Interdisciplinary care plan7 class nur3400

1. INTERDISCIPLINARY CARE PLAN 7
Class: NUR3400
Professor: Maikel Y. Portal APRN, FNP-BC
Miami Regional University
Abstract
Patient care has received much attention in today’s healthcare
system. It enhances the treatment plan by involving different
health specialists in caring for the patient. Interdisciplinary
approach involves elements such as leadership, teamwork,
patient-centered practice, and through communications. The
care providers ensure effective assessment of the condition thus
meeting patient’s desires and needs. The team pools their
knowledge and expertise together towards the recovery of the

2. patients not just the treatment of the disease. Ideally, effective
patient outcomes can be achieved through a collaborative
approach to the treatment plan. This reduces readmission rates
and avoids duplication of duties during the treatment process.
The future of health care delivery depends on how effectively
the health providers implement the interdisciplinary approach.
In this paper, the interdisciplinary care plan will be drafted for
McKay Johnson, a patient diagnosed with diabetes and heart
disease.
Keywords: interdisciplinary, therapy, diabetes, heart disease.
Background Information
Patient Name:?
Age: ?
Sex: ?
Demographics: ?
Condition: (Diabetes and Heart Disease) or any other PMH
Situation: Patient is forgetful and lives alone
Medical History
Johnson was diagnosed with type 2 diabetes in 2013, but he
reports he had symptoms one year before the diagnosis. The
medical record shows that he had fasting blood glucose records
showing values of 118-127 mg/dl, which categorized his
condition as “borderline diabetes.” In 2016, he was diagnosed
with heart problem. Johnson has been controlling diabetes until
last year when his family physician referred him to our hospital
for special treatment of the disease. His wife reports that her

3. husband began to experience abnormal heartbeats, difficulties in
breathing, and high blood pressure. The diagnosis shows that
Johnson recorded a pulse of 115 per minute while the systolic
blood pressure was 180 mm/Hg. He had bulging neck veins,
swelling in the legs, and fluids in the lungs. He had been on
glyburide (2.5 g every morning), Gymnema Sylvester, and
chromium picolinate to control diabetes. Johnson was also given
Angiotensin II receptor blockers and Statins to control heart
disease.
Johnson’s physical examination results show a BMI of 33.4
kg/m2, Pulse of 85 bpm, fasting glucose of 164 mg/dl, blood
pressure of 160/96 mmHg, JVP of 7 cm H2O, and 20
respirations per minute. He has lung crackles, no retinopathy,
swelling legs, non-palpable thyroid, no carotid bruits, and
diminishing vibratory sense to the forefoot. He reports regular
wheezing and dizziness throughout the day. The lab results
presented by the nurse show that Johnson has cholesterol-to-
HDL ratio of 4 (normal < 5.0), HDL cholesterol of 46 mg/dl
(normal < 40 mg/dl), triglycerides of 180 mg/dl (normal < 155
mg/dl), AIC of 7.5 % (normal 4-6 %), sodium of 137 mg/dl
(normal 136-146 mg/dl), potassium of 4.0 mg/dl (3.5-4.3
mg/dl), blood urea nitrogen 34 mg/dl (normal 6.1-30 mg/dl) and
Urine microalbumin of 42 mg (normal < 30 mg).
Medical Assessment
Based on Johnson’s medical history, physical examination, and
lab tests, it is evident he has uncontrollable type 2 diabetes and
heart disease. His hemoglobin level (7.5%) is slightly more than
the normal indicators (4-7%). He has a BMI of 32. 4 kg/m2 and
it is way above the BMI of a normal person. When an individual
exceeds a BMI of 30, he is termed as obese (Pop-Busui et al.,
2017). Johnson has elevated urine microalbumin and blood urea
nitrogen. These are the indicators of heart problem and diabetes.
Swelling legs, lung crackles, and regular wheezing are also the
signs of heart disease.
Care Plan
Johnson presents uncontrollable type 2 diabetes and heart

4. disease, which require a coordinated treatment process from all
nurses across the concerned disciplines. The first step of the
interdisciplinary team is to select the most pressing health issue
and prioritize his medical care in order to formulate an effective
treatment plan. The team has to follow the care plan for the two
diseases.
Nursing Intervention
Rationale
Assess the signs of hyperglycemia
A patient who uses insulin to treat type 2 diabetes is at risk of
developing hyperglycemia. Signs of hyperglycemia include
headache, fatigue, tachycardia, dizziness, and visual changes.
Assess glucose level before and after the meals
The glucose level should be between 140 mmHg and 180
mmHg. Non-intensive care patients should be maintained at less
than 140 mmHg (American Diabetes Association, 2019).
Monitor patient’s hemoglobin level
A level of 4-7% is desirable and shows the progress of the
treatment process.
Monitor blood pressure, apical pulse and peripheral pulse
Increased blood pressure is a sign of diabetes/heart disease.
Low pulse is a sign of decreasing tissue perfusion.
Do not take an axillary temperature
Elderly persons have poor peripheral circulation which
contributes to the formation of pocket airs in axillary areas
(Touhy, Jett, Boscart, & McCleary, 2018). This gives inaccurate
results.
Assess feet for temperature, and swellings. Monitor the color of
the skin
This will help to monitor peripheral perfusion. Pale skin color
is an indicator of decreased tissue perfusion.
Assess the pattern of physical activity
Regular physical activities assist in lowering the glucose level
(Naik, Dave, Stephens, & Davies, 2015). These activities
prevent further complications of diabetes and cardiac disease.
Administer basal insulin

