<p>Please insert 2 pages into the main thesis - page 39 and page 40</p> <p>- 2 separate PDF attachments will be included plus the main thesis.</p> / <p><strong>Background:</strong></p> <p><strong> </strong> Academic detailing (AD) provides evidence-based education to healthcare professionals in their practice setting and has been found to improve knowledge and prescribing in many situations. Personalized academic detailing (PAD) is a new initiative by the Hamilton Family Health Team (FHT) in which pharmacists integrated within the FHT provide an AD service to prescribers in their office.</p> <p><strong>Objective: </strong></p> <p>To describe and determine the feasibility of a smoking cessation (SC) PAD program.</p> <p><strong>Methods:</strong></p> <p>Design: Descriptive retrospective cohort pilot project</p> <p>Setting: Primary Care Setting</p> <p>Participants: FHT pharmacists, physicians, nurse practitioners (NPs) and their patients</p> <p>Intervention:</p> <p>Pharmacists receive basic AD training and education (upskilling) on SC; and provide education to clinicians</p> <p><strong>Feasibility Criteria for success:</strong> <ol> <li>PAD coordinator time to train pharmacists <40 >hours</li> <li>Average time for upskilling <20 >hours</li> <li>Average time for PAD session are <60 minutes and><30 minutes for initial and follow-up>visits, respectively</li> <li>Percentage of clinicians detailed within 3 and 6 months are >50% and >70%, respectively</li> <li>Number of new SC referrals to the pharmacist at 3 and 6 months are >5 patients/1.0 full-time equivalent (FTE) pharmacist and >10 patients/1.0 FTE pharmacist, respectively.</li> </ol></p> <p><strong>Results:</strong></p> <p>Eight pharmacists (5.8 FTE) received basic AD training and upskilling on SC PAD. Consent was obtained from 48/54 (88.9%) physicians and 9/10 (90.0%) NPs.</p> <p>The PAD coordinator training time was 29.1 hours. The median time for upskilling was 3.1 hours. The median time for PAD session was 15 and 5 minutes for an initial visit and follow-up visit, respectively. The number of clinicians detailed within 3 and 6 months were 50/64 (78.1%) and 57/64 (89.1%), respectively. The number of new SC referrals at 3 and 6 months was 66 and 200 patients, respectively.</p> <p><strong>Conclusion:</strong></p> <p>This pilot study showed that the main study is feasible with respect to the management, resources, process and scientific components.</p> / Master of Science (MSc)

<p>This thesis describes some of the prominent issues facing primary care practitioners regarding diabetes care. Type 2 diabetes (T2DM) is a common metabolic disturbance among Canadians, now reaching worldwide epidemic proportions. Alarmingly, diabetes prevalence is expected to increase significantly in future years. This increase in diabetes will lead to corresponding increases in the rates of complications, which place a burden on the health care system. However, interventions could prevent or delay T2DM and thus decrease morbidity and mortality associated with its complications if individuals at risk of developing diabetes are detected early.</p> <p>The first paper describes a systematic review to determine the effectiveness of T2DM screening methods using community or family practice-based systematic screening approaches compared to opportunistic family practice-based approaches. The second paper describes a novel community health initiative, the Community Health Awareness of Diabetes (CHAD) Program. It reports participant characteristics and satisfaction with the community-wide diabetes awareness demonstration project. The third paper examines whether the CHAD program was effective in increasing detection of diabetes. As routine diabetes care remains largely a family practice activity, and something that all family doctors participate in, the fourth paper reports on the current state of diabetes care in 96 Ontario family practices.. The final paper reports the findings of a qualitative study examining family physicians’ approach to insulin prescribing in older patients. Current prevalence figures estimate that 16% of people over 65 years have diabetes and family practitioners look after these individuals and their diabetes.</p> <p>Finally, recommendations are made as to how screening and care for diabetes in primary care could be improved. In summary, policies supporting community initiatives partnering with primary healthcare should be promoted in an effort to share the burden of screening for diabetes, and also to target appropriate screening to populations that need it the most.</p> / Doctor of Philosophy (PhD)

Equity of access to healthcare services is a concept which underpins current UK health policy. However evidence suggests that this is not achieved within community palliative care. Referrals can be tardy or not made at all. Most literature describes inequality in service utilisation, but does not aid understanding of why such inequalities exist. There is little research exploring the processes underpinning referral making rather than the outcomes of referrals such as service utilisation. The aim of this research was to investigate the influences on referral decisions made within community palliative care services. A qualitative case study strategy was chosen as the research approach as it provided a framework for facilitating the incorporation of multiple perspectives in a complex context, in a field where there has been little previous research, and where there is little theory to guide the investigation. Three cases (Primary Care Trusts) were studied. Data collection used multiple methods (interviews, observation and documentary analysis, as well as mapping and profiling the palliative care services provided within the cases) from multiple perspectives (general and specialist palliative care professionals, managers, commissioners and patients). Detailed data analysis followed a framework approach, comparing and contrasting patterns within and across cases with existing and developing theoretical propositions. Two core influences on the way health care professionals made referral decisions were found. First, their perception of their own role in providing palliative care. Autonomous professionals made independent judgements about referrals, influenced by their expertise, workload, the special nature of palliative care and the relationship they developed with patients. Second, their perception about those to whom they may refer. Professionals needed to know about services to refer, and then made a complex judgement about the professionals involved and what they could offer the referrer as well as the patient. These findings indicate that many more factors than an assessment of patients' clinical need affect referrals within community palliative care services. It appears that personal, inter-personal and inter-professional factors have the potential to shape referral practices. It may be that the combination of these factors has an influence on equitable access to community palliative care services. Practitioners could be more explicit about referral or non-referral rationales, and policy makers take account of these complex influences on referrals rather than just mandating change.

