Objective Older patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients. Methods This systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes. Results Of 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions. Conclusion Various interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.

Background Mental health disparities between Indigenous and non-Indigenous people in Canada are related to underlying economic, social, and political inequities that are legacies of colonization and the oppression of Indigenous cultures. It also widely acknowledged that mental health services currently available may not be culturally appropriate in supporting the health needs of Indigenous Canadians. A two-day Indigenous mental health forum examined mental health needs and gaps among Indigenous communities across the Regional Municipality of Wood Buffalo (RMWB) on Treaty 8 territory, in northern Alberta, Canada. This paper outlines the insights generated by stakeholder engagement at the forum to identify and prioritize directions for Indigenous mental health and build a vision and strategy for improving mental health services and programs for the region’s diverse Indigenous population. Methods We applied a modified nominal group technique (NGT) consensus method embedded within Indigenous knowledge to determine key priorities and directions for Indigenous-focused mental health and synthesize information from discussions that occurred at the forum. Following the NGT, a participatory community visioning exercise was conducted with participants to develop a vision, guiding principles, and components of an action plan for an Indigenous mental health strategy for the RMWB. Results Four key themes for setting priorities and directions for Indigenous mental health emerged from roundtable group discussions: 1) understand the realities of mental health experiences for Indigenous peoples, 2) design a holistic and culturally rooted mental health system, 3) foster cross-sectoral engagement and collaboration on mental health service delivery, and 4) focus on children and youth. The community visioning exercise helped stakeholders to visualize a direction or path forward for addressing existing gaps in the mental health system and opportunities for strengthening Indigenous mental health in the region. Conclusions Forum participants described mental health and well-being around holistic concepts of social and emotional well-being. Addressing Indigenous mental health and wellness involves multi-sectoral action in various settings including community and school through programs, policies, and other interventions that promote mental health for all Indigenous peoples, as well as for those at greater risk such as children and youth.

Following the 2016 Horse River Wildfire in northern Alberta, the provincial health authority, the ministry of health, non-profit and charitable organizations, and regional community-based service agencies mobilized to address the growing health and mental health concerns among Indigenous residents and communities through the provision of services and supports. Among the communities and residents that experienced significant devastation and loss were First Nation and Métis residents in the region. Provincial and local funding was allocated to new recovery positions and to support pre-existing health and social programs. The objective of this research was to qualitatively describe the health systems response to the health impacts following the wildfire from the perspective of service providers who were directly responsible for delivering or organizing health and mental wellness services and supports to Indigenous residents. Semi-structured qualitative interviews were conducted with 15 Indigenous and 10 non-Indigenous service providers from the Regional Municipality of Wood Buffalo (RMWB). Interviews were transcribed verbatim and a constant comparative analysis method was used to identify themes. Following service provider interviews, a supplemental document review was completed to provide background and context for the qualitative findings from interviews. The document review allowed for a better understanding of the health systems response at a systems level following the wildfire. Triangulation of semi-structured interviews and organization report documents confirmed our findings. The conceptual framework by Mirzoev and Kane for understanding health systems responsiveness guided our data interpretation. Our findings were divided into three themes (1) service provision in response to Indigenous mental health concerns (2) gaps in Indigenous health-related services post-wildfire and (3) adopting a health equity lens in post-disaster recovery. The knowledge gained from this research can help inform future emergency management and assist policy and decision makers with culturally safe and responsive recovery planning. Future recovery and response efforts should consider identifying and addressing underlying health, mental health, and emotional concerns in order to be more effective in assisting with healing for Indigenous communities following a public health emergency such as a wildfire disaster.

Background: The healthcare system is complex and difficult to navigate, particularly for patients with multiple chronic conditions and complex care plans. Patient adherence to care plans and patient health outcomes can be negatively impacted by language, financial, and other social barriers. Community Health Navigators (CHNs) are community members that are hired and trained to navigate the healthcare system, who work with patients to overcome barriers to care and support patient self-management by providing services tailored to needs. While these types of interventions can improve access to care in other settings, they are not well studied in Canada nor in Canadian primary care settings. Objective: For this pilot study, we aimed to determine the feasibility of a CHN intervention for patients with multiple chronic conditions. Our secondary objective was to assess the potential impact of a CHN intervention on patient-reported outcome measures. Methods: We used an observational single arm pre-post study design. Using interviewer-administered patient surveys, we assessed patient-reported outcomes at baseline (pre-enrolment), and 6-months and 12-months post-enrolment. The survey included instruments to assess quality of life (EQ-5D-5L), patient chronic disease care experience (PACIC), social support (mMOS-SS), and cost-related adherence to care (i.e. financial security to pay for care-related costs). Descriptive analysis was performed on survey data, and the sample was restricted to participants who completed both follow-up surveys (6- and 12-month).   Results: Of the 21 participants enrolled in our pilot study, the mean age was 61.3 years, 56% had an annual household income below $30,000, and 68% were born outside of Canada. The three most common conditions reported were hypertension (77%), diabetes (59%), and back problems (55%). The mean number of conditions a patient reported was 5.4 (SD 2.3, range 3-11). Of the sample enrolled, 14 (67%) patients completed both follow-up surveys. Mean social support (scale: 0-100), was 56, 68, and 75 at baseline, 6, and 12 months, respectively—indicating a potential increase in social support after the intervention. Mean self-ranked health (scale: 0-100) did not change over time. Mean patient experience with chronic disease care (scale: 1-3) was 2.01 at baseline; 2.24 at 6 months, and 1.89 at 12 months.  The proportion of patients who reported no difficulty paying for medical expenses increased from 36% at baseline to 79% at 6 months and 86% at 12 months. In other words, fewer patients reported difficulty paying for medical expenses at 6 months and at 12 months. Results presented here are preliminary; further analysis is underway which will include analysis of health outcomes using administrative data, statistical tests of survey data (where appropriate), and qualitative analysis of interview data. Conclusions: CHNs may improve patients’ social and financial support and satisfaction with care. Our pilot study demonstrates that a CHN intervention is feasible to implement in primary care for patients with multiple chronic conditions. These findings informed a large ongoing cluster-randomized pragmatic trial.