Evaluating the Implementation of Health Checks for Adults With Intellectual and Developmental Disabilities in Primary Care: The Importance of Organizational Context

Identifying barriers and facilitators to primary care practitioners implementing health assessments for people with intellectual disability: a Theoretical Domains Framework-informed scoping review

INTRODUCTION

People with intellectual disability experience poorer health outcomes compared with the general population, partly due to the difficulties of accessing preventive care in primary care settings. There is good evidence that structured annual health assessments can enhance quality of care for people with intellectual disability, and their use has become recommended policy in several high-income countries. However, uptake remains low. The Theoretical Domains Framework (TDF) offers a conceptual structure for understanding barriers to implementation and has been usefully applied to inform implementation of health assessments for other high-need groups, but not for people with intellectual disability. We conducted a scoping review of the literature, using the TDF, to identify barriers and facilitators influencing primary care practitioners' implementation of annual health assessments for people with intellectual disability as part of routine primary care practice.

METHODS

This study was conducted according to the JBI methodological approach for scoping reviews. Searches were conducted in Medline (OVID-SP), Embase (OVID-SP), PsycINFO (OVID-SP), CINHAL (EBSCO), Scopus (Elsevier) and Web of Science (Clarivate) for relevant peer-reviewed publications up to May 2023. Screening, full-text review and data extraction were completed by two independent reviewers. Data were extracted and mapped to the TDF to identify relevant barriers and facilitators.

RESULTS

The search yielded 1057 publications, with 21 meeting the inclusion criteria. Mapping data to the TDF, the most frequently identified domains were (a) environmental context and resources, (b) skills, (c) knowledge and (d) emotion. Predominant factors impacting on implementation included practitioners' lack of awareness about health assessments and their identified benefits; inadequate training and experience by practitioners in the delivery of health assessments for people with intellectual disability; insufficient time to provide health assessments; and practitioner burnout.

CONCLUSION

Using a theory-informed behavioural framework, our review aids understanding of the barriers and facilitators to improving the implementation of health assessments as part of routine care for people with intellectual disability. However, there is a clear need for further qualitative research to examine the perceptions of primary care practitioners regarding implementation barriers and facilitators to health assessments in general, including views from practitioners who are not currently undertaking health assessments.

Towards developing an intervention to support periodic health checks for adults with intellectual and developmental disabilities: Striving for health equity

BACKGROUND

Although the Canadian Consensus Guidelines for Primary Care of Adults with Intellectual and Developmental Disabilities recommends conducting periodic health checks in primary care, uptake is lacking. This study seeks to understand factors influencing the conduct of periodic health checks and identify what needs to change to increase them.

METHOD

Qualitative data from five stakeholder groups (adults with intellectual and developmental disabilities, primary care providers, administrative staff, family, disability support workers) was guided by the Behaviour Change Wheel and the Theoretical Domains Framework to identify barriers and 'what needs to change' to support periodic health checks.

RESULTS

Stakeholders (n = 41) voiced multiple barriers. A total of 31 common and 2 unique themes were identified plus 33 items 'needing to change'.

CONCLUSION

Despite barriers, stakeholders saw merit in periodic health checks as a preventative and equitable healthcare offering for adults with intellectual and developmental disabilities. Results will inform future intervention development steps.

Stakeholder Perspectives on Interprofessional Primary Care for Adults With Intellectual and Developmental Disabilities in Ontario, Canada

Access to high-quality primary care has been identified as a pressing need for adults with intellectual and developmental disabilities (IDD). Interprofessional primary care teams offer comprehensive and coordinated approaches to primary care delivery and are well-positioned to address the needs of adults with IDD. The overall aim of this article is to describe the current provision of interprofessional primary care for adults with IDD from the perspectives of patients, caregivers, and health providers. Results provide important insights into the current state of practice and highlight a critical need for further work in the field to develop processes to engage in team-based care and demonstrate the value of the approach for this population.