Objectives: The population, globally and nationally, is ageing and the numbers of those over the age of 65 is increasing. Given this increase in numbers, it is important that the physical and mental health needs of older adults are addressed by service providers. Depression is the most common form of mental ill health in this age group and effective treatments are available. The main aim of the study was to investigate the extent to which general practitioners‘ (GPs) are able to identify depression and offer appropriate treatment strategies to patients over the age of 65 presenting to non-urgent community GP clinics. Method: GPs assessed each participant, attending a general clinic appointment, for depression. Participants (n=31, mean age=75.6 years) completed, with the author, the Abbreviated Mental Test Score (AMTS), and two screening tools: the Structured Clinical Interview for DSM-IV (SCID) and the Geriatric Depression Score – short form, 15 item (GDS-15). A structured interview was conducted and patient records examined to gain demographic information for each patient. Cohen‘s Kappa was used to assess the level of agreement between the GP assessment and the objective measurements for depression. Results: Depression was identified by both the GP and the SCID in three cases. The inter-rater reliability between the SCID and the GP assessment of depression was good (Kappa = 0.61, p <0.001). The inter-rater reliability between the SCID and the GP assessment of dysthymia was poor (Kappa = -0.08, p =ns). Participant numbers prevented further analysis of how the independent variables recorded affected the diagnosis and treatment of depression by GPs. Conclusion: The findings suggest that GPs are able to identify depression but not dysthymia in their older adult patients. The difficulties in engaging GPs in research are explored. The strengths and weaknesses of the study are considered. The clinical implications of the study are discussed.

Class of 2017 Abstract / Objectives: (1) To assess the access to and quality of primary care for patients living with a psychiatric condition(s). (2) To identify demographic factors that may influence the access and quality of primary care services. Methods: Subjects were recruited at HOPE Inc., a behavioral health resource center, in Tucson, Arizona, during pharmacy student-run health fairs. Participants were surveyed using the Primary Care Assessment Tool (PCAT) a questionnaire developed by Johns Hopkins, which assess four domains of primary care. Participants were also surveyed about demographics, mental health diagnosis and their SMI designation. For objective (1): Descriptive statistics for each domain of the PCAT were performed to assess the level of access and quality of care, including comparison to a hypothesized score. For objective (2): Due to the small sample size only descriptive analysis of the demographic data was performed. Results: A total of 11 subjects were surveyed using the PCAT with an average score of 67.64±12.18. This was higher than the hypothesized score of 46. On average, in all four PCAT domains participants scored higher than the hypothesized, value. The lowest scoring domains were, “Care at first contact - Access” and “Coordination of care” (10.45±3.62, Hypothesized score: 8) and (12.36±5.82, Hypothesized score: 10) respectively. The highest scoring domain was “Care at first contact - utilization” (11.09±1.92, Hypothesized score: 12). Conclusions: This study helped to provide a framework for future studies of primary care services using the PCAT survey.

Primary care clinics are increasingly integrating psychological services into their service programs; however few studies have provided quantitative data to support these services. This study served as a program evaluation of the psychological services provided at the Ambulatory Care Clinic at the Virginia Commonwealth University Medical Center in Richmond, Virginia. It includes: 1) a description of the program, including types of patients served, their presenting problems, and treatments administered and 2) evidence of the impact of mental health services on primary care patients’ emotional adjustment and progress on behavioral goals. Data on exposure to stressful life events and intake and follow-up measures of depression, anxiety, smoking, insomnia, chronic pain, and weight loss were collected on 452 adult primary care patients. Although inferences are limited by the lack of a control or comparison group, preliminary findings indicate that the mental health services provided were effective. Implications and future directions are discussed.

Type 2 diabetes mellitus is a chronic disease that is associated with substantial morbidity, mortality, and health care cost. All patients with diabetes require a high level of clinical care to prevent the development of diabetic complications. The aim of this study was to compare the impact of a pharmaceutical care diabetic clinic within a primary care setting to standard care on clinical, humanistic and process outcomes in Type 2 diabetes patients. A randomised controlled trial was conducted in 9 general practices in Greater Glasgow Health Board. All patients with Type 2 diabetes, aged 18 years or over, taking an oral antidiabetic drug were recruited and stratified by practice, age, and gender, and then randomised into an active or control group. The patients in both groups were invited to a pharmaceutical care diabetic clinic within their general practice for three visits at three-monthly intervals. Active patients received review and allocated intervention by the pharmacist while control patients received review only without intervention by the pharmacist. Allocation remained blind until after the first evaluation. The pharmacist evaluated the appropriateness of the medication for the individual and their overall diabetic care. The pharmacist prepared a list of drug-related problems and a referral where appropriate. GP referrals were actioned in the active group but held back until after the conclusion of the study in the control group. Patient outcome measures include changes in HbA 1 c value, systolic blood pressure, health related quality of life (HRQOL), and drug related problems (DRPs) from baseline to the end of the study for both groups.

