Chaimaa Fanaki, MSPH1,2, Julie Fortin, MD3, Marie-Josée Sirois, PhD1,2,4,5, Edeltraut Kröger, BPharm, PhD1,2,6, Jacobi Elliott, PhD7, Paul Stolee, PhD7, Susie Gregg, OT8, Joanie Sims-Gould, RSW, PhD9, Anik Giguere, PhD1,2,3
1VITAM—Research Centre On Sustainable Health, Quebec, QC
2Quebec Centre for Excellence on Aging, Quebec, QC
3Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC
4Research Centre of the CHU de Québec, Quebec, QC
5Department of Readaptation, Université Laval, Quebec, QC
6Faculty of Pharmacy, Université Laval, Quebec, QC
7School of Public Health and Health Systems, University of Waterloo, Waterloo, ON
8Canadian Mental Health Association Waterloo Wellington Dufferin, Waterloo, ON
9Department of Family Practice, University of British Columbia, Vancouver, BC
DOI: https://doi.org/10.5770/cgj.26.646
ABSTRACT
Introduction
To help recognize and care for community-dwelling older adults living with frailty, we plan to implement a primary care pathway consisting of frailty screening, shared decision-making to select a preventive intervention, and facilitated referral to community-based services. In this study, we examined the potential factors influencing adoption of this pathway.
Methods
In this qualitative, descriptive study, we conducted semi-structured interviews and focus groups with patients aged 70 years and older, health professionals (HPs), and managers from four primary care practices in the province of Quebec, representatives of community-based services and geriatric clinics located near the practices. Two researchers conducted an inductive/deductive thematic analysis, by first drawing on the Consolidated Framework for Implementation Research and then adding emergent subthemes.
Results
We recruited 28 patients, 29 HPs, and 8 managers from four primary care practices, 16 representatives from community-based services, and 10 representatives from geriatric clinics. Participants identified several factors that could influence adoption of the pathway: the availability of electronic and printed versions of the decision aids; the complexity of including a screening form in the electronic health record; public policies that limit the capacity of community-based services; HPs’ positive attitudes toward shared decision-making and their work overload; and lack of funding.
Conclusions
These findings will inform the implementation of the care pathway, so that it meets the needs of key stakeholders and can be scaled up.
Key words: frailty, shared decision-making, screening, integrated care, home- and community-based care and services, autonomy and self-efficacy, person-centered care, preventive care
In Canada and other countries of the Organization for Economic Co-operation and Development, the demographic weight of people aged 65 and older is expected to increase from 15% in 2010, to about 25% by 2030.(1) Population aging is leading to an increase in the prevalence of chronic diseases and age-related disabilities(2) and in the number of older adults living with frailty.(3) Frailty consists of a reduction in the physiological reserves of multiple systems (endocrine system, musculoskeletal system, central nervous system, immune system), resulting in increased vulnerability to stressors.(4) Frailty, therefore, predisposes individuals to functional decline, falls, institutionalization, and death.(4) The increasing number of older adults living with frailty increases the pressure on health-care systems,(3) and preventing and delaying functional decline are therefore public health priorities.(5,6)
Screening for frailty is often recommended as a first step in managing frailty,(5,7,8) as a recent systematic review has shown that frailty can be limited or delayed with appropriate interventions such as strength exercises and protein supplementation.(9) Primary care is a logical place to screen and manage frailty because it is the first point of contact for patients, and primary-care health professionals (HPs) regularly interact with older adults.(10) Several studies, national policies, and guidelines have called for screening for frailty in primary care.(11,12) In addition to screening, primary-care redesign to manage frailty should include shared decision-making to choose a care plan based on the best available evidence about the risks and benefits of all available options, while ensuring that the patient’s values and preferences are considered.(13–16) Finally, to support implementation of the care plan, HPs should coordinate care processes with other health, social, and community services,(17) as older adults typically do not know community-based services well and may have difficulty reaching them.(18–20) We therefore plan to implement and evaluate a novel care pathway to address these needs. This will include screening to identify older adults at risk for adverse outcomes, patient and family engagement in shared decision-making, and optimized technology-enabled care coordination.
