Increasingly, experts recommend that military primary care clinics consider implementing delivery of care based on models of holistic wellness. Several wellness measurement tools exist, but none of these has been applied to a military primary care clinic. In this study, the psychometric testing of two holistic wellness measurement instruments was carried out for possible use with soldiers in primary care clinics. The instruments tested were the Perceived Wellness Model (Adams, Bezner, & Steinhardt, 1998) and the Optimal Living Profile (Renger et al., 2000). Both instruments appear suitable for use in future studies for measuring wellness in Cadet Soldiers. The measures provided by these instruments provide important data that professionals can use to assist young Soldiers in their multidimensional wellness development.

In the emerging field of knowledge translation (KT) evaluation is typically assigned the role of quality control, constructing judgments about the merit and worth of knowledge translation activities. To date however, there has been little, if any, record of attempts to use evaluation to facilitate knowledge translation. The purpose of this research was to examine the potential role of evaluation as a mechanism for integrated knowledge translation (IKT). This study was completed in two phases and employed a prospective multiple methods case study design. Phase one explored the context of primary care, the setting in which phase two was conducted. Phase two involved the implementation of an evaluation designed to facilitate knowledge translation; an evaluation of a Memory Clinic within a primary care setting in Ontario, Canada served as the case. The evaluation was participatory and used intentional strategies to support knowledge translation. A framework from the evaluation literature, Pathways of Influence, was used to examine the influence of the evaluation at the level of the individual, interpersonal and collective. This research provides the first known description of a KT-informed evaluation. At the level of the individual, a KT-informed evaluation influenced the individuals’ knowledge about the program, attitudes towards practice-based knowledge and clinical practices and processes. At the team/interpersonal level the evaluation was seen to influence the team’s social norms, supporting the team in thinking beyond their disciplinary boundaries and to develop a shared vision and common language. The evaluation did not have influence at the level of the broader organization, however had diffuse impact on two external organizations. Results of this study suggest that adding knowledge translation to the repertoire of evaluation purposes is a natural extension of the field. Integrated knowledge translation is designed to engage individuals in the synthesis, exchange and ethically sound application of knowledge and the results of this study demonstrate that a collaborative evaluation approach promotes this interest in a potentially powerful way. / Thesis (Ph.D, Education) -- Queen's University, 2013-08-30 16:48:36.698

Barn som lider av depression är ovanligt men i tonåren ökar sjukdomen markant. Primärvården blir ofta den första vårdkontakten. Vårdpersonal inom primärvården känner inte alltid till symtomen för depression hos ungdomar. Om tonåringar inte får hjälp med sin depression kan det leda till sämre livskvalitet och försämrad prestation i skolan. Syftet med studien är att undersöka hur primärvården kan identifiera depression hos ungdomar. Studien är en deskriptiv litteraturstudie med syfte att granska litteratur i det valda ämnet. Resultatet visar att screening för att identifiera ungdomsdepression inom primärvården är att rekommendera. Samtal är ytterligare en metod att identifiera depression. Besöket i primärvården skapar ett bra tillfälle att samtala med tonåringen om mental hälsa och depression. Om inte screening används finns det många tecken på depression hos ungdomar som primärvården kan observera. Det finns dessutom både skillnader och likheter mellan depressionstecknen hos pojkar och flickor i tonåren. / Children who suffer from depression are uncommon, but in adolescence the disease increases remarkably. Primary care is often the first health care contact. Health professionals in primary care do not always know the symptoms of depression in adolescence. If teens do not get help with their depression it can lead to lower quality of life and poorer performance in school. The aim of this study is to examine how primary care can identify depression in adolescents. The studay is a descriptive literature review aimed to examine the literature in the chosen subject. The results show that screening to identify youth depression in primary care is recommended. Conversation is an additional method to identify depression. The visit to primary care creates a good opportunity to talk with the teenager about mental health and depression. If no screening is used, there are many signs of depression in adolescents that primary care can observe. There are both similarities and differences between depression signs in boys and girls in their teens.

The prevalence of obesity (BMI≥30kg/m²) in the Scottish population is rising at an alarming pace. The health implications for those affected and the lack of sustained success in treatment, demands that new strategies be explored to improve patient outcomes (Harvey et al. 2005). Primary care nurses appear well placed to address obesity management. Therefore, the aim of this research was to develop and evaluate an evidence based, holistic, person centred approach to management, which was relevant to both professionals and those who are obese. A conceptual framework was developed to encompass the physical, social and emotional components of weight management in conjunction with the nursing models of Roper, Logan and Tierney and Peplau. The approach used mixed methods of data collection, which was carried out in two phases. Outcomes from the initial exploratory, longitudinal survey phase, involving 64 outpatients attending a specialist obesity clinic, showed that physical, social and emotional factors, in conjunction with beliefs about weight management are interrelated. Evidence from the exploratory phase contributed to the development of materials for the intervention phase which was implemented in primary care by nine practice nurses (PNs) who recruited 28 obese individuals for a three month period. Methods of data collection included questionnaires, booklets, field notes and interviews. ii The key findings of this study confirmed that obesity is complex and a holistic, person centred approach to weight management through partnership working between nurses and obese individuals can be effective. While PNs have a key role to play in obesity management they recognised their need for appropriate tools and education to help individuals towards self-management. The results also suggested that nurses and individuals who took ownership of this approach had successful outcomes in terms of weight loss.

