Fatal Underfunding? Explaining COVID-19 Mortality in Spanish Nursing Homes

The COVID-19 pandemic has exerted a disproportionate effect on older European populations living in nursing homes. This article discusses the 'fatal underfunding hypothesis', and reports an exploratory empirical analysis of the regional variation in nursing home fatalities during the first wave of the COVID-19 pandemic in Spain, one of the European countries with the highest number of nursing home fatalities. We draw on descriptive and multivariate regression analysis to examine the association between fatalities and measures of nursing home organisation, capacity and coordination plans alongside other characteristics. We document a correlation between regional nursing home fatalities (as a share of excess deaths) and a number of proxies for underfunding including nursing home size, occupancy rate and lower staff to a resident ratio (proxying understaffing). Our preliminary estimates reveal a 0.44 percentual point reduction in the share of nursing home fatalities for each additional staff per place in a nursing home consistent with a fatal underfunding hypothesis.

Coordinating women's preventive health care for rural veterans

PURPOSE

As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender-specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non-VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care.

METHODS

Between March and July 2019, semi-structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes.

FINDINGS

Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non-VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination.

CONCLUSIONS

The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care.

Approaches to Addressing Nonmedical Services and Care Coordination Needs for Older Adults

OBJECTIVE

Non-medical services care coordination for daily activities of living is crucial in improving older adults' health and enabling them to age in place, but little is known about specific practices and barriers in this space.

METHODS

Semi-structured interviews were conducted with 41 professionals serving older adults in greater Chicago, Illinois-which consists of diverse urban, suburban, and semi-rural communities-to contextualize non-medical services needs and care coordination processes.

RESULTS

In-home care, home-delivered meals, non-emergency transportation, and housing support were cited as the most commonly needed services, all requiring complex coordination support. Respondents noted a reliance on inefficient phone/fax usage for referral-making and cited major challenges in inter-professional communication, service funding/reimbursement, and HIPAA.

CONCLUSIONS

Non-medical services delivery for older adults is severely impacted by general siloing throughout the care continuum. Interventions are needed to enhance communication pathways and improve the salience and interdisciplinarity of non-medical services coordination for this population.

Sickle Cell Disease Care Planning for School Nurses

Schoolchildren with sickle cell disease (SCD) experience physiologic and psychologic stress that can affect school functioning, mental well-being, and physical health. Student needs are unique and individualized; however, school nurses can support students and families with SCD through comprehensive and thorough care planning efforts. In addition to components specific to individual prescriptions and other nonpharmacological therapies, school nurses should consider school access and inclusion, pain management, racism, and disease self-management when care planning. As a healthcare provider who may have several continuous years of near-daily contact with students, the school nurse is an imperative provider, educator, and advocate for students learning to manage their SCD and avoid the related complications and challenges.

Measuring Older Peoples' Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

Introduction

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users. In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Methods

A combination of quantitative and qualitative data and analysis methods was used to assess the usability and the quality of applying a PREM among older people presenting complex care needs, using the P3CEQ delivery in SUSTAIN as a case study. 228 service users completed the P3CEQ and nine SUSTAIN researchers participated in a consultation about their experience administering the questionnaire. P3CEQ scores were analysed quantitatively using principal component analysis and multilevel linear regression. P3CEQ open responses and researcher notes collected when administering the questionnaire were thematically analysed.

Results

Service user inclusion was high and most P3CEQ items had low non-response rates. Quantitative analysis and researcher experience indicate the relevance of face-to-face administration for obtaining such an amount of data in this population group. The presence of a carer increased inclusion of more vulnerable respondents, such as the cognitively impaired, but posed a challenge in data interpretation. Although several P3CEQ items were generally understood as intended by questionnaire developers, the analysis of open responses highlights how questions can lead to diverging and sometimes narrow interpretations by respondents. Cognitive impairment and a higher educational attainment were associated with lower levels of perceived person-centredness of care.

Conclusion

This study shows essential preconditions to meaningfully collect and analyse PREM data on older peoples' experiences with integrated care: face-to-face administration away from care providers, collection of reasons for non-response and open comments providing nuances to answers, and multilevel modelling taking into account diversity in the target population. Several areas of improvement for future PREM use in this population have been identified: use of administration and coding guides, inclusion of clear and easy to understand definitions and examples illustrating what questions do and do not mean, measures of the expectations of person-centred coordinated care, and procedures ensuring sound ethical research. These methodological learnings can enhance future evaluation of integrated care from a service user perspective.

Improving the Pediatric Floor Discharge Process Following Tonsillectomy

OBJECTIVES/HYPOTHESIS

Over 300,000 tonsillectomies are performed nationwide every year. In 2017, half of children undergoing tonsillectomy at our institution were admitted to the pediatric floor, with only 10.4% being discharged before 11 AM on postoperative day 1 (POD1). Our primary objective was to increase the percentage of patients discharged before 11 AM on POD1 to at least 50% within 1 year.

STUDY DESIGN

Prospective observational (quality improvement).

