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Context: Many older adults take multiple medications prescribed by a variety of providers, which leads to concerns about medication management, appropriateness, and adverse drug events. Interdisciplinary, team-based primary care models can improve coordination of health care services, which could translate to improved medication management and related outcomes. Objective: Evaluate the impact of interdisciplinary team-based primary care models implemented in two Canadian provinces--Ontario and Quebec--on outcomes related to medication use. Study Design and Analysis: Retrospective cohort analysis of population- level administrative health data. We used difference-in-differences analysis to compare older adults rostered to team-based primary care models, to older adults not rostered to team-based models. Dataset: Data housed at ICES in Ontario and the Institut national d'excellence en sante et services sociaux (INESSS) in Quebec. We focused on fiscal years 1999/00 to 2017/18. Population Studied: Eligible patients were between 66 and 104 years of age. We matched (1-to-1 propensity score matching without replacement) an exposure group of older adults who were rostered to a physician affiliated with a team-based primary care model to a comparison group of older adults rostered to non-team family physicians. Intervention: Quebec's Family Medicine Groups (implemented in 2002) and Ontario's Family Health Teams (implemented in 2005). Outcome Measures: Any adverse drug event resulting in hospitalization, polypharmacy (5+ medication classes), and any potentially inappropriate prescription (adapted from Beer's and STOPP/START criteria). Results: Matched cohorts included 429,104 older adults in Ontario and 310,198 in Quebec. In the year before they rostered, 53% and 40% of older adults had a potentially inappropriate prescription in Ontario and Quebec, respectively. In both provinces, 1% had an adverse drug event. Quebec's Family Medicine Groups were more likely to experience an adverse drug event (RR = 1.14; 95% CI: 1.10-1.17). We found no other differences between the exposure and comparison groups. Conclusions: The implementation of team-based primary care models in Ontario and Quebec was not associated with a variety of outcomes related to medication management. These results point to a need for further investigation of the composition and functioning of primary care teams to determine how they can support older adults with complex health needs, Presenters David Rudoler, PhD, Agnes Grudniewicz, PhD, Nichole Austin, PhD, Sara Allin, PhD, Richard Glazier, MD, MPH, Elisabeth Martin, PhD, Caroline Sirois, PhD, Erin [...]

Context: Implementing interprofessional advanced access (AA) requires reorganizing the practices of all team members to improve the timeliness of primary care. Often, team members do not know how to engage in a meaningful change process journey. Evidence-based change strategies that address fundamental care delivery processes could help improve timely access to the appropriate professionals while improving satisfaction of both staff and patients. Objective: To describe foundational evidence-based change strategies used by external facilitators to improve interprofessional AA in primary healthcare (PHC) clinics. Study design and analysis: Participatory action research was used to analyze change strategies and steps required for their implementation. AA indicators (3rd next available appointment, continuity of care, and availability for urgent care) were followed longitudinally to adapt the change strategies and assess their progressive impacts. This process led to the development of change packages. Setting: 8 interprofessional PHC clinics in Quebec, Canada. Population studied: Physicians, nurse practitioners, nurses, social workers and pharmacists. Intervention: External facilitators supported PHC clinics while relying on quality improvement techniques according to the Model for Improvement. Outcomes: Change packages: standardized tools to inform the planning, implementation, and monitoring of change strategies. These include: 1) Steps required to implement the strategy; 2) Key indicators to monitor change and evaluate the strategy's success; 3) Lessons learned from the process. Results: 4 different change packages were developed. 3 change packages support transformation of appointment systems, including a prioritization algorithm for appointment scheduling, integration of time slots for urgent care, and integration of an online appointment scheduler. One change package aims to improve patient flow and professional autonomy using collective orders. The contents of these change packages, including lessons learnt and impacts on key indicators of AA across participating clinics, will be presented. Conclusions: Improving AA in PHC is complex, but essential change strategies appeared to be common first steps among clinics undertaking this journey. Resulting change packages provide road maps to successfully guide the improvement of AA, lay a strong foundation for further improvement steps, and build a culture of improvement within and among PHC clinics., Presenters Isabelle Gaboury, PhD, Mylaine Breton, PhD, Francois Bordeleau, MSc, Kathy Perreault, PsyD, MPsy, Elisabeth Martin, MSc, Marie-Eve Poitras, PhD, MSc, RN, Sabina Malham, PhD, MSc, RM, Lara Maillet, PhD, [...]