This paper reports on the first phase of this broad research initiative, in which we planned the implementation of the pathway, before evaluating its impact on patient and provider experience and patient quality of life in a second phase. Given the acknowledged gap between the identification of evidence-based innovations and their consistent and widespread adoption in health care,(21) we intend to tailor this pathway and the implementation strategies to user needs prior to implementation, to improve implementation success. We therefore used theory to explore the potential factors influencing the adoption of this novel care pathway in primary care clinics in the province of Quebec, with the ultimate goal of tailoring it to the needs of key stakeholders and supporting its implementation.
This descriptive qualitative study involved individual interviews and focus groups with key stakeholders in three regions of the province of Quebec. As mentioned above, it is part of a larger quasi-experimental research project designed to evaluate the impact of the care pathway in nine primary care practices in three Canadian provinces.(22,23) This project was approved by the CIUSSS de la Capitale-Nationale en santé des populations et première ligne research ethics committee (2017-2018-12 MP), and we obtained written and signed informed consent from participants.
The proposed primary care pathway has three components. First is the InterRAI preliminary screener (www.interRAI.org),(24) which allows classification of patients according to their level of frailty. Second is the e-TUDE professional distance training program on shared decision making,(25) which includes five patient decision aids in printable and web-based formats. The decision aids were developed from a template,(26,27) and describe the benefits and harms of options to prevent functional decline. Third is a web-based directory of community-based support services—Caredove (Caredove, Orillia, ON)—to help HPs make referrals to local health services or community-based support services and enable implementation of the selected preventive option.
We recruited four primary care practices in the province of Quebec through our teams’ networks. In each practice, we recruited a convenience sample of HPs from any professions (e.g., nurses, social workers, physicians) who practiced there and the managers of the practices. We also recruited convenience samples of representatives of community-based support services, and of geriatric services near the practices. We also recruited six to eight patients who were a subsample of the 280 patients recruited as part of the broader project to assess the impact of the care pathway,(22) and who had varying levels of functional autonomy. Patients living with neurocognitive disorders were included in the study if they were accompanied by a caregiver who agreed to participate in the study and complete the questionnaires on behalf of the person for whom they were responsible.
We conducted semistructured focus groups and individual interviews using interview guides. Interviews with HPs, managers, and representatives of community-based support services and geriatric services were conducted face-to-face and lasted approximately 1 hour. They covered current experiences with providing care for older adults, the challenges and required resources they expected to need to adopt the proposed pathway, which we described to them in detail. Interviews with patients were conducted by telephone and lasted approximately 30 min. They concerned patients’ experiences of care. We conducted new interviews until we reached saturation, that is, until no further recurring themes emerged from the analysis.(28)
Our thematic data analysis combined deductive and inductive approaches,(29) by first looking for domains described in the Consolidated Framework for Implementation Research (CFIR),(30) and then for emergent themes and subthemes. The CFIR is a meta-theoretical framework that includes 39 constructs that are divided into 5 domains, for understanding the factors that influence implementation.
Two students (including CF) and one researcher (AG) collaborated on the analyzes. The two students first analyzed a portion of the data independently, and then met with the researcher to agree on an initial list of themes and subthemes. Any disagreements were resolved through discussion. Then, a single student (CF) analyzed the remaining data while validating any new themes with the other student. The researcher corroborated the results at the end of the analysis. Analysis of the qualitative data was facilitated by the use of software (NVivo12; QSR International (Americas) Inc., Burlington, MA).
The analytic code, data coding schemes, and interview guide materials for this study can be shared with other researchers, and are available directly from the corresponding author upon request.
We conducted 47 semistructured interviews and 8 focus groups with a total of 32 HPs, 27 patients, 8 managers, 16 representatives of community-based support services, and 6 representatives of geriatric services (Table 1). Two practices were located in the same area (practices #1 and #2), so we recruited a single sample of representatives from community support services and geriatric clinics for both. Very few caregivers of patients living with neurocognitive disorders participated in the broad-based pathway impact evaluation project, and none in the first phase presented here.
TABLE 1 Participant characteristics at each of the participating clinics
The following sections present the prevailing views of participants on key factors to consider when developing an implementation plan, grouped by CFIR domains and constructs. The citations mentioned in this section (C1 to C16) are reported in Table 2. The Appendix A presents a more detailed report on all themes and subthemes.
TABLE 2 List of citations mentioned in the text
Participants were generally positive about the proposed care pathway. Several of them appreciated that it would help reduce hospitalizations and unnecessary care (C1). On the other hand, some participants expressed concerns about the time needed to implement the pathway, which could lead to work overload. Some of the managers expressed concerns about the availability of funding to sustain the pathway in the future.
