgent need for healthcare providers and healthcare systems to support productive interactions with patients that promote sustained health behaviour change in order to improve patient and population health outcomes. Behaviour change theories and interventions have been developed and evaluated in experimental contexts; however, most healthcare providers have little training, and therefore low confidence in, behaviour change counselling. Particularly important is how to integrate theory and method to support healthcare providers to engage in behaviour change counselling competently. In this article, we describe a general training model developed from theory, evidence, experience and stakeholder engagement. This model will set the stage for future evaluation research on training needed to achieve competency, sustainability of competency, as well as effectiveness/cost-effectiveness of training in supporting behaviour change. Design and Methods A framework to support competency based training in behaviour change counselling is described in this article. This framework is designed to be integrative, sustainable, scalable and capable of being evaluated in follow-up studies. Results and Discussion Effective training in behaviour change counselling is critical to meet the current and future healthcare needs of patients living with, or at risk of, chronic diseases. Increasing competency in establishing change-based relationships, assessing and promoting readiness to change, implementing behaviour modification and addressing psychosocial issues will be value added to the healthcare system.

Introduction: Timely, precise, and relevant communication between hospital-based clinicians and primary care physicians post-discharge (DC) ensures quality transitions, thereby reducing patient safety incidents and preventing readmission. At the present time there is limited knowledge of elements of quality or methods to score the quality criteria in the context of DC summaries. The Nova Scotia Health Authority, a provincial health system responsible for the delivery of services in a small Canadian province, embarked on a system-level approach to the standardization of DC summaries in an effort to improve quality and safety at care transitions from hospital to primary care. Materials and Methods: A comprehensive literature review to retrieve items relevant to quality in DC summaries, retrospective audit of charts, a consensus development process, and, finally, validation of a scoring tool were conducted in order to develop a quality scoring tool for DC summaries. Results: Relevant items were identified through the literature review and consensus development process. Corresponding definitions that were established assisted the development of the quality criteria, which were subsequently used to score the quality of DC summaries in our organization. Conclusion: The scoring tool developed through this work will be applied to help us gain a more in-depth understanding of quality in DC summaries and support the development of suitable education and quality processes in the health authority that can best support safe care transitions for patients.

Background Recent evidence shows that patient engagement is an important strategy in achieving a high performing healthcare system. While there is considerable evidence of implementation initiatives in direct care context, there is limited investigation of implementation initiatives in decision-making context as it relates to program planning, service delivery and developing policies. Research has also shown a gap in consistent application of system-level strategies that can effectively translate organizational policies around patient and family engagement into practice. Methods The broad objective of this initiative was to develop a system-level implementation strategy to include patient and family advisors (PFAs) at decision-making points in primary healthcare (PHC) based on wellestablished evidence and literature. In this opportunity sponsored by the Canadian Foundation for Healthcare Improvement (CFHI) a co-design methodology, also well-established was applied in identifying and developing a suitable implementation strategy to engage PFAs as members of quality teams in PHC. Diabetes management centres (DMCs) was selected as the pilot site to develop the strategy. Key steps in the process included review of evidence, review of the current state in PHC through engagement of key stakeholders and a co-design approach. Results The project team included a diverse representation of members from the PHC system including patient advisors, DMC team members, system leads, providers, Public Engagement team members and CFHI improvement coaches. Key outcomes of this 18-month long initiative included development of a working definition of patient and family engagement, development of a Patient and Family Engagement Resource Guide and evaluation of the resource guide. Conclusion This novel initiative provided us an opportunity to develop a supportive system-wide implementation plan and a strategy to include PFAs in decision-making processes in PHC. The well-established co-design methodology further allowed us to include value-based (customer driven quality and experience of care) perspectives of several important stakeholders including patient advisors. The next step will be to implement the strategy within DMCs, spread the strategy PHC, both locally and provincially with a focus on sustainability.

