Evaluation of a primary care-based mobility clinic: Improving health care for individuals with mobility impairments in Ontario, Ca

Joseph Lee, James Milligan, Loretta Hillier and Colleen McMillan

Introduction

Although individuals with mobility impairments have similar basic health care needs as the general population, adults with physical disabilities are less likely to receive the same level of basic and preventative care as abled bodied individuals (Iezzoni, McCarthy, Davis, & Siebens, 2000). Barriers to health care include environmental barriers to access and lack of appropriate equipment (Guilcher et al., 2010; Hwang et al., 2009; Mudrick, Breslin, Liang, & Yee, 2012), limited health professional knowledge of the care needs of individuals with mobility impairments (McColl et al., 2008), and health system disincentives for providing care to this patient population (DeJong, 1997; Marks & Teasell, 2009). Consequently, many individuals with physical disabilities access emergency departments for primary care (Guilcher et al., 2010). There is much support in the literature for building capacity and developing infrastructure supports in primary care to assess, manage, and accommodate patients with disabilities and mobility impairments (McColl et al., 2008; Kroll, Beatty, & Bingham, 2003; Mann, Middleton, & Leong, 2007; Mann et al., 2007).

This paper describes the evaluation of an interprofessional primary care-based mobility clinic aimed at improving quality of care for adults with mobility impairments by improving their access to care and addressing the inequality of current delivery methods.

The Centre for Family Medicine (CFFM) Mobility Clinic

In Canada, Family Health Teams (FHT) consist of groups of health professionals (physicians, nurses, social workers, pharmacists, occupational therapists and other interprofessional care providers) working together to provide primary care within a patient-centered approach to care (Rosser, Colwill, Kasperi, & Wilson, 2010). The CFFM is a FHT in Kitchener, Ontario, Canada with 17 family physicians serving a patient base of over 23,000 patients in an urban setting of approximately 302,143 (Statistics Canada, 2006). This interprofessional Mobility Clinic includes a family physician, chiropractor, nurse, occupational therapist, project manager, administrative assistant, and a social worker and pharmacist as needed. A rehabilitation specialist is available to provide support via email or phone. The clinic provides a fully accessible physical environment including adequate space for wheelchair navigation, platform wheelchair scale, height-adjustable examination tables, a Hoyer lift to assist with transfers, and portable examination equipment (ophthalmoscope, otoscope, and blood pressure cuff). Team members also engage in outreach activities (e.g., home visits) and provide education and training opportunities to students, health professionals and the general public to increase their awareness of the health care issues faced by individuals with physical impairments.

Although referrals are accepted primarily among patients rostered within the CFFM, external referrals are accepted, mostly for spinal cord injured clients, who typically experience great difficulty accessing primary care (McColl et al., 2006). Comprehensive assessment includes a complete medical history, physical examination, medication review, standardized social, environmental, cognitive, mental health, and mobility assessment including balance, gait, falls, ambulation, use of assistive devices, and transfer mechanisms. The team works collaboratively to develop a plan of care based on the assessment results specific to the individual. Referral sources receive a detailed consultation note, which serves as an opportunity to increase their capacity to manage the health of their patients with clinic support to implement recommendations that are not feasible within regular family practice because of limited time, equipment, or expertise (shared care approach). The consultation note also represents a first step toward building relationships among external physicians and in this way supports building capacity within the community for the optimal care of individuals with mobility impairments. Detailed information about the clinic is available elsewhere (Lee, Milligan, Hillier, & McMillan, 2013).

Research Design

The study was framed using a mixed method design that doubled as both a methodology and a method (Creswell, Shope, Clark & Green, 2006) in that it involved collecting and analyzing data through the use of qualitative and quantitative approaches. This research design is well suited to health care to honour the subjective experiences of patients while acknowledging the evidence-based nature of medicine and delivery of services (Donovan et al., 2002). Congruent to a mixed method sequential design, a survey was undertaken that informed the interview guide. In the case of sequencing, we began with a quantitative followed by a qualitative phase within the study to fully appreciate the strengths of both approaches, in addition to recognizing the importance of triangulation as a form of rigor (Groeben & Rustemeyer, 1994).

