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Background In keeping with the changing needs of the Canadian population, primary care systems need to become more person-focused in providing quality care to older adults. As part of Health TAPESTRY, a complex intervention to strengthen primary care for older adults, a goal setting exercise was developed and tested in an initial feasibility study, intended to foster collaboration between patients and providers. Methods Participants—clinic clients—were recruited from the McMaster Family Health Team in Hamilton, Ontario. Five participants took part in the goal setting feasibility study phase I, which tested the functionality of a technology-enabled goal setting exercise between older adults and volunteers. Based on observations and feedback from volunteers, interprofessional team members, and older adults, the exercise was refined to include a guided survey and goals report. The goal setting survey is a list of probing questions designed based on SMART (specific, measurable, attainable, relevant, timely) goal setting strategies and goal attainment scaling (GAS). This was used in phase II, carried out with 16 participants, where the feasibility of goal setting and goal attainment with support from volunteers and interprofessional teams was tested. Volunteers carried out the goal setting survey via a tablet computer, a report of client goals was generated and sent to interprofessional teams, and client goals were discussed during clinic huddles. At 6 months of follow-up, clients self-evaluated their progress using GAS. Results and discussion The goal setting exercise in phase I took an average of 24:45 (SD 11:42) minutes and yielded a diverse set of life and health goals. Goals identified by older adults were primarily focused on the maintenance of a certain level of activity or health state. Phase I work resulted in important changes to the goal setting process (e.g., asking about goal setting later in conversation, changing wording of questions) and development of a summary report of goals sent to the interprofessional team. In phase II, 44 goals were set by 16 participants during an average 7:23 (SD 4:26) minute discussion. Of these goals, 43.9% were characterized as health goals while 63.4% were characterized as life goals. Under the umbrella of Life goals, productivity featured most prominently at 22.9% of all goals. Goal attainment was not measured in phase I. In phase II, clients had an average weighted goal attainment score of 51.5. Considering client preferences for one goal over another, 68.8% of clients, on average, at least partially achieved the goals they had set. Conclusion Goal setting as part of the Health TAPESTRY approach was feasible and provided interprofessional teams with client narratives that helped improve care management for older adults. The overall intervention—including the refined goal setting component—is being scaled and evaluated in a pragmatic randomized controlled trial.

Primary care providers are critical in providing and optimizing health care to an aging population. This paper describes the volunteer component of a program (Health TAPESTRY) which aims to encourage the delivery of effective primary health care in novel and proactive ways. As part of the program, volunteers visited older adults in their homes and entered information regarding health risks, needs, and goals into an electronic application on a tablet computer. A total of 657 home visits were conducted by 98 volunteers, with 22.45% of volunteers completing at least 20 home visits over the course of the program. Information was summarized in a report and electronically sent to the health care team via clients’ electronic medical records. The report was reviewed by the interprofessional team who then plan ongoing care. Volunteer recruitment, screening, training, retention, and roles are described. This paper highlights the potential role of a volunteer in a unique connection between primary care providers and older adult patients in their homes.

Objective The objective of this research was to explore self-management practices and the use of diabetes information and care among Black-Caribbean immigrants with type 2 diabetes. Method The study population included Black-Caribbean immigrants and Canadian-born participants between the ages of 35 to 64 years with type 2 diabetes. Study participants were recruited from community health centres (CHCs), diabetes education centres, hospital-based diabetes clinics, the Canadian Diabetes Association and immigrant-serving organizations. A structured questionnaire was used to collect demographics and information related to diabetes status, self-management practices and the use of diabetes information and care. Results Interviews were conducted with 48 Black-Caribbean immigrants and 54 Canadian-born participants with type 2 diabetes. Black-Caribbean immigrants were significantly more likely than the Canadian-born group to engage in recommended diabetes self-management practices (i.e. reduced fat diet, reduced carbohydrate diet, non-smoking and regular physical activity) and receive regular A1C and eye screening by a health professional. Black-Caribbean immigrant participants were significantly more likely to report receiving diabetes information and care through a community health centre (CHC) and nurses and dieticians than their Canadian-born counterparts. Conclusions CHCs and allied health professionals play an important role in the management of diabetes in the Black-Caribbean immigrant community and may contribute to this group's favourable diabetes self-management profile and access to information and care. Additional research is necessary to confirm whether these findings are generalizable to the Black-Caribbean community in general (i.e. immigrant and non-immigrant) and to determine whether the use of CHCs and/or allied health professionals is associated with favourable outcomes in the Black-Caribbean immigrant community as well as others.