Representatives of community-based support services felt that screening by physicians would allow effective identification of frailty and a timely monitoring of patients (C2), but they noted that the proposed pathway would increase demand for their services. Some HPs also felt that screening could open a Pandora’s box of questions, while physicians may lack the time to answer all of them (C3). One physician noted that asking a series of short questions is a far cry from the usual practice of getting the person to talk to understand their problem (C4).
Participants generally felt that decision aids would help to meet the different needs of patients, involve patients in the care process, and empower them (C5). They also felt that decision aids could raise patients’ awareness of prevention options. However, several participants pointed out that these tools could be too complex for people with low literacy skills. A number of participants welcomed the fact that the decision aids were available in different formats, and called for them to be integrated into electronic health records.
Participants generally felt that the web-based directory of support services would meet a public need to find and access the right local services (C6). Others pointed out the constraints on older people to access to this technology, such as technological illiteracy and financial constraints (C7).
In general, patients reported good communication with HPs. However, some indicated that they lacked information about community-based services and that their HPs rarely or never recommended such services to them (C8). Many participants pointed out that older adults often need support during the referral process, and that long waiting lists for services make it difficult to meet patients’ needs in a timely manner. Several of the participating patients said that they lacked information on how to manage their health properly (C9), while others saw it as their responsibility to take care of their health themselves—for example, by searching for health information online.
Information sharing between community services and primary care practices was reported as lacking. Most HPs reported referring their older patients to local community service centers. Representatives of community service stated that they received requests and referrals from a variety of sources, but rarely from physicians in primary care practices. They felt that physicians in primary care practices were generally unaware of the services offered by community support services and that this role could best be filled by social workers in these practices (C10).
Representatives of community support services also pointed to their lack of communication channels with physicians. Several of them also expressed concern that it would be a challenge to keep up with the potential increase in demand due to the implementation of the directory. They also pointed out that this could lead to additional pressure on their system, compounded by the lack of volunteers, time, and financial resources (C11).
Geriatric clinicians pointed to the lack of a coherent communication system between them and primary care practices, which hindered coordination and continuity of care, and potentially led to treatment delays.
Some participants reported competition between the proposed InterRAI preliminary screener and the Prisma-7 implemented in Quebec. Project overload was also cited as a barrier to implementation of the pathway.
Participants suggested that the components of the pathway be aligned with the province’s Alzheimer’s Plan to improve care for older adults with neurocognitive disorders. In addition, inconsistent government funding for community-based services was seen as a major barrier to implementation (C12).
HPs’ communication channels include interprofessional team meetings to keep track of patients and discuss treatment, and the electronic health record for standard internal communication and patient follow-up. HPs generally turn to the social workers in the practice when referring patients to community services (C13).
Participating HPs and managers generally felt that the care pathway was compatible with their current systems and practice processes.
All participating managers stressed the importance of HP training before implementation. Funding, time, and resources to implement and maintain the pathway were also a concern. Most managers and HPs estimated that implementation would increase the workload of HPs, especially that of physicians (C14).
The electronic health record was seen as important for information sharing between HPs during implementation and for coordination, but it was also reported that additions to the electronic health record were difficult because they had to be approved by the regional health authority.
HPs generally saw added value in the pathway to support their current practice, but some felt that their experience was more valuable than the proposed screening (C15).
Training was perceived as a means to improve HPs’ self-efficacy in implementing the pathway.
Some of the participants from geriatric or community services expressed concern that primary care HPs would not follow the proposed pathway.
Managers were all uncertain about task assignment. Most concluded that the new tasks needed to implement the pathway should be assigned to nursing assistants or nurse practitioners, with support from physicians who could intervene only as needed. However, one of the managers preferred that physicians be responsible for implementing the pathway because patients would feel more comfortable (C16).
Several managers considered having a nursing assistant screen patients in person or by telephone before the appointment. They also considered annual screening of all elderly patients in their practices, and indicated that the responsible person could create clickable notes or alerts in the electronic health record to indicate when screening is complete.
Practice managers suggested that some physicians could take on the role of implementation leader and be responsible for overseeing training. However, they also made clear that some of the individuals who would be best suited for this role would either be unwilling to participate in the project or might decline the role because they are already busy with other tasks.