Over an eight-month period patients were invited to complete a brief anonymous paper-based survey created for this study to measure their satisfaction with the clinic and outcomes in comparison to prior care. Surveys were completed by 36 patients (average age = 63 years; 53% female). All referral sources were invited to complete an anonymous on-line survey created to measure satisfaction with various aspects of the clinic, as well as practice-related outcomes in comparison to prior to their involvement with the clinic; eight surveys (37%) were completed (5 physicians; 6 respondents referred 6 or more patients to the clinic). The findings of the survey informed the questions of the interview guide to honor patient experience as a valid form of knowledge (Charmez, 1991).

Interviews were then conducted with a purposeful sample of 14 key stakeholders. Six informants (five physicians and one spinal cord injury-related community organization representative) participated in individual telephone interviews; eight Mobility Clinic team members participated in a group interview. Interviews were conducted to the point of saturation.

Information related to patient date of referral, demographics, type of mobility impairment, treatment recommendations and referrals to other services were collected for all patients assessed from January 1, 2010 to November 31, 2011.

Survey data were analyzed using descriptive statistics generated by SPSS software (IBM Corp, Version 20.0, Armonk, NY: IBM Corp). Interview transcripts were digitally recorded and transcribed. Constant iteration of the data was done until themes emerged allowing for a coding scheme. The transcriptions were independently reviewed by two authors to avoid bias and reduction of the data too early. The convergence of themes were then compared as a form of triangulation.

This study was approved by the University of Waterloo Office of Research Ethics.

Findings

Over 11 months, 171 patients were referred to the Mobility Clinic; 130 (76%) were assessed and 69 (40%) had completed at least one follow-up visit in clinic. Table 1 presents the characteristics of the patient population served by the clinic and assessment outcomes. The mean response time to assessment in the clinic (from the date of referral) was 4.6 weeks (SD = 4.0).

Forty-four percent of patient satisfaction survey respondents reported that access to preventive health care in the past had been difficult and 41.7% reported that access to care for acute illness had been difficult; the majority of these patients reported that that access to this type of care was now easier with the Mobility Clinic (57.1% and 76.9%, respectively). The majority reported that due to the clinic access to health care is now easier when their condition worsens (73.7%), when specialized equipment is needed (82.6%) and when access to allied health professionals is warranted (87.5%).

All of the referral source survey respondents were satisfied with the overall services provided by the Mobility Clinic, with 37.5% providing ratings of ‘very’ satisfied and 62.5% providing ratings of ‘extremely’ satisfied. Respondents were satisfied with the role that the clinic plays in providing access to primary care, access to interprofessional care, treatment/ care planning, follow-up care and the availability of clinic team members for informal consultation support (all mean ratings ≥ 4.4 on a 5-point scale). The majority of respondents reported that the clinic has had a positive impact on their understanding of the care needs of individuals with mobility impairments (63%) and on supports available to assist them with this care (88%).

Several key findings emerged from the qualitative data. There was general consensus among those interviewed that the clinic has contributed to improved access to comprehensive, interprofessional mobility assessments and care. Secondly, training activities and comprehensive consultation notes have impacted referring health professionals’ capacity to manage care of patients with mobility issues. Lastly, the clinic has reduced the burden of care to individual providers by providing a different level of expertise while enhancing access to community services and programs through system navigation support. It was also suggested that this access to care may reduce inappropriate or unnecessary visits to the emergency department and rehabilitation centres for issues that should managed within primary care.

Discussion

This study has a number of limitations. It is a single site, uncontrolled research design with a relatively small sample size. Future plans to implement this model of care in other FHT settings will provide opportunities for more rigorous research designs to measure practice improvements. Despite limitations, this study provides some preliminary support for significant improvements to access and quality of care for this patient demographic through the implementation of accessible interprofessional primary care-based Mobility Clinics that support capacity building among family physicians. As such, the clinic has demonstrated potential in filling long-standing and significant health care gaps related to environmental barriers, lack of specialized equipment, limited health professional knowledge and limited time within busy family medicine practices to conduct thorough mobility assessments (Iezzoni et al., 2000; Guilcher et al., 2010; Hwang et al., 2009; McColl et al., 2008). The increasing complexity of patients being managed in primary care and the increasing demand for service within the Mobility Clinic, suggests that there is a place for this type of interprofessional care model in primary care and a patient population to support it. Further implementation of this clinic and on-going research into innovative models of service delivery have the potential to significantly change the barriers that have historically prevented individuals with mobility impairments from accessing the same level of quality care as the general population.