Background Understanding and addressing the needs of frail persons is an emerging health priority for Nova Scotia and internationally. Primary healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not standard practice and, in general, there is a lack of awareness about how to identify and respond to frailty. A web-based tool called the Frailty Portal was developed to aid in identifying, screening, and providing care for frail patients in PHC settings. In this study, we will assess the implementation feasibility and impact of the Frailty Portal to: (1) support increased awareness of frailty among providers and patients, (2) identify the degree of frailty within individual patients, and (3) develop and deliver actions to respond to frailtyl in community PHC practice. Methods This study will be approached using a convergent mixed method design where quantitative and qualitative data are collected concurrently, in this case, over a 9-month period, analyzed separately, and then merged to summarize, interpret and produce a more comprehensive understanding of the initiative’s feasibility and scalability. Methods will be informed by the ‘Implementing the Frailty Portal in Community Primary Care Practice’ logic model and questions will be guided by domains and constructs from an implementation science framework, the Consolidated Framework for Implementation Research (CFIR). Discussion The ‘Frailty Portal’ aims to improve access to, and coordination of, primary care services for persons experiencing frailty. It also aims to increase primary care providers’ ability to care for patients in the context of their frailty. Our goal is to help optimize care in the community by helping community providers gain the knowledge they may lack about frailty both in general and in their practice, support improved identification of frailty with the use of screening tools, offer evidence based severity-specific care goals and connect providers with local available community supports.

PURPOSE To measure the effectiveness of a 4-month interdisciplinary multifaceted intervention based on a change in care delivery for patients with multimorbidity in primary care practices. METHODS A pragmatic randomized controlled trial with a mixed-methods design in patients aged 18 to 80 years with 3 or more chronic conditions from 7 family medicine groups (FMGs) in Quebec, Canada. Health care professionals (nurses, nutritionists, kinesiologists) from the FMGs were trained to deliver the patient-centered intervention based on a motivational approach and self-management support. Primary outcomes: self-management (Health Education Impact Questionnaire); and self-efficacy. Secondary outcomes: health status, quality of life, and health behaviors. Quantitative analyses used multi-level mixed effects and generalized linear mixed models controlling for clustering within FMGs. We also conducted in-depth interviews with patients, family members, and health care professionals. RESULTS The trial randomized 284 patients (144 in intervention group, 140 in control group). The groups were comparable. After 4 months, the intervention showed a neutral effect for the primary outcomes. There was significant improvement in 2 health behaviors (healthy eating with odds ratios [OR] 4.36; P = .006, and physical activity with OR 3.43; P = .023). The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results. CONCLUSIONS Quantitatively, this intervention showed a neutral effect on the primary outcomes and substantial improvement in 2 health behaviors as secondary outcomes. Qualitatively, the intervention was evaluated as positive. The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.

IntroductionCanadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but little evidence to support or refute this. The goal of this study is to inform primary care planning by: (1) identifying values and preferences shaping the practice intentions and choices of family medicine residents and early career PCPs, (2) comparing practice patterns of early-career and established PCPs to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of PCPs) or period effects (changes over time across all PCPs) and (3) integrating findings to understand the dynamics among practice intentions, practice choices and practice patterns and to identify policy implications.Methods and analysisWe plan a mixed-methods study in the Canadian provinces of British Columbia, Ontario and Nova Scotia. We will conduct semi-structured in-depth interviews with family medicine residents and early-career PCPs and analyse survey data collected by the College of Family Physicians of Canada. We will also analyse linked administrative health data within each province. Mixed methods integration both within the study and as an end-of-study step will inform how practice intentions, choices and patterns are interrelated and inform policy recommendations.Ethics and disseminationThis study was approved by the Simon Fraser University Research Ethics Board with harmonised approval from partner institutions. This study will produce a framework to understand practice choices, new measures for comparing practice patterns across jurisdictions and information necessary for planners to ensure adequate provider supply and patient access to primary care.