Barriers and Facilitators to Healthcare Access in Adults with Intellectual and Developmental Disorders and Communication Difficulties: an Integrative Review

This integrative review explores the barriers to and facilitators of healthcare access in adults with intellectual and developmental disorders (IDD) and communication difficulties (CD) using Levesque et al.'s conceptual framework of access to health. IDDs are a group of disorders that occur early in childhood and often involve language dysfunction. CDs are prevalent in adults with IDD. Several themes emerged as barriers to access for adults with IDDs and CDs including health literacy, understanding health information, and screening; fear and negative patient expectations; impaired autonomy; time; accommodation needs; insurance coverage and financial hardship; communication; coordination and continuity of care; and supporter presence and inclusion. Communication between providers, patients, and supporters is a significant barrier for adults with IDD and CD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40489-022-00324-8.

Organizational attributes of interprofessional primary care for adults with intellectual and developmental disabilities in ontario, Canada: a multiple case study

Background

Access to high-quality primary care has been identified as a pressing need for adults with intellectual and developmental disabilities (IDD). Adults with IDD live with complex physical and mental health conditions, use health services differently than the general population and continue to face challenges when accessing health services. Interprofessional primary care teams offer comprehensive and coordinated approaches to primary care delivery and are well-positioned to address the needs of adults with IDD and other vulnerable populations. Although interprofessional primary care teams are recommended, there is currently limited understanding of how interprofessional care is delivered and how access to a team of providers improves the health of this population. The aim of this paper is to describe the organizational attributes of interprofessional primary care for adults with IDD within and across models of team-based care in one local health service context.

Methods

A multiple case study was conducted with five interprofessional primary care teams in Ontario, Canada. Multiple methods were used to generate data including: a survey, document review, electronic medical record report and qualitative interviews. Pattern matching was the primary analytic approach for the within and across case analysis.

Results

Adults with IDD were found to be a small part of the patient population served and this group was poorly identified in three of five teams. Key organizational attributes that support the delivery of interprofessional primary care for adults with IDD were identified. Two examples of targeted programs of care for this group were also found. Despite the presence of interprofessional health providers in all teams, there were limited organizational processes to engage a wide-range of interprofessional services in the care of this group. There was no consistent reporting of outcomes or processes in place to measure the impact of interprofessional services for this population.

Conclusions

This study provides important insights into the current state of interprofessional primary care for adults with IDD in Ontario and highlight a critical need for further work in the field to develop organizational structures and processes to engage in team-based care and demonstrate the value of the approach for this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01502-z.

Adults with intellectual and developmental disabilities and interprofessional, team-based primary health care: a scoping review

OBJECTIVE

This scoping review aimed to examine the state of the evidence for interprofessional, team-based primary health care for adults with intellectual and developmental disabilities.

INTRODUCTION

Adults with intellectual and developmental disabilities are a complex, vulnerable population known to experience health inequities. Interprofessional primary health care teams are recommended to improve access to comprehensive and coordinated health care for these individuals. Limited information is available regarding what services interprofessional primary health care teams provide and how services are evaluated specific to the care of this population.

INCLUSION CRITERIA

This scoping review considered all studies that referenced individuals with intellectual and/or developmental disabilities who were 18 years or older. It considered all studies that referred to health care provision within a primary health care context. All studies that discussed the provision of interprofessional primary health care services were included. "Interprofessional primary health care team" was the term used to describe services provided by health providers (e.g. physicians, nurse practitioners, nurses, dietitians, social workers, mental health workers, occupational therapists, physical therapists) working in a team-based model of care.

METHODS

This scoping review was conducted in accordance with JBI methodology for scoping reviews. Quantitative, qualitative, and mixed methods study designs were considered for inclusion. In addition, systematic reviews, program descriptions, clinical reviews, and opinion papers were considered. Studies published in English and French were included. The period considered was from 2000 to the date of the searches (July and August 2018 for bibliographic databases and January 2019 for the final searches of unpublished studies and selected papers from key authors).