Acknowledgements

This study was funded by the Ontario Neurotrauma Foundation. The authors wish to thank Dr. Tara Jeji, Ontario Neurotrauma Foundation, and Dr. Michael Sharratt and Josie D’Avernas, Schlegel-University of Waterloo Research Institute for Aging, for their leadership in the development of this initiative. The work of Dr. Craig Bauman in the implementation of the clinic and supervision of data collection is gratefully acknowledged.

References

Charmez, K. (1991). Good Days, Bad Days: The Self in Chronic Illness and Time. New Brunswick, NJ: Rutgers University Press.

Creswell, J. W., Shope, R., Clark, V. L. & Green, D.O. (2006). How interpretive qualitative research extends mixed methods research. Research in the Schools, 13, 1-11.

DeJong, G. (1997). Primary care for persons with disabilities. An overview of the problem. Archives of Physical Medicine and Rehabilitation, 76, S2-S8.

Donovan, J., Mills, N., Smith, M., Brindle, L., Jacoby A., Peters, T., . . . .Hamdy, F. (2002). Quality improvement report: Improving design and conduct of randomized trials by embedding them in qualitative research: ProtecT (prostate testing for cancer and treatment) study. Commentary: presenting unbiased information to patients can be difficult. British Medical Journal, 325, 766-770.

Guilcher, S. J. T., Munce, S. E. P., Couris, C. M., Fung, K., Craven, B. C., Verrier, M., & Jaglal, S. B. (2010). Health care utilization in non-traumatic and traumatic spinal cord injury: a population-based study. Spinal Cord, 48, 45-50.

Groeben, N., & Rustemeyer, R. (1994). On the integration of quantitative and qualitative methodological paradigms. In I. Borg & P. Mohler (Eds.), Trends and perspectives in empirical social research (pp. 308-325). New York: de Gruyter.

Hwang, K., Johnston, M., Tulsky, D., Wood, K., Dyson-Hudson, T., & Komaroff, E. (2009). Access and coordination of health care service for people with disabilities. Journal of Disability Policy Studies, 20, 28-34.

Iezzoni, L. I., McCarthy, E. P., Davis, R. B., & Siebens, H. (2000). Mobility impairments and use of screening and preventive services. American Journal of Public Health, 90, 955-961.

Kroll, T., Beatty, P. W., & Bingham, S. (2003). Primary care satisfaction among adults with physical disabilities: the role of patient-provider communication. Management Care Quarterly, 11, 11-19.

Lee, J., Milligan, J., Hillier, L. M., & McMillan, C. (2013). Enhancing care for individuals with mobility impairments: Lessons learned in the implementation of a primary care-based Mobility Clinic. Healthcare Quarterly, 16,49-54.

Mann, L., Middelton, J. W., & Leong, G. (2007). Fitting disability into practice. Focus on spinal cord injury. Australian Family Physician, 36, 1039-1042.

Marks, M. B. & Teasell, R. (2009). More than ramps: accessible health care for people with disabilities. Canadian Medical Association Journal, 175, 329.

McColl, M. A., Forster, D., Shortt, S. E. D., Hunter, D., Dorland, J., Godwin, M., & Rosser, W. (2008). Physician experiences providing primary care to people with disabilities. Healthcare Policy, 4, 129-147.

McColl, M. A., Shortt, S. E. D., O'Brien, P., Godwin, M., Rowe, K., & Smith, K. (2006). Models of Integrated Rehabilitation and Primary Care. Final report to the Ontario Neurotrauma Foundation and Ontario Ministry of Health and Long-Term Care. Kingston, ON: Authors.

Patton, M. Q. (2002). Qualitative Evaluation and Research. Thousand Oaks, CA: Sage.

Rosser, W. W., Colwill, J. M., Kasperi, J., & Wilson, L. (2010). Patient-centered medical homes in Ontario. New England Journal of Medicine, 362, e7.

Statistics Canada (2006b). Population and dwelling counts, for census metropolitan areas, 2006 and 2001 censuses. Retrieved December 11, 2012, from http://www12.statcan.ca/english/census06/data/popdwell/Table.cfm?T=205&SR=1&S=3&O=D.&RPP=33.