5. Adhering to the prescribed medical regimens promotes tissue
perfusion. This will keep glucose at a normal level.
Report BP of more than 155 mmHg (systolic)
Hypertension is a common condition for diabetes and heart
disease. Controlling blood pressure can prevent further
complications such as stroke and retinopathy.
Monitor urine output as well as urine albumin
Urine albumin is a sign of diabetes while urine output shows the
control of both diabetes and heart disease.
Encourage Active ROM
ROM prevents venous pooling and promotes tissue perfusion.
Encourage bedrest with the head of the bed elevated at 45
degrees
This position prevents blood from returning to the heart thus
increasing oxygenation and decreasing dyspnea responsible for
cardiac attack (American Diabetes Association,2015).
Evaluate patient’s understanding of the medical conditions and
treatment plan
This reduces medication errors. Non-adherence to the prescribed
medication can lead to more complications such as
hypoglycemia and stroke.
Administer and monitor medication regimen
Proper administration of prescribed diabetic and heart disease
medication is important in stabilizing glucose level, hemoglobin
level, and blood pressure.
Review the patients current diet and nutritional needs
Proper diet helps maintain the normal level of glucose level
thus sustain the smooth flow of blood.
Treatment Goal
At the end of the treatment, Johnson should have blood glucose
level of less than 180 mmHg, BMI of less than 30.0 kg /m2,
Hemoglobin AIC level of less than 7%, blood urea nitrogen less
than 30 mg/dl, and Urine microalbumin of less than 30 mg/dl.
These results will be an indication of the successful treatment
plan.

6. Running head: CARE PLAN 1
CARE PLAN 6
References
American Diabetes Association. (2015). Cardiovascular disease
and risk management. Diabetes Care, 38(Suppl. 1), 49-57.
Retrieved from https://doi:10.2337/dc15-S011
American Diabetes Association. (2019). Cardiovascular disease
and risk management: Standards of medical care in diabetes-
2019. Diabetes Care, 42(Suppl. 1), 103–123. Retrieved from
https://doi.org/10.2337/dc19S010
Pop-Busui, R., Boulton, A., Feldman, E., Bril, V., Freeman, R.,
Malik, R. A. … Ziegler, D. (2017). Diabetic neuropathy: A
position statement by the American Diabetes Association.
Diabetes Care, 40(1) 136-154. Retrieved from
https://doi:10.2337/dc16-2042
Naik, V., Dave, R., Stephens, J. W., & Davies, J. S. (2015).
Evidence based prevention of type 2 diabetes: Role of lifestyle
intervention as compared to pharmacological agents.
International Journal of Diabetes and Clinical Research, 2(6).
49-56. Retrieved from
https://clinmedjournals.org/articles/ijdcr/international -journal-
of-diabetes-and-clinical-research-ijdcr-2-049.pdf
Touhy, T., Jett., K., Boscart, V., & McCleary, L. (2018).
Ebersole and Hess' gerontological nursing and healthy aging
(5th ed.). New York, NY: Elsevier - Health Sciences Division.
Case Analysis Operational Problems Engaging Patients - Part 1
In a single Word document 7 full pages (excluding cover page
and citations), APA style, answer the following questions. Use
the week's reading materials and video to guide your

7. responses.
1. Identify the most important facts surrounding the case.
2. Identify the key issue or issues.
3. Specify alternative courses of action.
4. Evaluate each course of action.
5. Recommend the best course of action.
Link -
https://www.youtube.com/watch?v=R5xITJk_V90&feature=yout
u.be
SYSTEMATIC REVIEW Open Access
Engaging patients to improve quality of
care: a systematic review
Yvonne Bombard1,2*, G. Ross Baker1, Elaina Orlando1,3,
Carol Fancott1, Pooja Bhatia1, Selina Casalino2,
Kanecy Onate1, Jean-Louis Denis4 and Marie-Pascale Pomey5
Abstract
Background: To identify the strategies and contextual factors
that enable optimal engagement of patients in the
design, delivery, and evaluation of health services.
Methods: We searched MEDLINE, EMBASE, CINAHL,
Cochrane, Scopus, PsychINFO, Social Science Abstracts,
EBSCO,
and ISI Web of Science from 1990 to 2016 for empirical studies
addressing the active participation of patients,
caregivers, or families in the design, delivery and evaluation of
health services to improve quality of care. Thematic
analysis was used to identify (1) strategies and contextual

8. factors that enable optimal engagement of patients,
(2) outcomes of patient engagement, and (3) patients’
experiences of being engaged.
Results: Forty-eight studies were included. Strategies and
contextual factors that enable patient engagement were
thematically grouped and related to techniques to enhance
design, recruitment, involvement and leadership action,
and those aimed to creating a receptive context. Reported
outcomes ranged from educational or tool development
and informed policy or planning documents (discrete products)
to enhanced care processes or service delivery and
governance (care process or structural outcomes). The level of
engagement appears to influence the outcomes of
service redesign—discrete products largely derived from low-
level engagement (consultative unidirectional
feedback)—whereas care process or structural outcomes mainly
derived from high-level engagement (co-design or
partnership strategies). A minority of studies formally evaluated
patients’ experiences of the engagement process
(n = 12; 25%). While most experiences were positive—
increased self-esteem, feeling empowered, or independent—
some
patients sought greater involvement and felt that their
involvement was important but tokenistic, especially when their
requests were denied or decisions had already been made.
Conclusions: Patient engagement can inform patient and
provider education and policies, as well as enhance service
delivery and governance. Additional evidence is needed to
understand patients’ experiences of the engagement process
and whether these outcomes translate into improved quality of
care.
Registration: N/A (data extraction completed prior to
registration on PROSPERO).