Background Frailty is associated with multi-system deterioration, and typically increases susceptibility to adverse events such as falls. Frailty can be better managed with early screening and intervention, ideally conducted in primary health care (PHC) settings. This study used the Consolidated Framework for Implementation Research (CFIR) as an evaluation framework during the second stage piloting of a novel web-based tool called the Frailty Portal, developed to aid in the screening, identification, and care planning of frail patients in community PHC. Methods This qualitative study conducted semi-structured key informant interviews with a purposive sample of PHC providers (family physicians, nurse practitioners) and key PHC stakeholders who were administrators, decision makers and staff. The CFIR was used to guide data collection and analysis. Framework Analysis was used to determine the relevance of the CFIR constructs to implementing the Frailty Portal. Results A total of 17 interviews were conducted. The CFIR-inspired interview questions helped clarify critical aspects of implementation that need to be addressed at multiple levels if the Frailty Portal is to be successfully implemented in PHC. Finding were organized into three themes 1) PHC Practice Context, 2) Intervention attributes affecting implementation, and 3) Targeting providers with frail patients. At the intervention level the Frailty Portal was viewed positively, despite the multi-level challenges to implementing it in PHC practice settings. Provider participants perceived high opportunity costs to using the Frailty Portal due to changes they needed to make to their practice routines. However, those who had older patients, took the time to learn how to use the Frailty Portal, and created processes for sharing tasks with other PHC personnel become proficient at using the Frailty Portal. Conclusions Structuring our evaluation around the CFIR was instrumental in identifying multi-level factors that will affect large-scale adoption of the Frailty Portal in PHC practices. Incorporating CFIR constructs into evaluation instruments can flag factors likely to impede future implementation and impact the effectiveness of innovative practices. Future research is encouraged to identify how best to facilitate changes in PHC practices to address frailty and to use implementation frameworks that honor the complexity of implementing innovations in PHC.

Background: Understanding and addressing the needs of frail patients has been identified as an important strategy by the Nova Scotia Health Authority (NSHA). Primary care (PC) providers are in a key position to aid in the identification of, and response to frailty as part of routine care. Unlike singular chronic conditions such as diabetes and hypertension which garner a disease-based approach and identification as part of standard practice, frailty is only just emerging as a concept for PC. The web-based Frailty Portal was developed to aid in the identification of, assessment and care planning for frail patients in PC practice. In this study we assess the implementation feasibility and impact of the Frailty Portal by: (1) identifying factors influencing the Frailty Portal’s use in community PC practice, and (2) examination of the immediate impact of the ‘Frailty Portal’ on frail patients, their caregivers and PC providers. Methods: A convergent mixed method approach was implemented among PC providers in community-based practice in the NSHA, Central Zone. Quantitative and qualitative data were collected concurrently over a 9-month period. A sample of patients who underwent assessment and/or their caregiver were approached for survey participation. Results: Fourteen community PC providers (10 family physicians, 4 nurse practitioners) completed 48 patient assessments and completed or begun 41 care plans; semi-structured interviews were conducted among 9 providers. Nine patients and 5 caregivers participated in the survey. PC providers viewed frailty as an important concept but implementation challenges were met, primarily with respect to the time required for use and lack of fit with traditional practice routines. Additional barriers included tool usability and accessibility, training and care planning steps, and privacy. Impacts of the tools use with respect to confidence and knowledge showed early promise. Conclusion: This feasibility study highlights the need for added health system supports, resources and financial incentives for successful implementation of the Frailty Portal in community PC practice. We suggest future implementation integrate the Frailty Portal to practice electronic medical records (EMRs) and target providers with largely geriatric practice populations and those practicing within interdisciplinary, collaborative primary healthcare (PHC) teams.

Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.