Background: Primary care providers, family physicians and nurse practitioners provide most mental health services in Canada. However, primary care providers lack knowledge, skills, and time to provide these services. Access to onsite mental health consultation or collaborative mental health care, affords primary care providers support to offer patients increased access to mental health services. Researchers suggest that interprofessional collaborative relationships are foundational to the success of collaborative mental health care. However, there is little understanding of how to build these relationships. Purpose: The purpose of this grounded theory study was to develop an understanding of how primary care and mental health care providers collaborate to deliver mental health care in primary care settings. Methods: Counsellors, family physicians, psychiatrists, nurse practitioners, and program leaders were recruited (N=40). Data were collected using individual (19) and focus group (7) semi-structured interviews. Interviews were audio recorded, transcribed and open coded. After open coding the first seven interviews, memos were written on each participant and focus group. These memos were sorted, compared to previous memos and then used to create a coding table. This iterative process of open coding, memo writing and then adding emergent codes to the coding table was repeated for all transcripts. Similar codes were grouped then collapsed to create the preliminary categories. Preliminary categories were sent to the participants after the primary care provider interviews and again after the provider focus groups to create the final categories. The final categories were compared to examine their relationships to one another. Findings: The main finding of this study is a theoretical rendering of the participants’ experiences and ascribed meaning of interprofessional collaboration to deliver mental health services in primary care. Specifically, a collaborative relationship building model with four developmental stages: 1) Primary Care Providers Need for Collaboration, 2) Initiating Co-location, 3) Fitting-in, and 4) Growing Reciprocity is offered. Conclusions: The findings underscore that collaborative care requires an understood need for collaboration, organizational support, contextually effective modes of communication, and a perception that collaboration improves patient care. Further research may explore the applicability of this model to other health care contexts. / February 2017

Asthma is a chronic respiratory disease affecting over 300 million individuals worldwide (Akinbami et al., 2012; Brashers, 2010). Despite increased knowledge regarding the mechanisms and pathophysiology of asthma and increased treatment options, the prevalence of asthma in the United States continues to rise (Akinbami et al., 2012). Evidence-based guidelines on the treatment and management of asthma have been available for over 20 years and the use of Asthma Action Plans (AAP) has been consistently recommended to provide patients with the self-management skills to control asthma symptoms. However, research has consistently demonstrated underutilized AAPs as a method to decrease asthma exacerbations. The purpose of this DNP project was to develop and implement a quality improvement (QI) initiative with Internal and Family Medicine in Mesa-Gilbert, Arizona that will improve asthma clinical management by providing the patient self-management skills needed to control the symptoms, prevent complications, and improve outcomes through the implementation of AAP standards for patients diagnosed with asthma. Using the Plan-Do-Study-Act (PDSA) method to promote quality improvement (QI), a root cause analysis was conducted to evaluate the current processes within the clinic. The QI team agreed upon a process change, which was implemented to promote the identification of patients with asthma so that an AAP could be implemented. The low rates of patients identified during the time period in which this QI project was conducted presented a limitation as to whether the process change was truly effective. This project discussed the process of QI using the PDSA Model for Improvement and need for evidence-based practice to promote improved patient outcomes. Further PDSA cycles and additional time are required to fully incorporate process change and to determine the effectiveness of the intervention.

Asthma is a chronic respiratory disease characterized by long- and short-term inflammation and bronchospasm susceptible to multiple triggers that affects patients across the lifespan. Asthma management is a primary care priority in Vermont, where there continues to be an above-average prevalence of asthma among both children and adults as compared to other states. However, many of Vermont's children and especially adults with asthma are not participating in regular check-ups for asthma management that would best prevent exacerbation of asthma symptoms. Several climate and weather elements including, but not limited to, extreme temperatures and particulate matter are known asthma triggers. Vermont's high per capita use of old woodstoves, pockets of poverty and cold winters are all factors that might collide to adversely impact residents' asthma. Insights into how climate and weather might be related to peak periods of acute asthma exacerbation (AAE) among individuals living in the rural Northeast Kingdom of Vermont (NEK) could provide valuable, regionally focused public health information to primary care providers on the front lines of asthma management. The objective of this research was to examine the potential relationship between the climate and weather of the NEK and visits for asthma exacerbation in the primary care setting. The research began with a retrospective chart review including visits to five different clinic sites in the NEK between 2009-2014 with the ICD-9 code for asthma exacerbation (493.xx) as the primary diagnosis. When visits were individually validated as an AAE, the clinic site, date of visit, and the patients' age and sex were documented. These validated visits were then analyzed against weather and climate data including temperature and air quality. Results suggest that while diurnal shifts and air quality do not show a strong relationship with AAEs in this area, colder days do appear to correlate to when patients visit primary care clinics in the NEK for AAEs.