9. Keywords: Patient engagement, Patient involvement, Quality of
care, Quality improvement, Health services,
Health delivery, Systematic review
* Correspondence: [email protected]
1Institute of Health Policy, Management and Evaluation,
University of
Toronto, 155 College Street 4th Floor, Toronto, Ontario M5T
3M6, Canada
2Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30
Bond St, Toronto,
Ontario M5B 1W8, Canada
Full list of author information is available at the end of the
article
© The Author(s). 2018 Open Access This article is distributed
under the terms of the Creative Commons Attribution 4.0
International License
(http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were
made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to
the data made available in this article, unless otherwise stated.
Bombard et al. Implementation Science (2018) 13:98
https://doi.org/10.1186/s13012-018-0784-z
Background
Patient engagement has become a cornerstone of quality
of care [1–6] and is a frequently stated goal for healthcare

10. organizations. Traditionally, and most commonly, this en-
gagement has focused on the relationship between pa-
tients and providers in making care decisions or how to
improve patient efforts to manage their own care [7].
However, there are growing efforts to integrate patients in
broader ways, including efforts to improve or redesign ser-
vice delivery by incorporating patient experiences [8–12].
These efforts are due in part to an increased recognition
and acceptance that users of health services have a rightful
role, the requisite expertise, and an important contribu-
tion in the design and delivery of services [4]. While the
nature of patient engagement may vary from including pa-
tients as members of a board to time-limited consultation
with patients on service redesign, its aims are consistent—
to improve the quality of care [11, 13, 14].
Healthcare organizations have a long tradition of
measuring the experience of patients, and health service
“users” including families, caregivers, and clients, with
their services. Yet, traditional satisfaction surveys often
prove difficult to translate into improved service delivery
[15, 16]. Indeed, research on patient engagement has
pointed to the importance of augmenting traditional sur-
veys and complaint processes, moving towards fuller en-
gagement of patients in reviewing and improving the
quality of service delivery in institutions and in the com-
munity [17–25]. This recognition has been accompanied
by a growth in the development of instruments to meas-
ure and improve the quality of care patients receive.
Over the past two decades, assessments of quality of
care from the patient perspective have shifted from pa-
tient satisfaction to patient experiences [26]. Increasing
literature indicates that it is not only feasible to involve
patients in the delivery or re-design of health care [9]
but that such engagement can lead to reduced hospital
admissions [27], improved effectiveness, efficiency and

11. quality of health services [28–31], improved quality of
life, and enhanced quality and accountability of heal th
services [9]. Frameworks of patient involvement have
been developed that move from the traditional view of
the patient as a passive recipient of a service to an inte-
gral member of teams re-designing health care [8, 11].
For example, one framework developed by Bate and
Robert (2006) describes a continuum of patient involve-
ment, which ranges from complaints, giving information,
listening, and consulting towards experience-based co-de-
sign of services [8]. Low-level engagement, such as con-
sulting, comprises largely unidirectional feedback (e.g.,
focus groups, surveys, interviews), whereas high-level en-
gagement, like co-design, represents a partnership in the
design or evaluation of services. A more recent framework
developed by Carman et al. describes various levels of
engaging patients and families in health and health care,
from consultation or involvement to partnership and shared
leadership in various activities including direct care,
organizational design, and governance to policy-making
[11]. Carman’s continuum of engagement was influenced by
Arnstein’s formative “ladder of citizen participation,” a con-
tinuum of public participation in governance ranging from
limited participation to a state of collaborative partnership
in which citizens share leadership or control decisions [32].
Governments and health care institutions are urged by
some experts to engage patients and other service users, in-
cluding caregivers and relatives in more robust ways [8, 33]
where patients are actively involved as partners or co-leads
in organizational re-design and evaluation of health care
delivery, as depicted by the red section in Carman’s frame-
work (Fig. 1). Despite the substantive body of research on
strategies to engage patients and their effects on patients
and health services, the literature is dispersed and has not

12. been recently synthesized into a coherent overview. If the
benefits of engaging patients in the design or delivery of
health care are to be realized at an organization or system
level, then effective strategies and the contextual factors en-
abling their outcomes need to be identified so that learning
can be generalized. We conducted a systematic review of
international English language literature on strategies for
actively engaging patients and families in improving or
redesigning health care and the contextual factors influen-
cing the outcomes of these efforts. The explicit questions
that guided our review were:
1. What are the strategies and contextual factors that
enable optimal engagement of patients in the
design, delivery, and evaluation of health services?
2. What are the outcomes of patient engagement on
services?
3. What are patients’ experiences of being engaged?
Methods
Approach
We took a comprehensive approach in our systematic
search and included all empirical qualitative, quantita-
tive, and mixed methods study designs across all settings
of care to address our narrow research questions. Our
review did not fit into typologies of literature reviews
[34, 35], given that we included qualitative and quantita-
tive studies (to capture the breadth of studies in this
area), employed a thematic analysis (given the multipli-
city of designs), and applied a quality appraisal. We
followed the PRISMA reporting criteria for Systematic
Reviews and Meta-Analyses (Fig. 2) [36].
Search strategy