We explored key stakeholders’ views on the potential factors influencing the adoption by primary care practices of a care pathway to prevent functional decline in community-dwelling older adults. Our findings suggest four main factors to consider in implementing this pathway: defining HPs’ role in implementation; integrating resources for the pathway into the electronic health record; ensuring communication between community-based support services and primary care practices; and increasing funding for community-based support services. Each of these factors is discussed below.
Practice managers should be offered multiple implementation scenarios with different roles for HPs to facilitate adaptation of the trajectory to their environment. Some of these scenarios should delegate screening and shared decision-making to nurses, and referral to community-based services to social workers, to limit physician workload. This is consistent with reports from Canada and other countries where preventive care is largely provided by primary care nurses.(31,32) However, primary care practices in Quebec typically have two nurses for every 10 physicians,(33,34) so nurses are pressed for time. Making elder care a priority for government and local health authorities could ensure that the care pathway take precedence amid all the competing demands on HPs.(35) For example, the BETTER program was successfully implemented by hiring additional staff for screening and prevention in primary care practices.(36) This acknowledged the ongoing roles and workload of HPs, which has been shown to be a key factor in the adoption of innovation.(37)
All the resources needed for implementation should be available in the electronic health record, which is reported to be essential for interdisciplinary teamwork.(38) However, the different systems used in participating practices do not allow for rapid integration of these resources and are not compatible with each other or with the systems used in other facilities. This lack of interoperability is a consequence of the decentralised management of health care in Canada.(39,40) The proposed InterRAI screening tool is part of a suite of instruments that complement each other to assess older adults in a variety of settings such as nursing homes and home care,(41) but they are rarely used in the province of Quebec.
Communication between settings is crucial for the implementation of the proposed pathway, and is facilitated by the directory and by improving HPs’ awareness of local resources. However, the proposed care pathway still lacks strategies to enable information sharing from community-based service representatives to primary care HPs. This lack of information sharing may explain the apparent contradiction between the HPs’ and the other participants’ statements about whether the HPs actually referred their elderly patients to local community-based services. The technology we proposed in this project—Caredove—includes features that allow HPs to formally refer older patients to community services and track the status of their referrals, as well as the services actually provided. The system also allows information to be shared with patients about services in their area and the ability to choose a service together with the patient. Previous research has shown that the creation of new partnerships and collaborations between primary care practices and community programs can increase HPs’ willingness to refer patients outside the health system.(35) Such partnerships can also make it easier to reach vulnerable populations and provide comprehensive services.(42–44) They can also support the implementation of new practices.(45)
Representatives from community-based support services expressed concern about whether they would be able to keep up with the potential increase in demand following the introduction of the pathway. Recent policy reforms in Canada have increasingly shifted social services delivery to community-based support services, which are funded on a project-by-project basis without covering basic operating costs.(46) As a result, community-based support services can only serve a limited number of clients and are struggling with growing waiting lists, declining volunteer numbers, and staff burnout.(46) To support the implementation of the pathway, long-term funding is needed to help community-based support services fulfill their roles.(46)
The CFIR allowed for a systematic examination of potential implementation issues to revise planned strategies and improve the chances of successful implementation. It is a strength that during this process we assessed the compatibility of the care pathway with patients’ perspectives on their care and needs, because it has already been noted as a limitation of studies using the CFIR that patients’ perspectives and experiences are not taken into account.(47,48) A limitation of this study is that participant age and gender were not considered as potential factors influencing pathway adoption. Intersectional factors should have been included to help illuminate how the interaction between social factors such as age and gender, as well as power structures, might influence decision-making and behavior, and to allow for consideration of these factors when developing implementation strategies.(49) Another limitation is that nonphysician HPs in some practices participated less in the discussions, so the results do not reflect well the determinants or logistical issues associated with implementation for these professional groups. The lack of caregivers in our sample also limits the transferability of our findings to older adults who rely on the support of a friend or family caregiver.
This study made it possible to identify the success factors in the implementation of a complex multicomponent intervention. The next steps will be to tailor the intervention to address limitations prior implementation. Identifying determinants of intervention implementation at multiple levels using a comprehensive theoretical framework should allow the intervention to be improved and support the success of implementation. While some of these determinants are easier to meet—for example, at the level of innovation or the internal context of primary care practices; others at the level of the external environment—for example, communication with community support services and external policies and incentives, may require longer-term efforts before implementation. This study will enable a focus on these determinants in the coming years to ensure that care for older adults includes preventive measures, starting with screening for frailty.