Context: Polypharmacy and inappropriate medications can lead to adverse drug events and avoidable health systems costs. Family physicians may find it challenging to manage multiple medications for seniors, especially in fragmented systems with multiple prescribers. Interprofessional primary care teams have capacity for improved medication management. However, we know little about how these teams work together to manage medications. Objective: To describe and understand how family physicians and interdisciplinary health providers (IHPs) work together when managing medications for seniors. Study Design and Analysis: Qualitative semi-structured interviews and thematic analysis. Setting: Interprofessional primary care Family Health Teams (FHTs) in Ontario. Population Studied: Administrators, family physicians, and IHPs (nurses, pharmacists, etc.). Results: Interviews (n=38) were conducted across six FHTs in Ontario. The way physicians and IHPs worked together to manage medications for seniors varied in and across FHTs. We identified three themes in the data related to approach to medication management: 1) no engagement with IHPs (i.e., physicians did not refer their patients to the team's IHPs), 2) some engagement (i.e., physicians referred patients to IHPs and IHP-led programs for medication management but rarely engaged in ongoing communication), and 3) shared care (i.e., physicians shared decision-making about care with IHPs, there was ongoing communication between physicians and IHPs). Some IHPs were frustrated with tailoring their approach to care and communication based on the preferences of each physician. These differences were perceived to be a result of hierarchy, work style and use of the electronic medical record, and physician expectations. Trust also appeared to be a factor in that the more physicians interacted with IHPs, the more comfortable and trusting they were giving them an active role in patient care. Regardless of the approach to medication management, participants agreed that physicians had the final say in patient care. Conclusions: Despite the FHT model's emphasis on teamwork, participants did not report a lot of shared care in medication management. While in many cases there was a lack of ongoing communication between IHPs and family physicians, there are opportunities to improve teamwork and strengthen collaboration., Presenters Agnes Grudniewicz, PhD, Monika Roerig, BSc, MA, Julie Vizza, BSc, MHS, Elisabeth Martin, PhD, Sara Allin, PhD, Erin Strumpf, David Rudoler, [...]

Context Primary health care services have undergone many transformations in recent years and are still in movement. Several studies have examined the factors that contribute to the success or failure of organizational change. The champion is a member of an organization who promotes innovation through social influence. Champions appear to be a critical factor in the success of organizational change. However, the causal relationship between the presence of the champion and the success of the organizational change is complex and still not well researched. There is a need to understand the underlying characteristics and mechanisms of the champion to understand when, why, and how they help facilitate organizational change. Objective To propose an initial theory based on the current literature that explains the mechanisms by which the champion can facilitate change in primary care. Study Design and Analysis Critical interpretive synthesis. Dataset Publications retrieved from MEDLINE, CINAHL, PsychINFO, and EconLit. Population Studied A total of 57 studies were included. Instrument The PHOENIX theoretical framework was used as a starting point. Outcome Measures Elements of context, process mechanisms, and outcomes were identified and integrated into an emerging theoretical framework to formulate hypotheses about plausible reasons and responses that explain the champion's effect according to context. Results The champion uses several actions to induce changes depending on the context. Our synthesis shows that no one specific action enables a champion to facilitate change, but rather change is achieved through a combination of small actions. Actions like coaching, providing training and feedback, resolving barriers, and involving the right people are recognized as affecting the process of change. The context within which a change is introduced, including the change's setting and characteristics, the champion's position, and the perception of peers, also modifies the champion's choice of actions and their effects. These actions seem to affect change through five main mechanisms: adapting the context to be conducive to change, sensitizing peers to the change, creating a positive perception of the change, striving for the social norm, and maintaining momentum during the change process. Conclusion This theory raises several hypotheses that will be tested and refined in a multiple case study and provides a solid foundation for a realistic evaluation of the champion., Presenters Elisabeth Martin, MSc, Dave Bergeron, PhD, RN, Pierre-Yves Kusion, BSc, Isabelle Gaboury, [...]

Background: Pediatric heart transplantation (HT) continues to be limited by the shortage of donor organs, distance constraints, and the number of potential donor offers that are declined due to the presence of multiple risk factors. Methods: We report a case of successful pediatric HT in which multiple risk factors were mitigated through a combination of innovative donor utilization improvement strategies. Results: An 11‐year‐old, 25‐kilogram child with cardiomyopathy and pulmonary hypertension, on chronic milrinone therapy and anticoagulated with apixaban, was transplanted with a heart from a Hepatitis C virus positive donor and an increased donor‐to‐recipient weight ratio. Due to extended geographic distance, an extracorporeal heart preservation system (TransMedics™ OCS Heart) was used for procurement. No significant bleeding was observed post‐operatively, and she was discharged by post‐operative day 15 with normal biventricular systolic function. Post‐transplant Hepatitis C virus seroconversion was successfully treated. Conclusions: Heart transplantation in donors with multiple risk factor can be achieved with an integrative team approach and should be taken into consideration when evaluating marginal donors in order to expand the current limited donor pool in pediatric patients. [ABSTRACT FROM AUTHOR]