13. In accordance with the core principles of systematic
review methodology [37], we conducted a systematic
Bombard et al. Implementation Science (2018) 13:98 Page 2 of
22
review of relevant literature with the help of a librarian
using the electronic databases of: MEDLINE, EMBASE,
CINAHL, the Cochrane Library, Scopus, PsychINFO,
Social Science Abstracts, AbiInform Business Source
Premier (EBSCO), and ISI Web of Science. We searched
the databases using the following subject headings related
to patient engagement—combinations of “patient”, “user”,
“client”, “caregiver”, “family” and “engage*”, “participat*”,
“involve*”, “consult*”; for those related to designing, evalu-
ating and delivery of services—combinations of “design”,
Fig. 1 Patient engagement frameworks used for the selection
and analyses of studies included in our review. The red box
indicates the level of
engagement along the continuum that is the focus of our studies
included in our review [11]. The organizing framework used for
analyzing the
studies reviewed [8]
Bombard et al. Implementation Science (2018) 13:98 Page 3 of
22
“deliver*”, “evaluat*”, “outcome”, “develop*”, “plan*” and
“health services”, “health care”, “health”, “service”. We in-
cluded a combination of search terms from each category

14. for each search, for example, “patient” AND “engage*”
AND “design” AND “health services”).
Criteria for selection
Studies were eligible for inclusion if they were available
empirical articles that explicitly investigated the partici-
pation of patients, caregivers, or families in the design,
delivery, and evaluation of health services, which aligns
with involving or partnering/sharing leadership with pa-
tients in organizational design and governance, reflecting
Carman’s framework (Fig. 1) [11]. Searches were re-
stricted to qualitative, quantitative, or mixed methods
articles published in English between January 1990 and
March 2016. We chose 1990 as this coincided with the
emergence of patient engagement particularly in mental
health services and the broader quality of care discourse.
All settings of care were eligible. We excluded articles
that did not explicitly address patient engagement, as
well as those that did not pertain to the broader design,
delivery, and evaluation of health services (e.g., directly
engaging patients in patient safety activities such as
challenging staff who treat them to wash their hands or
monitor the use of a safety checklist in their care, or in
their self-management or treatment decisions, or studies
pertaining to patient involvement in health research,
community development, or health promotion). We also
excluded articles that did not describe the outcome of
the engagement of patients and those in which the out-
comes did nor pertain to the design, delivery, or evalu-
ation of health services (e.g., those that related to
developing questionnaires or conceptual frameworks, in-
sights on how to engage patients or work collabora-
tively). We focused on studies that consulted, involved,
partnered, or co-designed health services with patients,
informed by Bate and Robert’s [8] and Carman et al.’s

15. [11] frameworks on patient engagement (Fig. 1). Finally,
theoretical or conceptual articles as well as those focused
on guideline development, instrument development, or
broader organizational issues were excluded.
Titles and abstracts of the papers were examined to
decide if the full article should be retrieved (Fig. 2). EO
and CF were the primary reviewers who examined the ti-
tles and abstracts, applied inclusion criteria to the articles,
and abstracted the data using an abstraction form. Any
disagreement and uncertainties regarding inclusion were
Fig. 2 Flow diagram for search and selection process. From:
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA
Group (2009). Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLoS Med 6 (6): e1000097.
https://doi.org/10.1371/journal.pmed1000097
Bombard et al. Implementation Science (2018) 13:98 Page 4 of
22
discussed and agreed upon by an additional reviewer (YB)
on the abstraction form. We conducted calibration exer-
cises to ensure reliability in applying the selection criteria.
Reviewers independently screened the titles and abstracts,
and discrepancies were discussed and reviewed by the
third reviewer. There was a 95.46% observed agreement
and 85.75% expected agreement between primary re-
viewers, with a kappa statistic of 0.703 (standard error,
0.021; 95% confidence interval, 0.662–0.744), which is
relatively high compared to other knowledge synthesis
protocols reporting 50% consistency rates [34].

16. Data abstraction and synthesis
Data abstraction forms were used to describe the studies’
population, location (i.e., country), goals, methodology, and
outcomes (Table 1); contextual factors influencing engage-
ment (i.e., leadership and specific barriers and facilitators
to patient engagement) (Table 2); and patients’ experience
with the engagement and evaluation of study quality
(Tables 2 and 3). Studies were then categorized by the level
of patient engagement using Bate and Robert’s (2006) con-
tinuum of patient involvement [8]. Consistent with our
aims to review strategies for actively engaging patients and
families in improving or redesigning health care, we
focused on studies using co-design or those consulting
patients but also using elements of co-design—i.e., the
more active levels of engagement on the Bates and Robert
continuum. We classified changes or products of engaging
patients as “quality of care outcomes” and the impact of
the engagement on patients as “patients experience
outcomes” (Table 1). Quality of care outcomes were
categorized into one of the following: developing education
or a service-related tool, informing policy or planning
documents, and enhancing services or governance. Study
quality was assessed by one person and two verifiers using
a quality appraisal tool that systematically reviews disparate
forms of evidence and methodologies on a scale from “very
poor,” “poor,” “fair,” and “good” [38], which reflected the
mixed methods articles in our review. Verification involved
systematically checking and confirming the fit between
each criterion of the assessment tool and the conceptual
work of analysis and interpretation of study quality among
a subset of studies. We also assessed the possible impact of
study quality on the review’s findings (akin to a “sensitivity
analysis” conducted for meta-analyses).
Data analysis
Data were analyzed to address the three research ques-