The authors would like to thank all participants: the patients, the staff of the participating primary care practices, geriatric services and community-based services. We also thank Laëtitia Coudert, Allyson Bernier, Clémence Bravetti, Marie-France de Lafontaine, Audrey Dzomo, Thalie Flores-Tremblay, Carolyne Gosselin, Christine Marcotte, and Vanina Tchuente for their contribution to participant recruitment, Anaïs Fortin-Maltais for her contribution to the analyzes, and Katherine Hastings for her writing assistance.
We have read and understood the Canadian Geriatrics Journal’s policy on disclosing conflicts of interest and declare that we have none.
This work was supported by the Canadian Frailty Network (CFN) [grant #TG2015-24], which is funded by the Government of Canada’s Networks of Centres of Excellence (NCE) program. CF received a scholarship from the Quebec Centre for Excellence on Aging (Centre d’Excellence sur le Vieillissement de Québec).
1 Azeredo AC, Payeur FF. Vieillissement démographique au Québec: comparaison avec les pays de l’OCDE. Données sociodémographiques en bref [Internet]. 2015 June;19(3):1–9. Available from: https://statistique.quebec.ca/en/fichier/vieillissement-demographique-au-quebec-comparaison-avec-les-pays-de-locde.pdf
2 Canadian Institute for Health Information. Seniors in transition: Exploring pathways across the care continuum—methodology notes [Internet]. Ottawa, ON; 2017. Available from: https://www.cihi.ca/sites/default/files/document/seniors-transition-methodology-notes-2017-en-web.pdf
3 Bleijenberg N, Drubbel I, ten Dam VH, Numans ME, Schuurmans MJ, de Wit NJ. Proactive and integrated primary care for frail older people: Design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT). BMC Geriatr. 2012 Dec;12:16.
4 Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet [Internet]. 2013 Mar 02 [cited 2017 Jul 14];381(9868):752–62. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673612621679
5 Ambagtsheer RC, Beilby JJ, Visvanathan R, Dent E, Yu S, Braunack-Mayer AJ. Should we screen for frailty in primary care settings? A fresh perspective on the frailty evidence base: A narrative review. Prev Med. 2019 Feb 01;119:63–69.
6 World Health Organization. Global strategy and action plan on ageing and health [Internet]. Geneva: WHO; 2017. Available from: https://www.who.int/publications/i/item/9789241513500
7 Dent E, Martin FC, Bergman H, Woo J, Romero-Ortuno R, Walston JD. Management of frailty: Opportunities, challenges, and future directions. Lancet. 2019 Oct 02;394(10206):1376–86.
8 Abbasi M, Rolfson D, Amandeep SK, Dabravolskaj J, Dent E, Xia L. Identification and management of frailty in the primary care setting. Can Med Assoc J [Internet]. 2018 Sep 24;190(38):E1134–40. Available from: http://www.cmaj.ca/lookup/doi/10.1503/cmaj.171509
9 Travers J, Romero-Ortuno R, Bailey J, Cooney M-T. Delaying and reversing frailty: A systematic review of primary care interventions. Br J Gen Pract. 2019 Jan 01;69(678):e61–69.
10 Drey M, Wehr H, Wehr G, et al. Das frailty-syndrom in der hausärztlichen praxis. Eine pilotstudie. Z Gerontol Geriatr. 2011 Feb;44(1):48–54.
