Table 6 Feedback from providers, peer support volunteers and participants
Component | Characteristic | Feedback from feasibility study | Suggested changes for RCT |
|---|---|---|---|
Program | |||
Administration | Burden | Program requires considerable time for coordination, communication, and document completion, particularly at beginning [I]a | -Emphasize that all team members help RN with administration |
-Provide RN/RD with copies of all forms for all clients at start of program | |||
Case conferences | Length of meeting | Variable over 6-month program (initial meetings took more time, but this decreased as experience with clients/program increased) [I] | -Allow 1 h per month for case conferences, which has proven to be more time than usually required |
Client goals | Minimal discussion of client-centered goals (mainly identified implications for educational content of upcoming group sessions) [I] | -Maintain group focus because preferred by providers and other changes (peer support volunteers at case conferences) will require a more general format (to avoid confidentiality concerns) | |
Community service referrals | Minimal discussion of client’s specific service needs (mainly identified information on general services to share in group sessions) [I] | -Modify visit record to capture information on community referrals | |
Home visits | Challenges of setting | Limited access to clinical information, assessments and resources available at office (e.g., primary chart information, kinesiology assessment forms/handouts, blood pressure monitors, place to record client action items/goals) [I] | -Train providers to perform assessment similar to kinesiologist’s assessment (gait and mobility test called “Timed Up and Go”) |
Provider attendance | Preferable to have both providers (RN, RD), especially for first visit and/or for complex clients (safety concerns, maximize/confirm observations, collaborate on complex care issues) [I] | -Have RN and RD attend the first home visit and up to 50 % of all follow-up visits | |
Provider training | Providers requested more training on motivational interviewing, management strategies for common diabetes discordant conditions (e.g., COPD, arthritis) and social determinants of health, information on assessing and recommending activities for frail older adults, and information about the Home Support Exercise Program (HSEP) [I] | -Provide more training on motivational interviewing | |
-Revise training manual to include information on theory, common comorbidities, and determinants of health | |||
-Train program coordinator, RN and RD on HSEP | |||
Length of time | Variable over the 6-month program (initial meetings longer but decreased with understanding about client’s health status/issues and experience with program) [I] | -Allow 3 h for initial visit and 2.5 h for follow-up visits | |
Frequency of visits | Bi-monthly visits worked well for most clients, although a more flexible model that enabled extra visits would benefit some clients [I] | -Allow for a maximum of 3 home visits over 6 months (initial visits, 2 bi-monthly follow-up visits) | |
Scheduling | Scheduling was left to the providers, which resulted in delays between baseline interviews and the first home visit, and caused some home visits to be scheduled beyond the 6-month period [I] | -Provide providers with schedule of all home visits and group sessions (for full 6 months) at start of program | |
Group sessions | Challenges | Group format limits ability to focus on client-centered goals and needs (individual goals/needs too personal for group format) [I] | -Reinforce importance of maintaining group-focus at group sessions in training |
Difficult to ensure that all people, including the quieter individuals, have an opportunity to contribute and that group content is relevant to everyone in group [I, P] | -Ensure that training program and manual reinforces group facilitation skills and importance of maintaining a group focus in group sessions | ||
Schedule | Schedule that suited clients had following features: mid-day start, education session at end, ≥1 h between meals and physical exercise [I] | -multiple sites will be used in RCT and may have different start times and schedule needs to be structured accordingly | |
Length of session | Session should not exceed 3 h and could be less [I, PS, P] | -Shorten group sessions to 2 h | |
Attendance by team members | Team members only attended their portion of the group session; it would be better to have the whole team stay for the entire session to ensure consistency [I] | -Recommend that all team members (program coordinator, RN and RD) stay for the entire group session in the RCT | |
Physical exercise component | Exercises were not always appropriate for all clients—e.g., exercises need to more varied and to accommodate the wide range of ages and physical abilities [I, P] | -Train RN, RD, and program coordinator in HESP and have them deliver the physical exercise component (HESP consists of basic exercises that everyone can do, and can be adapted to different abilities) | |
Better integration of Health Support Exercise Program (HESP) discussed at group sessions with other program components (e.g., providers did not review HESP at home visits because assumed done at group sessions and lacked training) [I, P] | -Train RN and RD on HESP | ||
Alternatives to the kinesiology assessment should be explored. It is required prior to participation in physical exercise session to minimize the risk of injury, but it delayed start of the group sessions and post-program interviews [I] | -Train providers to conduct similar assessment (a gait and mobility assessment called “Timed Up and Go”) | ||
Include money in the budget for simple exercise equipment (e.g., Thera-Bands) which were used during the exercise sessions and some clients wanted to continue using these at home [I] | -Use HESP in the RCT, which does not use Thera-Bands (instead uses equipment readily available in the home) | ||
Program coordinator, physical activity leader | Program coordinator and physical activity leaders requested more information on diabetes [I] | -Recommend that RN/RD be present at entire group session | |
Program coordinator indicated that a minimum of 2 h is required for reminder phone calls to clients about upcoming group sessions [I] | -Allow 3 h of time to prepare for and travel to the group session (e.g., make reminder calls, order food etc) | ||
Peer support volunteers | Motivational interview training is an unrealistic expectation; instead prepare volunteers with questions for use in conversation with clients [I] | -Do not train peer support volunteers on motivational interviewing, just general guidance on support strategies | |
Enabling providers to meet volunteers before the program starts could help maximize their synergistic impact [I, PS] | -Provide opportunity for providers to meet peer support volunteers at start of program | ||
After attending a few group sessions, clients began assuming responsibility for directing the sessions and providing peer support [I, PS] | -This may reduce the need for peer support volunteers at the group sessions for the RCT | ||
More advanced notice of upcoming group sessions would help facilitate participation of peer support volunteers in the session [PS] | -No changes recommended as this was not a pervasive issue | ||
Meal component | Educational potential of meal time could be enhanced (e.g., combining snack with educational session to experience different foods, teach balanced snacking, show suitable snacks) [I, P] | -Provide recipes to interested clients (if meals not catered) | |
-Provide hardcopy of other diet-related materials as appropriate | |||
Smaller meals (e.g., soup, sandwiches) preferred by clients and more compatible with exercise component [I, P] | -Serve soup and sandwiches at group sessions (not hot meals) | ||
Frequency of sessions | Some peer support volunteers thought monthly sessions were too infrequent [PS] | -Retain monthly group sessions in RCT because clients report having many other appointments | |
Attendance of family/friends | Potentially beneficial for clients to have family/friends attend (e.g., to encourage client adherence, education for family/friends) [I, P] | -Revise RCT to allow family/friends to attend group sessions | |
Transportation | Very few clients required transportation services [I] | -Maintain transportation in RCT as some clients may be coming from rural areas | |
Resource materials | Participants indicated a preference for hardcopy handouts rather than referrals to the internet for resource materials [P] | -Recommend to providers to provide hardcopy materials as much as possible | |