17. tions, with the intention of (1) identifying strategies and
contextual factors that enable optimal engagement of pa-
tients in the design, delivery, and evaluation of health ser -
vices; (2) identifying the outcomes of patient engagement;
and (3) exploring patients’ experiences of being engaged.
YB analyzed the data using quantitative (i.e., frequency
analysis) and qualitative methods. YB used thematic ana-
lysis to identify the strategies and contextual factors (i.e.,
barriers and facilitators), outcomes, and experiences of op-
timal patient engagement. This process involved identify-
ing prominent or recurring themes in the literature
(relevant to our research questions) and summarizing the
findings of different studies under thematic headings using
summary tables. A coding framework was developed to
thematically describe the strategies and contextual factors
enabling patient engagement. YB and RB refined the
framework as new data emerged during the analysis.
Results
Included studies
We found a total of 20,957 studies about involving pa-
tients in the design, delivery, or evaluation of health care.
Of these, we excluded 20,909 because they did not report
outcomes related to health care delivery, design, or evalu-
ation (n = 67) or only informed/consulted with patients, as
opposed to engage them in co-design (n = 91) (Fig. 2;
Additional file 1: Table S3 & Additional file 2: Figure S1).
Our final sample of studies included 48 papers involving
patients, families, and caregivers along with service users,
health care providers, staff, board members, health care
managers, administrators, and decision-makers (Table 1).
The publication date of the included studies spanned from
1993 to 2016, and interestingly, co-design was employed
as early as 1993 to as recently as 2015 in published stud-
ies. Of the 48 included studies, 27 were qualitative studies;

18. 3 were quantitative; 13 constituted mixed methods stud-
ies, which included qualitative, quantitative methods; and
5 comprised user panels or advisory meetings (Table 4).
We restricted our analysis to articles actively engaging pa-
tients. Half of the articles (n = 24) included consultative
activities typical of low-level engagement (i.e., where pa-
tients provided input on research design or measures as
part of the research or administrative team). The other
half were co-design (high-level engagement—i.e., delibera-
tive, reflexive processes where patients and providers work
together to create solutions [39]) (Table 4). Engagement
efforts spanned a range of services, including pediatrics,
community and primary care, and most frequently oc-
curred in mental health services (n = 17; 35%—Tables 4
and 1). Studies originated from various countries, with
most deriving from the UK (n = 26; 54%) (Tables 4 and 1).
Few studies formally evaluated patients’ experiences of the
process of being engaged (n = 12; 25%) (Additional file 3:
Table S1).
Strategies for optimal patient engagement to improve
quality of care
We identified various strategies that contributed to opti -
mal patient engagement, which were mediated by key
contextual factors that enabled or constrained the
Bombard et al. Implementation Science (2018) 13:98 Page 5 of
22
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00
[7
5]
U
K
D
o
cu
m
en
t
an
al
ys
is
in
te
rv
ie
w
s
q
u
es
ti
o
n
n

31. ai
re
M
en
ta
l
h
ea
lt
h
se
rv
ic
es
N
o
t
cl
ea
r
C
o
-d
es
ig
n
D
ev
el
o
p

32. ed
a
n
ew
p
ro
g
ra
m
A
ch
ie
ve
d
a
cu
lt
u
re
ch
an
g
e
to
w
ar
d
s
va
lu
in

33. g
u
se
rs
’
kn
o
w
le
d
g
e,
ex
p
er
ti
se
,
co
n
tr
ib
u
ti
o
n
s,
an
d
g
re
at
er

34. p
o
w
er
-s
h
ar
in
g
Ba
rn
es
an
d
W
is
to
w
19
94
[4
0]
U
K
U
se
r
p
an
el

35. s
C
o
m
m
u
n
it
y
m
en
ta
l
h
ea
lt
h
an
d
d
is
ab
ili
ti
es
se
rv
ic
es
N
o

36. t
d
is
cu
ss
ed
C
o
n
su
lt
at
iv
e
w
it
h
so
m
e
co
-d
es
ig
n
Id
en
ti
fie
d
st
ra

37. te
g
ie
s
fo
r
u
se
r
in
vo
lv
em
en
t;
so
m
e
ev
id
en
ce
o
f
se
rv
ic
e
im
p
ro
ve

38. m
en
ts
;
d
ev
el
o
p
ed
a
“c
h
an
g
e
ag
en
d
a”
A
ch
ie
ve
d
a
cu
lt
u
re

39. ch
an
g
e
vi
a
“t
o
p
-d
o
w
n
”
ap
p
ro
ac
h
fr
o
m
lo
ca
l
au
th
o
rit
y
Be

40. rg
et
al
.2
01
5
[5
0]
N
o
rw
ay
U
se
r
b
o
ar
d
C
o
m
m
u
n
it
y
H
IV
/A
ID
S

41. p
re
ve
n
ti
o
n
7
C
o
-d
es
ig
n
C
re
at
ed
a
d
es
ig
n
fo
r
an
o
u
tp
at
ie

42. n
t
cl
in
ic
Em
p
o
w
er
m
en
t
an
d
au
to
n
o
m
y
o
f
u
se
rs
th
ro
u
g
h
“a

43. ct
iv
e
ci
ti
ze
n
sh
ip
”
an
d
a
“e
g
al
it
ar
ia
n
sp
iri
t”
Bl
ic
ke
m
et
al
.2
01
3
[9

44. 2]
U
K
Fo
cu
s
g
ro
u
p
s
M
en
ta
l
h
ea
lt
h
se
rv
ic
es
8
in
in
te
rv
ie
w

45. s
C
o
n
su
lt
at
iv
e
to
co
-d
es
ig
n
D
ev
el
o
p
ed
an
d
te
st
ed
a
p
ro
to
co