Background Recognizing the significant impact of wait times for care for individuals with complex chronic conditions, we applied a LEAN methodology, namely – an adaptation of Value Stream Mapping (VSM) to meet the needs of people with multiple chronic conditions and to improve wait times without additional resources or funding. Methods Over an 18-month time period, staff applied a patient-centric approach that included LEAN methodology of VSM to improve wait times to care. Our framework of evaluation was grounded in the needs and perspectives of patients and individuals waiting to receive care. Patient centric views were obtained through surveys such as Patient Assessment of Chronic Illness Care (PACIC) and process engineering based questions. In addition, LEAN methodology, VSM was added to identify non-value added processes contributing to wait times. Results The care team successfully reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction are also outcomes of this innovative initiative. In addition, successful transformations and implementation have resulted in resource efficiencies without increase in costs. Patients have shown significant improvements in functional health following Integrated Chronic Care Service (ICCS) intervention. The methodology will be applied to other chronic disease management areas in Capital Health and the province. Conclusion Wait times to care in the management of multimoribidities and other complex conditions can add a significant burden not only on the affected individuals but also on the healthcare system. In this study, a novel and modified LEAN methodology has been applied to embed the voice of the patient in care delivery processes and to reduce wait times to care in the management of complex chronic conditions.

Individuals with multimorbidity have complex care needs along with significant impacts to their functional health and quality of life. Recent evidence-based and experience-based explorations have revealed the importance of patient perspectives and functional health management in improving care delivery and health outcomes for individuals with multimorbidity. The impact of managing multimorbidity is evident at multiple levels of healthcare – the individual, the provider, and the system. Our local experience dealing with these challenges has led to the development of a functional health model that includes patient perspectives in care delivery within the Integrated Chronic Care Service (ICCS) of the health authority in Nova Scotia. In this paper, we present a discussion of the challenges, guiding models, and service-level transformations that have been integrated into care delivery at the ICCS to meet the healthcare needs of people with multiple health conditions. We describe our redesign strategies for care team planning, treatment approach, and patient inclusion. Journal of Comorbidity 2016;6(2):76–84

Improving care for chronic conditions requires system-level transformations to ensure multiple levels of adoption and sustainability of the implemented improvements. These comprehensive solutions require transformations and supports at various levels, leadership and process changes at service/program level. Recognizing the importance of an organization-wide strategy to mitigate the growing issue of chronic disease prevention and management, a novel system-level approach has been developed in a district health authority in Nova Scotia, Canada. In this paper, the contextual factors and efforts that led to the conceptual framework of the Chronic Disease Prevention and Management (CDPM) "Corridor©" to management of chronic conditions are discussed. The CDPM Corridor© essentially constitutes a system-level redesign process; common elements, tools and resources; and a hub of supports for chronic disease prevention and management. The CDPM Corridor

IntroductionSignificant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada.Methods and analysisWe will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method.Ethics and disseminationThis study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.

Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (

Multiple chemical sensitivity (MCS) is a chronic condition prevalent in women; the symptoms are reproducible with repeated low-level chemical exposure. Evidence gathered through clinical observations suggests that women with MCS may be at risk for autonomic nervous system dysfunction as evidenced by abnormal heart rate and pulse pressure responses to exercise. The primary objective of this study was to describe the hemodynamic response to postural shift in 17 women with MCS. Using impedance cardiography, hemodynamic measures were taken while sitting and immediately upon standing. The hemodynamic response to standing was increased heart rate (p < .0001), decreased stroke volume (p = .002), decreased left ventricular ejection time (p < .0001), increased diastolic blood pressure (p = .01), and increased systemic vascular resistance (p =.002). Although this pattern of hemodynamic response was normal, the magnitude of the changes was considerably less than those observed previously in healthy participants. These findings warrant further investigation.