11 Muscedere J, Andrew MK, Bagshaw SM, et al. Screening for frailty in Canada’s health care system: A time for action. Can J Aging [Internet]. 2016 Sep 23 [cited 2017 Jul 14];35(03):281–97. Available from: http://www.journals.cambridge.org/abstract_S0714980816000301
12 Nan J, Duan Y, Wu S, et al. Perspectives of older adults, caregivers, healthcare providers on frailty screening in primary care: A systematic review and qualitative meta-synthesis. BMC Geriatr [Internet]. 2022 Jun 03;22(1):482. Available from: https://doi.org/10.1186/s12877-022-03173-6
13 Elliott J, McNeil H, Ashbourne J, Huson K, Boscart V, Stolee P. Engaging older adults in health care decision-making: A realist synthesis. Patient [Internet]. 2016 Oct;9(5):383–93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27048393
14 Buurman B, Martin F, Conroy S, eds. Holistic assessment of older people. In: Rikkert MO, Conroy S, Bleijenberg N, et al. Silver Book II [Internet]. London: British Geriatric Society; 2019. Available from: https://www.bgs.org.uk/resources/silver-book-ii-holistic-assessment-of-older-people
15 Andrew MK, Dupuis-Blanchard S, Maxwell C, et al. Social and societal implications of frailty, including impact on Canadian healthcare systems. J Frailty Aging [Internet]. 2018 Oct 08;7(4):217–23. Available from: https://doi.org/10.14283/jfa.2018.30
16 Janssen J, Giguere A, Pel-Littel RE, van der Weijden T. Comorbidities. In: Ho E, Bylund C, van Weert J, Basnyat I, Bol N, Dean M, eds. The International Encyclopedia of Health Communication [Internet], 1st ed. London: Wiley-Blackwell; 2022. p.3000. Available from: https://www.amazon.co.uk/International-Encyclopedia-Health-Communica-tion/dp/0470673958
17 McCarthy D, Ryan J, Klein S. Models of care for high-need, high-cost patients: An evidence synthesis. Issue Br (Commonw Fund) [Internet]. 2015 Oct;31:1–19. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26591906
18 Vieira Zamora FM. The lived experiences of the oldest-old using community support and health services: A missing piece in age-friendly city development [Msc thesis] [Internet]. London, ON: University of Western Ontario; 2015. Available from: https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=4782&context=etd
19 Tindale J, Denton M, Ploeg J, et al. Social determinants of older adults’ awareness of community support services in Hamilton, Ontario. Health Soc Care Comm [Internet]. 2011 Nov 1;19(6):661–72. Available from: https://doi.org/10.1111/j.1365-2524.2011.01013.x
20 Mc Grath M, Clancy K, Kenny A. An exploration of strategies used by older people to obtain information about health-and social care services in the community. Health Expect. 2016;19(5):1150–59.
21 Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004 Feb; 8(6):1–72.
22 Sims-Gould J, Elliott J, Tong CE, Giguère A, Mallinson S, Stolee P. A national intervention to support frail older adults in primary care: A protocol for an adapted implementation framework. BMC Geriatr [Internet]. 2021 Aug 4;21:453. Available from: https://doi.org/10.1186/s12877-021-02395-4
23 Stolee P, Elliott J, Giguere AM, et al. Transforming primary care for older Canadians living with frailty: Mixed methods study protocol for a complex primary care intervention. BMJ Open. 2021 May 01;11(5):e042911.
24 Hirdes JP. Addressing the health needs of frail elderly people: Ontario’s experience with an integrated health information system. Age Ageing [Internet]. 2006 Jul;35(4):329–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16788076
25 Lawani MA, Côté L, Coudert L, et al. Professional training on shared decision making with older adults living with neurocognitive disorders: A mixed-methods implementation study. BMC Med Inform Decis [Internet]. 2020 Aug 12;20(1):189. Available from: https://doi.org/10.1186/s12911-020-01197-9
26 Bogza L, Patry-Lebeau C, Farmanova E, et al. User-Centered Design and Evaluation of a web-based decision aid for older adults living with mild cognitive impairment and their health care providers: Mixed methods study. JMIR. 2020 Aug;22(8):e17406. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468645/
27 Bilodeau G, Witteman HO, Légaré F, et al. Reducing complexity of patient decision aids for community-based older adults with dementia and their caregivers: Multiple case study of Decision Boxes. BMJ Open [Internet]. 2019 May 1 [cited 2020 Nov 29];9(5):e027727. Available from: https://bmjopen.bmj.com/content/9/5/e027727.abstract
28 Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: Systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018 Dec;18(1):148.
29 Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006 Mar;5(1):80–92.
30 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci [Internet]. 2009 Aug 7;4:50. Available from: https://doi.org/10.1186/1748-5908-4-50
31 Freund T, Everett C, Griffiths P, Hudon C, Naccarella L, Laurant M. Skill mix, roles and remuneration in the primary care workforce: Who are the healthcare professionals in the primary care teams across the world? Int J Nurs Stud. 2015 Mar;32(3):727–43.
32 Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: Is there enough time for prevention? Am J Public Health. 2003 Apr;93(4):635–41.