46. l
fo
r
PL
A
N
S,
a
co
m
m
u
n
it
y-
b
as
ed
re
fe
rr
al
sy
st
em
C
lo
se
en
g
ag

47. em
en
t
o
f
p
o
te
n
ti
al
u
se
rs
re
su
lt
ed
in
a
g
ra
ss
ro
o
ts
u
n
d
er
st
an

48. d
in
g
o
f
th
e
su
p
p
o
rt
va
lu
ed
b
y
in
d
iv
id
u
al
s
In
te
rv
ie
w
s
Su

49. rv
ey
s
6
fo
cu
s
g
ro
u
p
s
(t
o
ta
l
n
u
m
b
er
n
o
t
d
is
cu
ss
ed
)

50. Bo
n
e
et
al
.2
01
3
[9
3]
U
SA
C
o
m
m
u
n
it
y-
ac
ad
em
ic
ad
vi
so
ry
co
m
m

51. it
te
e
C
an
ce
r
sc
re
en
in
g
fo
r
A
fr
ic
an
A
m
er
ic
an
s
N
o
t
d
is
cu
ss

52. ed
C
o
-d
es
ig
n
D
ev
el
o
p
ed
a
co
m
m
u
n
it
y
h
ea
lt
h
w
o
rk
er
m
o

53. d
el
to
en
g
ag
e
A
fr
ic
an
-A
m
er
ic
an
co
m
m
u
n
it
ie
s
in
ca
n
ce
r
sc
re
en

54. in
g
an
d
ca
re
Id
en
ti
fie
d
th
e
co
m
m
u
n
it
y-
ac
ad
em
ic
ad
vi
so
ry
co
m

55. m
it
te
e
as
vi
ta
l
to
d
es
ig
n
in
g
th
e
se
rv
ic
e
an
d
en
su
rin
g
it
s
ef

56. fe
ct
iv
en
es
s
Br
o
o
ks
20
08
[6
4]
U
K
Fo
cu
s
g
ro
u
p
s
G
en
er
al

57. h
ea
lt
h
se
rv
ic
es
52
C
o
-d
es
ig
n
Pa
ti
en
t
in
vo
lv
em
en
t
in
au
d
it
in

58. g
p
ro
ce
ss
es
,
d
ev
el
o
p
m
en
t
o
f
p
at
ie
n
t
q
u
es
tio
n
n
ai
re
s,
p

59. o
lic
ie
s,
an
d
fr
am
ew
o
rk
s
Re
in
fo
rc
ed
th
e
im
p
o
rt
an
ce
o
f
p
at

60. ie
n
t
n
ar
ra
ti
ve
s
an
d
kn
o
w
le
d
g
e
in
o
rg
an
iz
at
io
n
an
d
d
el
iv
er
y

61. o
f
h
ea
lt
h
ca
re
In
te
rv
ie
w
s
O
b
se
rv
at
io
n
s
Bu
ck
20
04
[7
6]
U
S

62. C
it
iz
en
ad
vi
so
ry
b
o
ar
d
G
en
er
al
h
ea
lt
h
se
rv
ic
es
(f
o
r
h
o

63. m
el
es
s
in
d
iv
id
u
al
s)
7
C
o
n
su
lt
at
iv
e
to
co
-d
es
ig
n
D
ev
el
o
p
ed

64. in
fo
rm
at
io
n
al
b
ro
ch
u
re
s
an
d
re
co
m
m
en
d
at
io
n
s
fo
r
lo
ca
l

65. in
te
rv
en
ti
o
n
s
an
d
se
rv
ic
es
to
im
p
ro
ve
g
en
er
al
h
ea
lt
h
se
rv
ic

66. es
fo
r
th
e
h
o
m
el
es
s
A
ch
ie
ve
d
co
lla
b
o
ra
ti
o
n
an
d
m
u
tu
al
ed
u

67. ca
ti
o
n
Bombard et al. Implementation Science (2018) 13:98 Page 6 of
22
T
a
b
le
1
O
ve
rv
ie
w
o
f
p
at
ie
n
t
en
g
ag
em
en

68. t
st
u
d
ie
s
to
im
p
ro
ve
q
u
al
it
y
o
f
ca
re
(C
o
n
tin
u
ed
)
St
u
d
y

69. C
o
u
n
tr
y
In
te
rv
en
ti
o
n
Ty
p
e
o
f
se
rv
ic
e
Sa
m
p
le
si
ze
Le
ve
l

70. o
f
en
g
ag
em
en
t
O
u
tc
o
m
es
o
n
q
u
al
it
y
o
f
ca
re
Im
p
ac
t
o
n

71. in
st
it
u
tio
n
C
ar
ls
o
n
an
d
Ro
se
n
q
vi
st
19
90
[5
1]
Sw
ed
en
C
o
n

72. su
lt
at
io
n
m
ee
ti
n
g
s
D
ia
b
et
es
ca
re
24
3
C
o
n
su
lt
at
iv
e
to
co

73. -d
es
ig
n
Im
p
le
m
en
ta
ti
o
n
o
f
ca
re
im
p
ro
ve
m
en
t
p
ro
g
ra
m
s
an
d

74. p
at
ie
n
t
in
fo
rm
at
io
n
Id
en
ti
fie
d
p
ro
b
le
m
s
an
d
st
ep
s
to
so
lv

75. e
th
em
In
te
rv
ie
w
s
Tr
ai
n
in
g
co
u
rs
e
C
aw
st
o
n
20
07
[6
9]
U
K

76. Fo
cu
s
g
ro
u
p
s
Pr
im
ar
y
ca
re
72
in
fo
cu
s
g
ro
u
p
s;
37
2
vi
a
q
u
es

77. ti
o
n
n
ai
re
s
C
o
n
su
lt
at
iv
e
to
co
-d
es
ig
n
Re
co
m
m
en
d
at
io
n
s
an