Chronic disease is a highly expensive but preventable problem to the healthcare system. Evidence suggests that impacting modifiable behaviours and risk management factors in the areas of physical inactivity, unhealthy diet, stress and obesity can alleviate the burden of chronic disease problem to a large extent. Despite this recognition, the challenge is embedding these recognized priorities into the community and in primary care in a sustainable and meaningful manner. Primary Health Care in Capital Health responded to this challenge by developing and implementing a free, interprofessional and community-based service, namely, the Community Health Teams (CHTs), that offers health and wellness, risk factor management, wellness navigation and behaviour-based programming. In this paper, the development and implementation of the CHTs are discussed. Preliminary outcomes for the model are significant and promising. Formal and large-scale studies are planned to validate these outcomes with additional research rigour.

IntroductionPeople are living longer; however, they are not necessarily experiencing good health and well-being as they age. Many older adults live with multiple chronic conditions (MCC), and complex health issues, which adversely affect their day-to-day functioning and overall quality of life. As a result, they frequently rely on the support of friend and/or family caregivers. Caregivers of older adults with MCC often face challenges to their own well-being and also require support. Currently, not enough is known about the health and social care needs of older adults with MCC and the needs of their caregivers or how best to identify and meet these needs. This study will examine and synthesise the literature on the needs of older adults with MCC and those of their caregivers, and identify gaps in evidence and directions for further research.Methods and analysisWe will conduct a scoping review of the peer-reviewed and grey literature using the updated Arksey and O’Malley framework. The literature will be identified using a multidatabase and grey literature search strategy developed by a health sciences librarian. Papers, reports and other materials addressing the health and social care needs of older adults and their friend/family caregivers will be included. Search results will be screened, independently, by two reviewers, and data will be abstracted from included literature and charted in duplicate.Ethics and disseminationThis scoping review does not require ethics approval. We anticipate that study findings will inform novel strategies for identifying and ascertaining the health and social care needs of older adults living with MCC and those of their caregivers. Working with knowledge-user members of our team, we will prepare materials and presentations to disseminate findings to relevant stakeholder and end-user groups at local, national and international levels. We will also publish our findings in a peer-reviewed journal.

Medically unexplained symptoms (MUS) are known to be costly, complex to manage and inadequately addressed in primary care settings. In many cases, there are unresolved psychological and emotional processes underlying these symptoms, leaving traditional medical approaches insufficient. This paper details the implementation of an evidence-based, emotion-focused psychotherapy service for MUS across two family medicine clinics. The theory and evidence-base for using Intensive Short-Term Dynamic Psychotherapy (ISTDP) with MUS is presented along with the key service components of assessment, treatment, education and research. Preliminary outcome indicators showed diverse benefits. Patients reported significantly decreased somatic symptoms in the Patient Health Questionnaire-15 (d = 0.4). A statistically significant (23%) decrease in family physicians’ visits was found in the 6 months after attending the MUS service compared to the 6 months prior. Both patients and primary care clinicians reported a high degree of satisfaction with the service. Whilst further research is needed, these findings suggest that a direct psychology service maintained within the family practice clinic may assist patient and clinician function while reducing healthcare utilization. Challenges and further service developments are discussed, including the potential benefits of re-branding the service to become a ‘Primary Care Psychological Consultation and Treatment Service’.

Tara Sampalli, Roy A Fox, Robert Dickson, Jonathan FoxIntegrated Chronic Care Service, Primary Health Care, Capital Health, Nova Scotia, CanadaAbstract: Multimorbidity is defined as the coexistence of multiple chronic conditions. Individuals with multimorbidity typically present with complex needs and show significant changes in their functional health and quality of life. Multimorbidity in the aging population is well recognized, but there has been limited research on ways to manage the problem effectively. More recent studies have demonstrated a high prevalence of multimorbidity in the younger demographics aged under 65 years. There is a definite need to develop models of care that can manage these individuals effectively and mitigate the impact of illness on individuals and the financial burden to the health care system. An integrated model of care has been developed and implemented in a facility in Nova Scotia that routinely treats individuals with multiple chronic conditions. This care model is designed to address the specific needs of this complex patient population, with integrated and coordinated care modules that meet the needs of the person versus the disease. The results of a pilot evaluation of this care model are also discussed.Keywords: multimorbidities, integrated care, self-management, functional health, quality of life