Contributors

Joseph Lee, MD, CCFP, FCFP, MClSc
Centre for Family Medicine Family Health Team, 10B Victoria Street South, Kitchener, Ontario, Canada, N2G 1C5 and Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada, L8S 4L8. Email: jlee@mcmaster.ca

James Milligan, BSc.P.T., MD, CCFP
Centre for Family Medicine Family Health Team, 10B Victoria Street South, Kitchener, Ontario, Canada, N2G 1C5 and Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada, L8S 4L8. Email: James.Milligan@medportal.ca

Loretta M. Hillier, M.A.
Specialized Geriatric Services, St. Joseph’s Health Care London, and Aging, Rehabilitation & Geriatric Care Research Centre of the Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada N6C 5J1. Email: lmhillier@rogers.com

Colleen McMillan, BES, MSW, PhD
Centre for Family Medicine Family Health Team, 10B Victoria Street South, Kitchener, Ontario, Canada, N2G 1C5 and University of Waterloo, Renison College, Waterloo, Ontario, Canada, N2L 3G4. Email: c7mcmillan@uwaterloo.ca
Corresponding Author: lmhillier@rogers.com

Table 1 Characteristics of the patient population served in the Mobility Clinic and assessment outcomes (N = 130)


Variable

Clinic Patients

n = 130

Age, years mean ± SD

62 ± 18

Sex

Female

65 (50%)

Male

65 (50%)

Available Family Physician*

124 (95%)

Mobility Aid Use†

68 (52%)

Reason for Referral

Balance/ gait issues

22 (13%)

Chronic pain (neuralgia, fibromyalgia, sciatica, unspecified)

21 (12%)

Cerebral Palsy

11 (4%)

Falls‡

34 (20%)

Mobility issues/ assessment

24 (14%)

Multiple Sclerosis

10 (6%)

Obesity

10 (6%)

Osteoarthritis

10 (6%)

Paraplegia/ Quadriplegia

5 (3%)

Preventive services (e.g., Pap/ gyne assessment, physical)

10 (6%)

Spinal cord injury

8 (5%)

Visual/ auditory impairments/ communication issues

7 (4%)

Multiple issues

8 (5%)

Miscellaneous§

45 (26%)

Wait Time to Assessment (from referral date)

Within the week referred

11 (9%)

Within the week referred

11 (9%)

One-two weeks

30 (23%)

Three-four weeks

34 (26%)

Five–eight weeks

25 (19%)

> 9 weeks

29 (22%)

Use of special equipment║

59 (45%)

Treatment recommendations

Exercise instructions

44 (34%)

Radiograph investigations

35 (27%)

Equipment/ assistive devices

35 (27%)

Supplements (vitamin D, calcium)

39 (30%)

Falls prevention information

12 (9%)

Medication for acute/chronic conditions

17 (13%)

Laboratory investigations

8 (6%)

Physiotherapy/ chiropractor

2 (2%)

Follow-up with other health providers

9 (7%)

Chiropody

5 (4%)

Consultation with specialist/family physician

10 (8%)

Home assessment (Occupational Therapy)

3 (2%)

Education¶

4 (3%)

Referrals to other services

CCAC# – assessment (feeding, swallowing, seating, home care)

2 (2%)

Physiotherapy/ chiropractor

6 (5%)

CFFM Professionals (e.g., Chiropodist, Dietitian, Social Worker, pain clinic)

14 (11%)

Miscellaneous**

13 (10%)

Notes:

*Six patients were orphaned at the time of their referral to the clinic; primary care was assumed by a family physician within the CFFM.

† This is likely an underestimate as collection of this information started several months after the launch of the clinic.

‡Falls related to balance and gait issues, Meniere’s disease, pain, unspecified/ unknown causes.

§ Miscellaneous: For conditions identified for 3 or fewer patients, including ataxia, autonomic dysreflexia, cerebrovascular accident, osteoporosis, spinal conditions (deformity, spina bifida.

║ Scale, lift, examination table; this is likely an underestimate as collection of this information started several months after the launch of the clinic.

¶ Education on red flags, signs and symptoms of when to go to Emergency Department, medical condition.

#In Ontario, Community Care Access Centres (CCAC) are responsible for the provision of home care services.

**Miscellaneous: Referrals made only once, including optometry clinic, adult day program, respite, lifeline, transportation service.


 

International Journal of Disability, Community & Rehabilitation
Volume 13, No. 1
www.ijdcr.ca
ISSN 1703-3381
  

  
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