A hand-off represents the transfer of patient information and care responsibility between a sending and receiving provider. Hand-offs occur in single locations such as inpatient wards and across care settings like from primary care offices to emergency departments. This care transition quality improvement (QI) project was created to improve patient hand-off communication from a primary care office to a hospital based emergency department within the greater Phoenix, AZ metropolitan area. No uniform hand-off process existed before the QI project. The purpose of the QI project was to demonstrate process necessary to achieve desired outcomes, in this case, a superior patient hand-off. The QI project goal was to develop a standardized hand-off protocol and tool. The aim of this QI project was to replace existing hand-off methods with a formalized new hand-off process and tool used during care transition from a primary care office to an emergency department. QI project methods followed two (2) plan-do-study-act (PDSA) cycles involving QI team meetings and end-user feedback that iteratively led to the adoption of a standardized hand-off process and tool. PDSA cycle one identified the best handoff tool. PDSA cycle two established an efficient process for conducting hand-offs. The new hand-off tool consistently demonstrated superior information transfer. Program participant satisfaction increased and was reflected by positive feedback as most nurses and doctors embraced the new process.

Purpose of the Study: The purpose of this study was to test an investigator-developed culturally relevant eating disorder assessment tool, the Risk Assessment of Eating Disorders (RAED), for eventual clinical application in assessing eating disorders in Hispanic women. This study also examined clinical guidelines, developed by the investigator to guide providers in using culturally appropriate behaviors during the assessment process.Research Questions: 1. What do Hispanic women identify and endorse as relevant areas of assessment for detection of potential eating disorders? 2. What culturally competent questions and provider behaviors or interactions do Hispanic women endorse as enabling them to volunteer specific information about their eating disorders? Background: Although some knowledge exists regarding appropriate and effective assessment questions to detect eating disorders, clinicians lack a culturally relevant and brief tool for use in primary care. Literature on existing assessment instruments and the Theory of Cultural Marginality informed development of the tool and guidelines.Method: Five Hispanic females with diagnosed eating disorders completed the RAED tool and scored items for relevance and clarity. This was followed by interviews and discussions with participants concerning perceptions of provider behaviors that enable or inhibit women reporting specific disordered eating behaviors to providers. Results: The results supported relevance and clarity of a 14-item RAED for assessing eating disorders. Seven clinical guidelines were developed on culturally appropriate provider behaviors to help Hispanic women volunteer specific information on their eating disorder behaviors. Discussion: A shorter assessment was developed for eventual use in advance practice nursing. The participants also identified provider behaviors including empathy, a non-judgmental attitude, and being willing to sit down with the patients, as enabling them to speak up about their eating disorder. The Theory of Cultural Marginality was useful in developing the RAED items and Provider Guidelines for assessment. Continued research of the RAED and clinical guidelines was recommended to provide adequate empirical support for use of the assessment tools and theory by advance practice nurses in primary care of Hispanic women, as well as all women with eating disorders.

Background: Youth and young adults have the highest incidence and prevalence of mental health issues, and most do not receive the services they need. Mental health is an essential component of wellness, and primary care providers (PCPs) serve a critical role in promoting mental well-being, identifying problems, facilitating and coordinating services, and managing and monitoring mental health outcomes. Many barriers exist to incorporating mental health into routine primary care for adolescents, and little is known about the specific nature of the obstacles that impede the quality improvement process related to integrating mental and physical health and how to overcome them. Objectives: The purpose of this DNP project was to gain insight into the PCP role, exploring perceptions, current practices, and barriers related to screening, identifying, and managing adolescent mental health needs, understand the challenges and opportunities, and guide future quality improvement projects that reflect and respond to the needs of adolescents in the local community in effective and sustainable ways. Methods: The project was designed as a needs assessment, and conducted as an anonymous 20 question survey that was distributed to 13 local PCPs that routinely provide primary care services to the community’s adolescent population. Results: Nine of the surveys were completed and returned. Time constraints and competing demands were dominant concepts, reported as primary barriers to screening, collaboration with mental health professionals, and addressing mental health in general. The participants articulated the need for high-quality professional mental health involvement, improved collaboration, inter-professional development, and inter-agency cooperation to successfully promote mental health and provide excellent care that improves outcomes. They also displayed an interest in innovative solutions and organizational restructuring to better coordinate mental health services. Conclusion: This project offered preliminary insight into the challenges faced by PCPs addressing adolescent mental health in primary care, and generated ideas for further exploration to guide quality improvement initiatives designed to support the providers' capacity to incorporate mental health into routine care, and contribute to the community’s efforts in promoting mental health for local youth. PCPs occupy esteemed roles in the community, and their perspectives and insight are invaluable.