78. d
so
m
e
ch
an
g
es
m
ad
e
to
im
p
ro
ve
d
ia
b
et
es
m
an
ag
em
en
t
in
p

79. rim
ar
y
ca
re
C
re
at
ed
re
se
ar
ch
-c
o
m
m
u
n
it
y
p
ar
tn
er
sh
ip
s
in
ev
al

80. u
at
in
g
se
rv
ic
es
b
u
t
h
ad
a
m
o
d
es
t
im
p
ac
t
o
n
se
rv
ic
e
ch
an
g

81. e
In
te
rv
ie
w
s
Q
u
es
ti
o
n
n
ai
re
C
o
ad
20
08
[4
1]
U
K
Yo
u
th

82. C
o
u
n
ci
l
Pe
d
ia
tr
ic
s—
ac
u
te
ca
re
yo
u
th
se
rv
ic
es
17
C
o
-d
es
ig

83. n
D
em
o
n
st
ra
te
d
im
p
ac
t
o
f
yo
u
th
co
u
n
ci
l
o
n
sp
ec
ifi
c
ar

84. ea
s
o
f
im
p
ro
ve
m
en
t
Id
en
ti
fie
d
w
ay
s
o
f
p
ro
m
o
ti
n
g
fu
rt
h

85. er
in
vo
lv
em
en
t
C
o
ke
r
et
al
.2
01
4
[7
2]
U
SA
C
o
m
m
u
n
it
y
ad
vi

86. so
ry
b
o
ar
d
Pe
d
ia
tr
ic
s
3
C
o
-d
es
ig
n
D
ev
el
o
p
ed
ca
re
m
o
d

87. el
s
fo
r
w
el
l-c
h
ild
ca
re
N
o
t
d
is
cu
ss
ed
El
w
el
l
20
14
[4
8]
U
K

88. G
ro
u
p
m
ee
ti
n
g
s
A
cu
te
ca
re
N
o
t
d
is
cu
ss
ed
C
o
n
su
lt
at
iv
e
to

89. co
-d
es
ig
n
D
ev
el
o
p
ed
an
d
im
p
le
m
en
te
d
ca
re
p
at
h
w
ay
s
fo

90. r
ce
llu
lit
is
ca
re
in
th
e
h
o
sp
it
al
U
se
r
in
vo
lv
em
en
t
cr
ea
te
d
th
e
d

91. es
ire
to
ch
an
g
e
in
th
e
o
rg
an
iz
at
io
n
A
lig
n
ed
u
se
r
in
vo
lv
em
en
t

92. w
it
h
st
ra
te
g
ic
d
ire
ct
io
n
s
En
n
is
et
al
.2
01
4
[7
0]
U
K
Fo
cu
s
g
ro

93. u
p
s,
in
te
rv
ie
w
s,
se
rv
ic
e
u
se
r
p
la
n
n
in
g
co
m
m
it
te
e,
su
rv
ey
s,

94. u
sa
b
ili
ty
te
st
in
g
M
en
ta
l
h
ea
lt
h
se
rv
ic
es
12
1
u
se
rs
vi
a
su
rv
ey
s,

95. u
n
cl
ea
r
n
u
m
b
er
vi
a
fo
cu
s
g
ro
u
p
s,
8
u
se
rs
vi
a
u
sa
b
ili
ty

96. te
st
in
g
,4
u
se
rs
vi
a
se
rv
ic
e
u
se
r
p
la
n
n
in
g
co
m
m
it
te
e
C
o
n
su

97. lt
at
iv
e
to
-
co
-d
es
ig
n
D
ev
el
o
p
ed
el
ec
tr
o
n
ic
p
er
so
n
al
h
ea
lt
h

98. re
co
rd
fo
r
m
en
ta
l
h
ea
lt
h
p
at
ie
n
ts
N
o
t
d
is
cu
ss
ed
En
riq
u
ez

99. et
al
.2
01
0
[6
7]
U
SA
Fo
cu
s
g
ro
u
p
s
q
u
es
ti
o
n
n
ai
re
s
H
IV
an

100. d
in
ti
m
at
e
p
ar
tn
er
vi
o
le
n
ce
p
re
ve
n
ti
o
n
7
u
se
r
p
ar
tn
er
s
in

101. d
es
ig
n
;3
1
p
ar
ti
ci
p
an
ts
in
fe
as
ib
ili
ty
st
u
d
y
C
o
-d
es
ig
n
Fe
as

102. ib
ili
ty
o
f
n
ew
se
rv
ic
e
w
as
es
ta
b
lis
h
ed
,w
h
ic
h
im
p
ro
ve
d
p
ro

103. te
ct
iv
e
h
ea
lt
h
b
eh
av
io
rs
,
se
lf-
es
te
em
,s
o
ci
al
su
p
p
o
rt
,
an
d
at

104. ti
tu
d
es
to
w
ar
d
s
p
ar
tn
er
vi
o
le
n
ce
D
el
iv
er
y
o
f
in
te
rv
en
ti
o
n

105. w
as
d
ee
m
ed
fe
as
ib
le
,c
o
m
m
u
n
it
y-
p
ro
vi
d
er
p
ar
tn
er
sh
ip
w
as

106. w
el
l
re
ce
iv
ed
an
d
en
h
an
ce
d
ac
ce
p
ta
b
ili
ty
o
f
th
e
in
te
rv
en

