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The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p =.001) and nurses (p <.001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p =.015) and nurses (p <.001). Nurses created more alternatives to in-person visits than family physicians (p <.001) and coordinated health and social services more than family physicians (p =.003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p =.003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to evaluate the effects of the V1SAGES case management intervention (Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support) for frequent users of health care services with chronic disease and complex care needs on psychological distress and patient activation.Methods: We used a 2-phase sequential mixed methods design. The first phase was a pragmatic randomized controlled trial with intention-to-treat analysis that measured the effects of the intervention compared with usual care on psychological distress and patient activation before and after 6 months. The second phase had a qualitative descriptive design and entailed thematic analysis of in-depth interviews (25 patients, 6 case management nurses, 9 health managers) and focus groups (8 patients' spouses, 21 family physicians) to understand stakeholders' perceived effects of the intervention on patients.Results: A total of 247 patients were randomized into the intervention group (n = 126) or the control group (n = 121). Compared with usual care, the intervention reduced psychological distress (odds ratio = 0.43; 95% CI, 0.19-0.95, P = .04), but did not have any significant effect on patient activation (P = .43). Qualitative results suggested that patients and their spouses benefitted from the case management intervention, gaining a sense of security, and stakeholders noted better patient self-management of health.Conclusions: Together, our study's quantitative and qualitative results suggest that case management reduces psychological distress, making patients and caregivers feel more secure, whereas impact on self-management is unclear. Case management is a promising avenue to improve outcomes among frequent users of health care with complex needs. [ABSTRACT FROM AUTHOR]

Background: The prevalence of comorbid anxiety and depressive disorders is high among patients with chronic diseases in primary care, and is associated with increased morbidity and mortality rates. The detection and treatment of common mental disorders in patients with chronic diseases can be challenging in the primary care setting. This study aims to explore the perceived needs, barriers and facilitators for the delivery of mental health care for patients with coexisting common mental disorders and chronic diseases in primary care from the clinician and patient perspectives. Methods: In this qualitative descriptive study, we conducted semi-structured interviews with clinicians (family physician, nurse, psychologist, social worker; n =18) and patients (n = 10) from three primary care clinics in Quebec, Canada. The themes explored included clinician factors (e.g., attitudes, perception of roles, collaboration, management of clinical priorities) and patient factors (e.g., needs, preferences, access to care, communication with health professionals) associated with the delivery of care. Qualitative data analysis was conducted based on an interactive cyclical process of data reduction, data display and conclusion drawing and verification. Results: Clinician interviews highlighted a number of needs, barriers and enablers in the provision of patient services, which related to inter-professional collaboration, access to psychotherapy, polypharmacy as well as communication and coordination of services within the primary care clinic and the local network. Two specific facilitators associated with optimal mental health care were the broadening of nurses' functions in mental health care and the active integration of consulting psychiatrists. Patients corroborated the issues raised by the clinicians, particularly in the domains of whole-person care, service accessibility and care management. Conclusions: The results of this project will contribute to the development of quality improvement interventions to increase the uptake of organizational and clinical evidence-based practices for patients with chronic diseases and concurrent common mental disorders, in priority areas including collaborative care, access to psychotherapy and linkages with specialized mental health care. [ABSTRACT FROM AUTHOR]

Background. Communication barriers between persons living in poverty and healthcare professionals reduce care effectiveness. Little is known about the strategies general practitioners (GPs) use to enhance the effectiveness of care for their patients living in poverty. Objective. The aim of this study was to identify strategies adopted by GPs to deliver appropriate care to patients living in poverty. Methods. We conducted in-depth semi-structured interviews with 35 GPs practising in Montreal, Canada, who regularly provide care to underprivileged patients in primary care clinics located in deprived urban areas. Analysis consisted of interview debriefing, transcript coding, thematic analysis and data interpretation. Results. GPs develop specific skills for caring for these patients that are responsive to their complex medical needs and challenging social context. Our respondents used three main strategies in working with their patients: building a personal connection to overcome social distance, aligning medical expectations with patients' social vulnerability and working collaboratively to empower patients. With these strategies, the physicians were able to enhance the patient-physician relationship and to take into account the impact of poverty on illness self-management. Conclusions. Our results may help GPs improve the health and care experience of their vulnerable patients by adopting these strategies. The strategies' impacts on patients' experience of care and health outcomes should be evaluated as a prelude to integrating them into primary care practice and the training of future physicians. [ABSTRACT FROM AUTHOR]

Background: The aim of this paper is to share the results of a scoping review that examined the relationship between health care disparities and the multiplicity of vulnerability factors that are often clustered together. Methods: The conceptual framework used was an innovative dynamic model that we developed to analyze the co-existence of multiple vulnerability factors (multi-vulnerability) related to the phenomenon of the 'Inverse Care Law'. A total of 759 candidate references were identified through a literature search, of which 23 publications were deemed relevant to our scoping review. Results: The review confirmed our hypothesis of a direct correlation between co-existing vulnerability factors and health care disparities. Several gaps in the literature were identified, such as a lack of research on vulnerable populations' perception of their own vulnerability and on multimorbidity and immigrant status as aspects of vulnerability. Conclusions: Future research addressing the revealed gaps would help foster primary care interventions that are responsive to the needs of vulnerable people and, eventually, contribute to the reduction of health care disparities in society. [ABSTRACT FROM AUTHOR]