Primary care clinics are increasingly integrating psychological services into their service programs, however few studies have used a comparison group to demonstrate the effectiveness of these services. This study evaluated the psychological services provided at the Ambulatory Care Clinic (ACC) at the Virginia Commonwealth University Health System (VCUHS) by comparing changes in 147 patients’ PHQ-9 depression scores and GAD-7 anxiety scores over time to the scores of 139 patients at the Hayes E. Willis Health Center, a comparison clinic with demographically similar patients but no integrated psychological services. Assessment data were collected from participants in the ACC at VCUHS during their first or second primary care psychology appointment and during their 3rd-5th appointment. To maximize similarity in baseline levels, participants in the Hayes clinic were matched to participants from the ACC at VCUHS according to their initial levels of depression and anxiety. Participants from the Hayes clinic were then evaluated with follow-up measures of depression and anxiety at approximately the same time interval as their matched counterparts from the ACC at VCUHS. Results indicated that participants from the ACC at VCUHS experienced significantly greater decreases in their depression and anxiety scores compared to participants in the Hayes Clinic. These results remained significant after accounting for participants’ medication for depression and anxiety and participants’ medical diagnoses. The influence of additional mental health services, treatment resistance factors, marital status, employment status, and general demographic variables were also evaluated. This study provided modest preliminary evidence that indicate integration of psychological services is effective. Strengths, limitations, and implications and future directions are discussed.

This study served as an initial evaluation of integrated psychology services within a clinic designed to serve uninsured patients with complex medical concerns and high utilization histories at the Medical College of Virginia in Richmond, Virginia. The current study evaluates patient outcomes, and more specifically, it further quantifies and describes the role that psychologists play in the primary care setting and their impact on utilization of medical care and in improved health outcomes. Additionally, the study evaluates psychologists’ success at treating mental and behavioral health conditions within the primary care model. The present study demonstrates that patients with complex medical and mental health needs can be effectively managed and treated in an integrated ambulatory care clinic. Care within this clinic resulted in significant improvements in depression, anxiety, HbA1c, cholesterol, and blood pressure. The findings suggested possible improvements in behavioral health outcomes such as insomnia as well, but more structured follow-up data are needed in future research to explore this relationship. Additionally it is possible that reductions in BMI may be significant if followed over a longer period of time. Utilization outcomes were more mixed, and contrary to the expectation that integrated services and improvements in health would be related to decreased utilization. Given the shift in health outcomes over the follow-up period, it is possible that early increases in utilization at the six-month mark, may shift to reductions in utilization and cost if the window of observation is expanded.

Evidence for the timing and frequency of monitoring chronic conditions in primary care is often of low quality or absent. Recently, a methodology based upon repeated measures of monitoring tests has been developed to evaluate monitoring strategies which differ by frequency and the length of interval. In studies using this approach, it has been shown that there is potential for substantial over-detection and over-treatment through routine monitoring. The aim of this thesis was to extend the existing methodology to outcomes with highly skewed distributions and tests that are interpreted as dichotomous or categorical states. These methods were applied to find evidence for the intervals of monitoring for microalbuminuria in people with type 1 diabetes and screening for diabetic retinopathy. Statistical models were used to describe the progression of albuminuria and retinopathy and estimate the rates of false positive and false negative tests over time. Simulation was then used to create hypothetical cohorts of people being monitored and screening at different frequencies and for different baseline risk. The impact of changing the timing of tests within the programme was measured and evaluated. The basic framework of the methodology can be usefully extended to tests that have categorical outcome or highly skewed distributions. More frequent monitoring of microalbuminuria in people with type 1 diabetes, and more frequent screening of diabetic retinopathy leads to disproportionate numbers of false positive results and potential over-treatment or referral to specialist services. As with any other clinical intervention, monitoring and screening intervals should be based upon solid evidence. Monitoring for microalbuminuria and screening for diabetic retinopathy less frequently would reduce the rates of false positives tests but the implications of less surveillance need further investigation.