107. ti
o
n
Er
w
in
et
al
.2
01
6
[7
1]
U
SA
Fo
cu
s
g
ro
u
p
s
Pe
d
ia
tr
ic
s—

108. as
th
m
a
20
C
o
n
su
lt
at
iv
e
to
co
-d
es
ig
n
D
ev
el
o
p
ed
n
ew
p
ro
to
co

109. l
an
d
to
o
lf
o
r
p
at
ie
n
t
d
is
ch
ar
g
e
C
o
lla
b
o
ra
ti
ve
m
o
d
el
en

110. h
an
ce
d
th
e
p
er
ce
p
tio
n
o
f
ED
cl
in
ic
ia
n
s
as
p
ar
tn
er
s
in
as
th
m
a

111. co
n
tr
o
l
In
te
rv
ie
w
s
Su
rv
ey
s
Fa
ct
o
r
20
02
[5
7]
U
SA
Fo
cu
s
g
ro

112. u
p
s
Su
b
st
an
ce
u
se
rs
29
C
o
-d
es
ig
n
D
ev
el
o
p
m
en
t
o
f
a
“s
u

113. rv
iv
al
g
u
id
e”
to
im
p
ro
ve
ac
ce
ss
to
tr
ea
tm
en
t
C
re
at
ed
an
d
m

114. ai
n
ta
in
ed
th
e
p
ar
ti
ci
p
at
io
n
o
f
u
se
rs
in
al
l
as
p
ec
ts
o
f
g
u
id

115. e
d
ev
el
o
p
m
en
t
Fe
rr
ei
ra
-P
in
to
19
95
[5
8]
M
ex
ic
o
In
te
rv
ie
w

116. s
C
o
m
m
u
n
it
y
H
IV
/A
ID
S
p
re
ve
n
ti
o
n
10
5
C
o
-d
es
ig
n
D
ev

117. el
o
p
m
en
t
an
d
im
p
le
m
en
ta
ti
o
n
o
f
p
re
ve
n
ti
o
n
p
ro
g
ra
m

118. In
cr
ea
se
d
se
lf-
ef
fic
ac
y
an
d
se
lf-
es
te
em
o
f
co
m
m
u
n
it
y
p
ar
tn
er
s,
b

119. ey
o
n
d
th
e
p
ro
g
ra
m
’s
o
u
tc
o
m
es
Q
u
es
ti
o
n
n
ai
re
s
Bombard et al. Implementation Science (2018) 13:98 Page 7 of
22

120. T
a
b
le
1
O
ve
rv
ie
w
o
f
p
at
ie
n
t
en
g
ag
em
en
t
st
u
d
ie
s
to
im
p

121. ro
ve
q
u
al
it
y
o
f
ca
re
(C
o
n
tin
u
ed
)
St
u
d
y
C
o
u
n
tr
y
In
te
rv

122. en
ti
o
n
Ty
p
e
o
f
se
rv
ic
e
Sa
m
p
le
si
ze
Le
ve
l
o
f
en
g
ag
em
en
t

123. O
u
tc
o
m
es
o
n
q
u
al
it
y
o
f
ca
re
Im
p
ac
t
o
n
in
st
it
u
tio
n
Fi
tz

124. g
er
al
d
20
11
[7
8]
U
K
“S
er
io
u
s
g
am
e”
M
en
ta
l
h
ea
lt
h
se
rv
ic
es

125. 25
C
o
n
su
lt
at
iv
e
to
co
-d
es
ig
n
U
se
r
re
-d
es
ig
n
o
f
la
yo
u
t
an
d
fu
rn

126. is
h
in
g
s
o
f
a
n
ew
se
rv
ic
e
u
n
it;
d
es
ig
n
o
f
a
m
ed
ic
at
io
n
d
is

127. p
en
si
n
g
sy
st
em
A
ch
ie
ve
d
fle
xi
b
ili
ty
an
d
in
cl
u
si
vi
ty
th
ro
u
g
h

128. a
g
am
e
fo
rm
at
Fr
az
ie
r
20
07
[4
2]
U
SA
Sc
h
o
o
l-b
as
ed
p
ro
g
ra

129. m
M
en
ta
l
h
ea
lt
h
se
rv
ic
es
N
o
t
d
is
cu
ss
ed
C
o
-d
es
ig
n
D
ev
el
o

130. p
ed
a
sc
h
o
o
l-b
as
ed
m
en
ta
l
h
ea
lt
h
se
rv
ic
e
p
ro
g
ra
m
w
it
h

131. ac
ti
ve
en
g
ag
em
en
t
o
f
co
m
m
u
n
it
y
p
ar
tn
er
s
an
d
cl
in
ic
ia
n
s
A

132. ch
ie
ve
d
su
cc
es
sf
u
l
co
lla
b
o
ra
ti
o
n
b
et
w
ee
n
co
m
m
u
n
it
y
an
d
cl
in

133. ic
ia
n
s
o
n
cu
rr
ic
u
lu
m
d
ev
el
o
p
m
en
t
G
ib
so
n
20
05
[6
0]
U
K

134. In
te
rv
ie
w
s,
q
u
es
ti
o
n
n
ai
re
s,
w
o
rk
sh
o
p
s
Pe
d
ia
tr
ic
o
n
co
lo

135. g
y
40
C
o
n
su
lt
at
iv
e
to
co
-d
es
ig
n
Re
co
m
m
en
d
at
io
n
s
fo
r
st
ru

136. ct
u
re
…