There is growing interest in recent years in applying ontologies to represent disease concepts because they have the ability to depict the domain knowledge with a superior level of expressiveness and precision. Ontologies have been predominantly used to represent well-categorized disease concepts. However, there are challenges in representing the domain knowledge for heterogeneous and poorly categorized systems. In this study, a methodology to create an ontology to represent the domain knowledge for complex and chronic health conditions is explored. The domain of complex chronic conditions can be viewed not only as heterogeneous but also as dynamic with new knowledge continually evolving. The methodology includes the development of a controlled vocabulary to create the first layer of semantic interoperability. The controlled vocabulary is then converted into a patient profile ontology to add deeper semantics, conceptually and relationally in the heterogeneous domain knowledge.

One of the major challenges to delivering effective health care to patients with complex, chronic health problems is that health systems have been designed to deal with acute episodic illness. This has lead to increasing specialization in treatment of disease, focused on individual body systems and indeed one part of one organ. When a person becomes acutely ill and requires expertise that cannot be managed by a primary care physician they are referred for specialized care. As the population ages we are seeing more chronic health conditions which require long term management, often punctuated by episodes requiring acute care. As the burden of chronic disease has increased it has been recognized that management becomes more complex when there are interacting problems like hypertension, cardiac disease and diabetes. Individual “diseases” are more easily managed, but when there are multiple diagnoses, management becomes more difficult. Fortunately many of these chronic conditions have clear guidelines for monitoring and treatment, and even where there can be several problems in the same patient the guidelines are followed. However, patients who develop more difficult problems in more than one body system often end up with treatment from multiple specialists. Coordination of the efforts of the various specialists usually rests in the hands of primary care physicians, which presents many challenges (Henningsen et al 2003, Verhaak et al. 2006). In Canada, family physicians provide primary care and for the most part work independently, not within a team of other health professionals. Most family physicians have a heavy workload and usually see many patients during fairly short visits. Patients with multiple, interacting problems present a major challenge for family physicians(Fink & Rosendal 2008). When someone is chronically ill with multiple conditions, they often see different clinicians at different sites. This increases the risks of errors and of poor care coordination. Undoubtedly this increases suffering for the individual and higher health care costs for society. These issues have been recognized in the elderly population and the speciality of geriatrics has developed which specializes in the management of the frail elderly (Rockwood et al 1994). Frailty is more likely with more health problems or deficits (Rockwood et al 2004), and the most frail individuals present greater challenges in management. 2

Objective: To determine the content coverage in SNOMED CT® to represent the multidisciplinary terms and concepts in the domain for complex chronic conditionsMethods: An evaluation of the coverage of multidisciplinary health factors in SNOMED CT® for the complex and chronic condition, Multiple Chemical Sensitivity (MCS) is conducted in the study. The methodology included a retrospective audit of patient charts and feedback from multidisciplinary clinicians in the creation of a controlled vocabulary used in the generation of patient profiles for MCS. Clinicians and experts in the field reviewed and tested the vocabulary for its usefulness (scope, specificity and structure) by re-coding 3 patient profiles using the vocabulary. Cohen's kappa analysis was conducted to determine inter-rater reliability. Cronbach's alpha analysis was conducted to determine the internal reliability of the survey questionnaire.Results: One hundred patient charts and 9 clinicians from varying health disciplines participated in the study. SNOMED CT® was shown to capture nearly 82% of the concepts spanning multidisciplinary areas of health focus. The nutrition area of health focus had the highest level of exact matches Furthermore post-coordination was applied in an attempt to improve coverage of concepts to 75% ( of 45 terms) of the missing terms in SNOMED CT ® . Seventy-five percent (n=9) of the clinicians agreed on the overall usefulness of the vocabulary.Conclusions: SNOMED CT® had a reasonable coverage of the multidisciplinary health concepts required to describe a complex and chronic condition. Standardizing the multidisciplinary vocabulary with reference tag to a widely used reference terminology such as SNOMED CT® to discuss the terms and concepts used may improve the understanding across disciplines and communities of practice. Overall, based on the availability of concepts in SNOMED CT® and the feedback from clinicians, the approach looks promising and should be further explored.