RESULTS

The search identified 2761 records. Despite the global search strategy, only 20 records were included in the final review, mainly consisting of work based in the United States and Canada. Results were heterogeneous and descriptive in nature, consisting of cross-sectional designs, program descriptions, and clinical reviews. The findings represent only a few distinct interprofessional primary health care team models of care and multiple contributions from a small pool of researchers. Roles for physicians, nurse practitioners, nurses, social workers, and mental health providers were identified. Ten studies identified either patient-reported outcomes or health-utilization outcomes. Overall, there was no consistent reporting of outcomes across studies, and outcomes specifically related to many interprofessional services were not captured. Although interprofessional, team-based approaches are supported at a policy and practice level, the concept of interprofessional primary health care for this population remains understudied and is challenged by differences in primary health care provision across the world, complexity in how the field is defined, as well as a lack of consistent reporting of the organizational attributes and processes that support interprofessional primary health care provision.

CONCLUSIONS

To fully realize the potential of interprofessional primary health care teams, health services research is needed to describe organizational attributes and processes, and evaluate interventions for this population. Engaging in this work will ultimately provide a more fulsome evidence base to support high-quality, interprofessional primary health care provision for adults with intellectual and developmental disabilities.

Defining and assessing context in healthcare implementation studies: a systematic review

BACKGROUND

The implementation of evidence-based healthcare interventions is challenging, with a 17-year gap identified between the generation of evidence and its implementation in routine practice. Although contextual factors such as culture and leadership are strong influences for successful implementation, context remains poorly understood, with a lack of consensus regarding how it should be defined and captured within research. This study addresses this issue by providing insight into how context is defined and assessed within healthcare implementation science literature and develops a definition to enable effective measurement of context.

METHODS

Medline, PsychInfo, CINAHL and EMBASE were searched. Articles were included if studies were empirical and evaluated context during the implementation of a healthcare initiative. These English language articles were published in the previous 10 years and included a definition and assessment of context. Results were synthesised using a narrative approach.

RESULTS

Three thousand and twenty-one search records were obtained of which 64 met the eligibility criteria and were included in the review. Studies used a variety of definitions in terms of the level of detail and explanation provided. Some listed contextual factors (n = 19) while others documented sub-elements of a framework that included context (n = 19). The remaining studies provide a rich definition of general context (n = 11) or aspects of context (n = 15). The Alberta Context Tool was the most frequently used quantitative measure (n = 4), while qualitative papers used a range of frameworks to evaluate context. Mixed methods studies used diverse approaches; some used frameworks to inform the methods chosen while others used quantitative measures to inform qualitative data collection. Most studies (n = 50) applied the chosen measure to all aspects of study design with a majority analysing context at an individual level (n = 29).

CONCLUSIONS

This review highlighted inconsistencies in defining and measuring context which emphasised the need to develop an operational definition. By providing this consensus, improvements in implementation processes may result, as a common understanding will help researchers to appropriately account for context in research.

Barriers and facilitators to improving health care for adults with intellectual and developmental disabilities: what do staff tell us?

INTRODUCTION

Adults with intellectual and developmental disabilities (IDD) have high rates of morbidity and are less likely to receive preventive care. Emergency departments and primary care clinics are important entry points into the health care system. Improving care in these settings can lead to increased prevention activities, early disease identification, and ongoing management. We studied barriers and facilitators to improving the care of patients with IDD in three primary and three emergency care sites in Ontario.

METHODS

Data sources included structured implementation logs at each site, focus groups (n = 5) and interviews (n = 8). Barriers and facilitators were coded deductively based on the Consolidated Framework for Implementation Research (CFIR). Synthesis to higher level themes was achieved through review and discussion by the research team. Focus was given to differences between higher and lower implementing sites.

RESULTS

All sites were challenged to prioritize care improvement for a small, complex population and varied levels of implementation were achieved. Having national guidelines, using local data to demonstrate need and sharing evidence on value were important engagement strategies. Factors present at higher implementing sites included strong champions, alignment with site mandate, and use of electronic prompts/reminders. Lower implementing sites showed more passive endorsement of the innovation and had lower capacity to implement.