33 Breton M, Lévesque JF, Pineault R, Hogg W. Primary care reform: Can Quebec’s family medicine group model benefit from the experience of Ontario’s family health teams? Healthcare Pol. 2011 Nov;7(2):e122.
34 Tourigny A, Aubin M, Haggerty J, et al. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician. 2010 Jul 01;56(7):e273–82.
35 Warner G, Lawson B, Sampalli T, Burge F, Gibson R, Wood S. Applying the consolidated framework for implementation research to identify barriers affecting implementation of an online frailty tool into primary health care: A qualitative study. BMC Health Serv Res [Internet]. 2018 May 31 [cited 2020 Jan 10];18:395. Available from: https://doi.org/10.1186/s12913-018-3163-1
36 Grunfeld E, Manca D, Moineddin R, et al. Improving chronic disease prevention and screening in primary care: Results of the BETTER pragmatic cluster randomized controlled trial. BMC Fam Pract. 2013 Dec;14(1):175.
37 Gagnon MP, Desmartis M, Labrecque M, et al. Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. J Med Syst [Internet]. Epub 2010/08/13. 2012 Feb;36(1):241–77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20703721
38 Misfeldt R, Suter E, Oelke N, Hepp S, Lait J. Creating high performing primary health care teams in Alberta, Canada: Mapping out the key issues using a socioecological model. J Interprof Educ Pract. 2017 Mar 01;6:27–32.
39 Chang F, Gupta N. Progress in electronic medical record adoption in Canada. Can Fam Physician. 2015 Dec 01;61(12):1076–84.
40 Alami H, Lehoux P, Gagnon MP, Fortin JP, Fleet R, Ag Ahmed MA. Rethinking the electronic health record through the quadruple aim: Time to align its value with the health system. BMC Med Inform Decis. 2020 Feb;20(1):32.
41 Hirdes JP, Ljunggren G, Morris JN, et al. Reliability of the interRAI suite of assessment instruments: A 12-country study of an integrated health information system. BMC Health Serv Res. 2008 Dec;8(1):277.
42 Spiro A, Oo SA, Marable D, Collins JP. A unique model of the community health worker: The MGH Chelsea community health improvement team. Fam Community Health. 2012 Apr 01;35(2):147–60.
43 McCann TV, Clark E. Adopting care provider-facilitator roles: community mental health nurses and young adults with an early episode of schizophrenia. Soc Theory Health. 2005 Feb 01;3:39–60.
44 Mullins CD, Shaya FT, Blatt L, Saunders E. A qualitative evaluation of a citywide Community Health Partnership Program. J Natl Med Assoc. 2012 Jan 01;104(1–2):53–60.
45 Valaitis RK, Carter N, Lam A, Nicholl J, Feather J, Cleghorn L. Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: A scoping literature review. BMC Health Serv Res. 2017 Dec;17(1):1–14.
46 Gibson K, O’Donnell S, Rideout V. The project-funding regime: Complications for community organizations and their staff. Can Pub Admin. 2007;50(3):411–36.
47 Morgan D, Kosteniuk J, O’Connell ME, et al. Barriers and facilitators to development and implementation of a rural primary health care intervention for dementia: A process evaluation. BMC Health Serv Res. 2019 Dec;19:1–8.
48 Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016 May;11:72.
49 Etherington N, Rodrigues IB, Giangregorio L, et al. Applying an intersectionality lens to the theoretical domains framework: A tool for thinking about how intersecting social identities and structures of power influence behaviour. BMC Med Res Methodol [Internet]. 2020 Jun;20:169. Available from: https://doi.org/10.1186/s12874-020-01056-1
TABLE 1 Characteristics of the proposed intervention that may influence its implementation, based on the CFIR(30)
TABLE 2 Specific characteristics of the proposed frailty screening that may influence implementation, based on the CFIR(30)
TABLE 3 Characteristics of the proposed patient decision aids that may influence implementation, based on the CFIR(30)
TABLE 4 Characteristics of the proposed directory of local community resources that may influence implementation, based on the CFIR(30)
TABLE 5 Factors relative to the outer setting that may influence implementation, based on the CFIR(30)
TABLE 6 Factors related to the internal context (in this case, primary care practices), the characteristics of the individuals working there, and the implementation process, based on the CFIR(30)
Canadian Geriatrics Journal, Vol. 26, No. 2, June 2023