Tara Sampalli1, Elizabeth Berlasso1, Roy Fox1, Mark Petter21Nova Scotia Environmental Health Centre, Fall River, Nova Scotia, Canada; 2Doctoral Candidate, Department of Psychology, Dalhousie University, Halifax, CanadaBackground: The objective of this study was to examine the effect of a mindfulness-based stress reduction (MBSR) program on women diagnosed with conditions such as multiple chemical sensitivity (MCS), chronic fatigue syndrome (CFS), and fibromyalgia (FM). Methods: The intervention group underwent a 10-week MBSR program. Symptoms Checklist Inventory (SCL-90R) was used as outcome measure and was administered before the start of the program (pre-), immediately upon completion (post-) and at three-month follow-up. Women on the wait list to receive treatment at the Nova Scotia Environmental Health Centre were used as control subjects for the study.Results: A total of 50 participants in the intervention group and 26 in the wait-list controls group were recruited for this study. Global scores in the intervention group reached statistical significance pre-post (

The aim of this study was to look at the impact of a multidisciplinary approach to treatment of individuals with multiple chemical sensitivity (MCS) and to present preliminary results which compare health care utilization pre- and postmanagement of individuals with MCS.The design for this study was that for a cohort study.The setting for this study was the Nova Scotia Environmental Health Centre (NSEHC; Fall River, Nova Scotia, Canada).Following ethical approval, individuals who had filled a detailed-symptoms questionnaire and had agreed to participate in research activities were linked to their medical insurance records, using encrypted numbers and a blind procedure for confidentiality. Diagnosis by the NSEHC; physicians followed the consensus criteria for multiple chemical sensitivity (MCS). A total of 563 patients formed 3 cohorts (145 in 1998; 181 in 1999; and 237 in 2000).Physicians' visits by general practitioner and by specialists, emergency and hospital separations, and associated costs showed a relative decrease in the years following the consultation at the NSEHC. The overall yearly decline in consultations between the years before the initial consultation until 2002, for each cohort, was: 9.1% for the 1998 cohort; 8% for the 1999 cohort; and 10.6% for the 2000 cohort; compared with 1.3% for the overall Nova Scotia population. Relative to the provincial utilization costs, the standardized average yearly decrease in utilization costs for the 3 cohorts combined was 8.7%, or a total savings of $77,440. The 1998 cohort showed a sustained decrease up to 2002, reaching a level similar to the overall Nova Scotia population. Those with high symptom scores had the highest reduction in mean physician visits (31% for the 1998 cohort) in the following years.Presented in this paper are the preliminary results of the health care utilization costs in the management of individuals with MCS. Despite the limitations of our study design, the initial findings from this study are encouraging and warrant further exploration. These results indicate a possible impact on the long-term health care utilization from the NSEHC's management strategies, although a further controlled study, with a longer follow-up, may be necessary to confirm these findings.