Background: Ensuring access to timely and appropriate primary healthcare for people living in poverty is an issue facing all countries, even those with universal healthcare systems. The transformation of healthcare practices and organization could be improved by involving key stakeholders from the community and the healthcare system in the development of research interventions. The aim of this project is to stimulate changes in healthcare organizations and practices by encouraging collaboration between care teams and people living in poverty. Our objectives are twofold: 1) to identify actions required to promote the adoption of professional practices oriented toward social competence in primary care teams; and 2) to examine factors that would encourage the inclusion of people living in poverty in the process of developing social competence in healthcare organizations. Methods/design: This study will use a participatory action research design applied in healthcare organizations. Participatory research is an increasingly recognized approach that is helpful for involving the people for whom the research results are intended. Our research team consists of 19 non-academic researchers, 11 academic researchers and six partners. A steering committee composed of academic researchers and stakeholders will have a decisionmaking role at each step, including knowledge dissemination and recommendations for new interventions. In this project we will adopt a multiphase approach and will use a variety of methods, including photovoice, group discussions and interviews. Discussion: The proposed study will be one of only a few using participatory research in primary care to foster changes aimed at enhancing quality and access to care for people living in poverty. To our knowledge this will be the first study to use photovoice in healthcare organizations to promote new interventions. Our project includes partners who are targeted for practice changes and improvements in delivering primary care to persons living in poverty. By involving knowledge users, including service recipients, our study is more likely to produce a transformation of professional practices and encourage healthcare organizations to take into account the needs of persons living in poverty. [ABSTRACT FROM AUTHOR]

Background: Chronic diseases represent a major challenge for health care and social services. A number of people with chronic diseases require more services due to characteristics that increase their vulnerability. Given the burden of increasingly vulnerable patients on primary care, a pragmatic intervention in four Family Medicine Groups (primary care practices in Quebec, Canada) has been proposed for individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain) who are frequent users of hospital services. The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program. The goals of this study are to: (1) analyze the implementation of the intervention in the participating practices in order to determine how the various contexts have influenced the implementation and the observed effects; (2) evaluate the proximal (self-efficacy, self-management, health habits, activation and psychological distress) and intermediate (empowerment, quality of life and health care use) effects of the intervention on patients; (3) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention. Methods/Design: The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders (Family Medicine Group and health centre management, Family Medicine Group practitioners, patients and their families, health centre or community partners). The data will be obtained through individual and group interviews, project documentation reviews and by documenting the intervention. Evaluation of the effects on patients will be based on a pragmatic randomized before-after experimental design with a delayed intervention control group (six months). Economic analysis will include cost-effectiveness and cost-benefit analysis. Discussion: The integration of a case management intervention delivered by nurses and self-management group support into primary care practices has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care. Decision-makers, managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practices in the region and elsewhere. [ABSTRACT FROM AUTHOR]

Background: The inverse care law persists: people living in poverty have the greatest needs and face considerable challenges in getting the care they need. Evidence reveals that GPs encounter difficulties in delivering care to poor patients, while many of those patients feel stigmatized by healthcare professionals. Patients living in poverty report negative healthcare experiences and unmet healthcare needs. Indeed, there is a growing recognition in primary care research of the importance of addressing the capabilities and social conditions of the poor when delivering care. Few studies have looked at the factors contributing to effective and "socially responsive" care for people living in poverty. Methods/Design: Our study adopts a qualitative ethnographic approach in four healthcare organizations in deprived areas of metropolitan Montreal (Québec, Canada), using patient shadowing techniques and interviews. Data will be collected through fieldwork observations and informal interviews with patients before and after consultations. We will observe medical consultations, care organization activities, and waiting areas and reception of patients. We will conduct a total of 36 individual interviews with 12 GPs and 24 patients. The interviews will be audio-recorded and transcribed for purposes of analysis. The analysis consists of debriefing sessions, coding and interpretive analysis. Discussion: This study aims to investigate how positive healthcare interactions between physicians and patients can improve the management of chronic conditions. We hypothesize that factors related to care organization, to healthcare professionals' experience and to patients may enhance the quality of healthcare interactions, which may have positive impacts for preventing and managing chronic conditions. Our study will provide a unique set of data grounded in the perspectives of healthcare professionals and of patients living in poverty. [ABSTRACT FROM AUTHOR]

Introduction. Advanced access is an organizational model that has shown promise in improving timely access to primary care. In Quebec, it has recently been introduced in several family medicine units (FMUs) with a teaching mission. The objectives of this paper are to analyze the principles of advanced access implemented in FMUs and to identify which factors influenced their implementation. Methods. A multiple case study of four purposefully selected FMUs was conducted. Data included document analysis and 40 semistructured interviews with health professionals and staff. Cross-case comparison and thematic analysis were performed. Results. Three out of four FMUs implemented the key principles of advanced access at various levels. One scheduling pattern was observed: 90% of open appointment slots over three- to four-week periods and 10% of prebooked appointments. Structural and organizational factors facilitated the implementation: training of staff to support change, collective leadership, and openness to change. Conversely, family physicians practicing in multiple clinical settings, lack of team resources, turnover of clerical staff, rotation of medical residents, and management capacity were reported as major barriers to implementing the model. Conclusion. Our results call for multilevel implementation strategies to improve the design of the advanced access model in academic teaching settings. [ABSTRACT FROM AUTHOR]