uberculosis (TB), caused by Mycobacterium tuberculosis infection, is spread through airborne, aerosolized droplet nuclei produced by persons with pulmonary TB during forceful expiration (e.g., coughing, sneezing). 1 TB disease most commonly affects the lungs but can involve almost any organ of the body and was a major cause of morbidity and mortality in Canada throughout the first half of the 20 th century. Since then, the Canadian incidence rate of new cases has steadily declined to approximately 4.7 per 100,000 population per year. 2 The highest rates of TB disease occur in three groups: Aboriginal (28/100,000), 2 foreign-born (13/100,000) 2 and the elderly. In the elderly, incidence rates increase with age, from 5.4 (65-74 years) to 8.5 (≥75 years) per 100,000. 2 Classic symptoms of active pulmonary disease are cough, fatigue, weight loss, fever and night sweats. However, elderly patients may present atypically (unexplained weight loss, anorexia, weakness, or change in cognitive status), such that many active cases may be undiagnosed. 3 In 1956, 75% of persons living in large cities in Ontario had latent TB infection (LTBI) by the age of 60. 4 In 2007, 20-30% of those aged 65 or older in long-term care (LTC) facilities may be infected. 5 Because persons with LTBI remain at risk for reactivation and post-primary TB disease, health care professionals caring for institutionalized elderly must be aware of the risks of TB in the elderly in order to manage this diagnosis. A 1992 survey of 29 nursing homes and 26 homes for the aged in metropolitan Toronto found that 20% of respondent institutions reported at least one case of active TB in the previous five years. 6 Outbreaks reported in nursing homes in the United States demonstrate that TB transmission is very efficient within closed environments. 7-9 In Arkansas, unrecognized TB in a resident led to infection of 49 other residents, including 8 cases of active TB disease and 1 death. 7 A second outbreak in the state led to infection of 52 employees, 23 residents and 1 visitor. 9 Spread from a nursing home into the community was also reported in a Washington outbreak involving 6 residents, 1 employee and 1 visitor. 8 To our knowledge, there have been no published reports of TB outbreaks in long-term care facilities in Canada. We present an outbreak of TB that occurred in a Residential and Long-Term Care (LTC) facility in Ontario among staff members and residents from May 2010 to January 2011. METHODS Following diagnosis of the index case, case finding was carried out by the local public health unit through the conventional concentric circle approach described in the Canadian Tuberculosis Standards (i.e., casual and community contacts are tested only if close

Background A quality improvement (QI) focus in systems strategically investing resources to achieve the Quadruple Aim (i.e., better population health, lower system costs, improved patient care, and an engaged and productive workforce) presents an opportunity to reorient health services towards population health promotion. Setting An interdisciplinary team linked across a large regionalized healthcare system engaged in a (Saskatoon) Region-wide 90day QI initiative focused on patient safety. Intervention The team worked directly with healthcare teams to link cultural safety, patient-centeredness, and health equity to other dimensions of healthcare quality. The team provided data from health status reports, equity analyses of healthcare utilization, and stakeholder consultations and adapted QI methods, including A3 thinking and Plan-Do-Check-Act (PDCA) cycles. Outcomes Throughout the 90 days, use of the terms Bhealth equity^and Bcultural safety^increased among healthcare teams and in region-wide communications. Within the year following the initiative, the Region made public and ongoing commitments to address health inequities. Implications System-wide QI initiatives present opportunities to promote population health approaches, shift perspectives and language, and ultimately influence organizational culture. Learnings are relevant to health promotion practitioners attempting to engage healthcare partners, and for health systems strategically investing for improved population health.

Changing demographic trends and population needs have increased demand for chronic complex care and contributed to rising health care costs. The study sought to identify unmet health care needs of older adults and opportunities for service improvement in a high need suburban neighborhood of a prairie province. The insights provided by older adults informed the service design for a new model of integrated care in community settings. Narrative inquiry methodology was used to understand care experiences through stories. Stories of older adults' health care journeys were elicited with semi-structured interviews. A paradigmatic approach to analysis was applied with holistic coding, mapping of story elements followed by comparison and theming across participants' stories. Older adults perceived that relationship and informational continuity fostered effective communication and supported coordination of care. Timely access to care was valued and flexibility in types of medical encounters was suggested as an option to improve provider responsiveness. Access to information about community resources was limited and older adults required support with navigation. Structural (e.g. availability of services and transportation), financial and personal barriers exist for older adults to access and use community health services. Health care transitions were inadequately supported by comprehensive discharge planning, timely communication and follow up post discharge. New models of care need to embrace person-centred and goal directed approaches to the delivery of care to improve patient experience. Older adults offer valuable perspectives as community partners and co-designers of systems change in efforts to re-engineer health services.

Objectives: Mainstream environmental assessment (EA) methodologies often inadequately address health, social and cultural impacts of concern for Canadian indigenous communities affected by industrialization. Our objective is to present a holistic, culturally-appropriate framework for the selection of indigenous health indicators for baseline health assessment, impact prediction, or monitoring of impacts over time. Methods: We used a critical population health approach to explore the determinants of health and health inequities in indigenous communities and conceptualize the pathways by which industrialization affects these determinants. We integrated and extended key elements from three indigenous health frameworks into a new holistic model for the selection of indigenous EA indicators. Results: The holistic model conceptualizes individual and community determinants of health within external social, economic and political contexts and thus provides a comprehensive framework for selecting indicators of indigenous health. Indigenous health is the product of interactions among multiple determinants of health and contexts. Potential applications are discussed using case study examples involving indigenous communities affected by industrialization. Conclusion: Industrialization can worsen indigenous health inequities by perpetuating the health, social and cultural impacts of historic environmental dispossession. To mitigate impacts, EA should explicitly recognize linkages between environmental dispossession and the determinants of health and health inequities and meaningfully involve indigenous communities in the process.