We conducted a pilot study using a randomized, single-blind, placebo-controlled exposure among 10 individuals with and 7 without reported chemical sensitivities in a dedicated testing chamber. Objectives of the study were to explore the length of the adaptation period to obtain stable readings, evaluate responses to different substances, and measure the level and type of symptomatic and physiologic reactions to low-level exposures. Reported and observed symptoms, electrodermal response, heart rate, skin temperature, surface electromyogram, respiratory rate, contrast sensitivity, and the Brown-Peterson cognitive test were used and compared between cases and controls and between test substances (glue, body wash solution, dryer sheet) and control substances (unscented shampoo and clean air). Subjects with chemical sensitivities (cases) took longer to adapt to baseline protocols than did controls. After adaptation, despite small study numbers, cases displayed statistically significant responses (all measures, p < 0.02) in tonic electrodermal response to test substances compared with controls and compared with the control substance. Symptoms were also higher in cases than in controls for the body wash solution (p = 0.05) and dryer sheets (p = 0.02). Test–retest showed good agreement for both symptoms and tonic electrodermal responses (McNemar’s test, p = 0.32 and p = 0.33, respectively). Outside of skin conductance, other measures had no consistent patterns between test and control substances and between cases and controls. This study shows the importance of using an adaptation period in testing individuals with reported chemical sensitivities and, despite small numbers, raises questions about underlying mechanisms and level of reactivity to low-level chemical exposures in sensitive individuals.

Tara Sampalli1,2, Michael Shepherd2, Jack Duffy21Capital District Health Authority, 2Dalhousie University, Halifax, NS, CanadaBackground: Research has shown that accurate and timely communication between multidisciplinary clinicians involved in the care of complex and chronic health conditions is often challenging. The domain knowledge for these conditions is heterogeneous, with poorly categorized, unstructured, and inconsistent clinical vocabulary. The potential of boundary object as a technique to bridge communication gaps is explored in this study.Methods: A standardized and controlled clinical vocabulary was developed as a boundary object in the domain of a complex and chronic health condition, namely, multiple chemical sensitivity, to improve communication among multidisciplinary clinicians. A convenience sample of 100 patients with a diagnosis of multiple chemical sensitivity, nine multidisciplinary clinicians involved in the care of patients with multiple chemical sensitivity, and 36 clinicians in the community participated in the study.Results: Eighty-two percent of the multidisciplinary and inconsistent vocabulary was standardized using the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED® CT as a reference terminology. Over 80% of the multidisciplinary clinicians agreed on the overall usefulness of having a controlled vocabulary as a boundary object. Over 65% of clinicians in the community agreed on the overall usefulness of the vocabulary.Conclusion: The results from this study are promising and will be further evaluated in the domain of another complex chronic condition, ie, chronic pain. The study was conducted as a preliminary analysis for developing a boundary object in a heterogeneous domain of knowledge.Keywords: multidisciplinary care, complex and chronic conditions, multiple chemical sensitivity, boundary objects

Roy Fox1, Tara Sampalli1, Jonathan Fox11Nova Scotia Environmental Health Centre, Fall River, NS, CanadaAbstract: The Nova Scotia Environmental Health Centre is a treatment facility for individuals with chronic environmental conditions such as multiple chemical sensitivity, chronic fatigue syndrome, fibromyalgia, chronic respiratory conditions and in some cases chronic pain. The premise of care is to provide a patient-centred multidisciplinary care approach leading to self-management strategies. In order to measure the outcome of the treatment in these complex problems, with overlapping diagnoses, symptoms in many body systems and suspected environmental triggers, a detailed symptoms questionnaire was developed specifically for this patient population and validated. Results from a pilot study in which an abbreviated symptoms questionnaire based on the top reported symptoms captured in previous research was used to measure the efficacy of a multidisciplinary care approach in individuals with multiple chemical sensitivity are presented in this paper. The purpose of this study was to examine the extent, type and patterns of changes over time in the top reported symptoms with treatment measured using the abbreviated symptoms questionnaire. A total of 183 active and 109 discharged patients participated in the study where the health status was measured at different time periods of follow up since the commencement of treatment at the Centre. The findings from this study were successful in generating an initial picture of the nature and type of changes in these symptoms. For instance, symptoms such as difficulty concentrating, sinus conditions and tiredness showed early improvement, within the first 6 months of being in treatment, while others, such as fatigue, hoarseness or loss of voice, took longer while others showed inconsistent changes warranting further enquiry. A controlled longitudinal study is planned to confirm the findings of the pilot study.Keywords: multiple chemical sensitivity, multidisciplinary, chronic conditions