CONCLUSION

Providing effective care for small, complex groups, such as adults with IDD, is critical to improving long-term health outcomes but is challenging to achieve. At a systemic level, funding incentives, access to expertise and improved electronic record systems may enhance capacity.

Health conditions, functional status and health care utilization in adults with cerebral palsy

AIM

Health conditions in children with cerebral palsy (CP) are well described, yet health is less defined with advancing age. We examined health conditions, functional status and health care utilization in adults with CP across age groups.

METHODS

We collected cross-sectional data on health conditions, functional status and utilization from the medical records of adults with CP across a large university-affiliated primary care network using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey. Data from the National Health and Nutrition Examination Survey and National Health Interview Survey provided prevalence estimates for the general population as comparison.

RESULTS

Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07). Conversely, there were lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses. Independence with all activities of daily living decreased from 37.5% at 18-29 years of age to 22.5% in those 60 and over. Seizure disorders, urinary incontinence and gastroesophageal reflux disease were all independently associated with lower functional status. As expected, health care utilization increased with advancing age.

CONCLUSIONS

Adults with CP should be monitored for conditions occurring at higher prevalence in CP, as well as common conditions occurring with advancing age. Age-related functional decline should be anticipated, especially with coexisting seizure disorders and urinary incontinence.

Long-term condition management in adults with intellectual disability in primary care: a systematic review

Background

Adults with intellectual disabilities have higher morbidity and earlier mortality than the general population. Access to primary health care is lower, despite a higher prevalence of many long-term conditions.

Aim

To synthesise the evidence for the management of long-term conditions in adults with intellectual disabilities and identify barriers and facilitators to management in primary care.

Design & setting

Mixed-methods systematic review.

Method

Seven electronic databases were searched to identify both quantitative and qualitative studies concerning identification and management of long-term conditions in adults with intellectual disability in primary care. Both the screening of titles, abstracts, and full texts, and the quality assessment were carried out in duplicate. Findings were combined in a narrative synthesis.

Results

Fifty-two studies were identified. Adults with intellectual disabilities are less likely than the general population to receive screening and health promotion interventions. Annual health checks may improve screening, identification of health needs, and management of long-term conditions. Health checks have been implemented in various primary care contexts, but the long-term impact on outcomes has not been investigated. Qualitative findings highlighted barriers and facilitators to primary care access, communication, and disease management. Accounts of experiences of adults with intellectual disabilities reveal a dilemma between promoting self-care and ensuring access to services, while avoiding paternalistic care.

Conclusion

Adults with intellectual disabilities face numerous barriers to managing long-term conditions. Reasonable adjustments, based on the experience of adults with intellectual disability, in addition to intervention such as health checks, may improve access and management, but longer-term evaluation of their effectiveness is required.

From the EBM pyramid to the Greek temple: a new conceptual approach to Guidelines as implementation tools in mental health

Guideline methods to develop recommendations dedicate most effort around organising discovery and corroboration knowledge following the evidence-based medicine (EBM) framework. Guidelines typically use a single dimension of information, and generally discard contextual evidence and formal expert knowledge and consumer's experiences in the process. In recognition of the limitations of guidelines in complex cases, complex interventions and systems research, there has been significant effort to develop new tools, guides, resources and structures to use alongside EBM methods of guideline development. In addition to these advances, a new framework based on the philosophy of science is required. Guidelines should be defined as implementation decision support tools for improving the decision-making process in real-world practice and not only as a procedure to optimise the knowledge base of scientific discovery and corroboration. A shift from the model of the EBM pyramid of corroboration of evidence to the use of broader multi-domain perspective graphically depicted as 'Greek temple' could be considered. This model takes into account the different stages of scientific knowledge (discovery, corroboration and implementation), the sources of knowledge relevant to guideline development (experimental, observational, contextual, expert-based and experiential); their underlying inference mechanisms (deduction, induction, abduction, means-end inferences) and a more precise definition of evidence and related terms. The applicability of this broader approach is presented for the development of the Canadian Consensus Guidelines for the Primary Care of People with Developmental Disabilities.