METHODS

A multidisciplinary quality improvement (QI) team was assembled. The primary outcome was "timely discharges," defined as percentage of patients discharged before 11 AM on POD1; secondary outcomes were percentage of patients discharged before 1 PM and mean length of stay (hours). Seven-day readmission rate served as our balancing measure. Prior year data served as baseline. A process map, Ishikawa diagram, and Pareto chart were utilized to identify specific target areas for improvement. Key interventions included announcement of our initiative, an electronic health record-based handoff text prompt, discharge checklist, automated discharge instructions, encouragement to place discharge orders by 9 AM and implementation of early POD1 rounds. Data were collected on a biweekly basis and the primary and secondary outcomes were plotted on control charts and analyzed using rules for special cause variation.

RESULTS

Within 12 months, POD1 discharges before 11 AM and before 1 PM increased to 44.9% and 83.8%, respectively, with sustained improvement for the first 6 months of the subsequent year. Mean length of stay decreased, and 7-day readmission rates were unchanged.

CONCLUSIONS

By understanding the factors influencing timely POD1 discharges after tonsillectomy, key interventions were implemented to achieve an increase in timely discharges.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Measuring care coordination by social workers in a foster care medical home

A social worker coordinated medical care for children in foster care in a foster care medical home (FCMH) and tracked care coordination (CC) activities using a modified Care Coordination Measurement Tool© (mCCMT). Of the 60 subjects, most were younger than 5 years, and 60% had a behavioral and/or medical condition. Primary CC activities included behavioral support for families and health system navigation. The CC prevented 11 emergency department (ED) visits, 9 placement disruptions, and 42 patient privacy violations. Children assigned to a FCMH have diverse CC needs and benefit from social workers' specialized skills.

"I'm Dealing With That": Illness Concerns of African American and White Cancer Patients While Undergoing Active Cancer Treatments

BACKGROUND

National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory.

OBJECTIVE

To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites.

METHODS

A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis.

RESULTS

Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity).

CONCLUSIONS

The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience.

Association of Care Coordination Experience and Health Services Use with Main Provider Type for Children with Inflammatory Bowel Disease

OBJECTIVES

To describe care coordination experience for families of children with inflammatory bowel disease (IBD) and compare use of health services between families who identified a primary care physician (PCP) vs a gastroenterologist as a child's main provider.

STUDY DESIGN

This is a cross-sectional survey of care coordination experiences and health services use for children 6-19 years old receiving care in the IBD program at a children's hospital during 2018. English-speaking parents completed the Family Experiences with Coordination of Care Survey about their child's main provider and reported past-year health services. Bivariate testing and multivariate logistic regression explored differences in care coordination experience and health services by main provider, adjusted for demographic and clinical variables.

RESULTS

A total of 113 of 270 (42%) invited patients participated. Among 101 patients with complete data, 41% identified a PCP main provider. Performance on 5 of 16 Family Experiences with Coordination of Care indicators was higher for patients reporting a gastroenterologist vs a PCP main provider. However, having a PCP vs gastroenterologist main provider was associated with greater use of any past-year primary care services (adjusted proportion 94% vs 75%; P = .01) and of mental health services when needed (95% vs 60%; P < .01). Need for IBD-related hospitalization and emergency department visits did not differ between groups.

CONCLUSIONS

Children with IBD may experience trade-offs in care coordination quality and important, non-disease-focused health services based on whom parents perceive as the main provider. Efforts to enhance cross-team coordination among families and primary and specialty care teams are needed to improve overall care quality.

The Impact of Technology-Enabled Care Coordination in a Complex Mental Health System: A Local System Dynamics Model

Background

Prior to the COVID-19 pandemic, major shortcomings in the way mental health care systems were organized were impairing the delivery of effective care. The mental health impacts of the pandemic, the recession, and the resulting social dislocation will depend on the extent to which care systems will become overwhelmed and on the strategic investments made across the system to effectively respond.

Objective

This study aimed to explore the impact of strengthening the mental health system through technology-enabled care coordination on mental health and suicide outcomes.

Methods

A system dynamics model for the regional population catchment of North Coast New South Wales, Australia, was developed that incorporated defined pathways from social determinants of mental health to psychological distress, mental health care, and suicidal behavior. The model reproduced historic time series data across a range of outcomes and was used to evaluate the relative impact of a set of scenarios on attempted suicide (ie, self-harm hospitalizations), suicide deaths, mental health–related emergency department (ED) presentations, and psychological distress over the period from 2021 to 2030. These scenarios include (1) business as usual, (2) increase in service capacity growth rate by 20%, (3) standard telehealth, and (4) technology-enabled care coordination. Each scenario was tested using both pre– and post–COVID-19 social and economic conditions.

Results

Technology-enabled care coordination was forecast to deliver a reduction in self-harm hospitalizations and suicide deaths by 6.71% (95% interval 5.63%-7.87%), mental health–related ED presentations by 10.33% (95% interval 8.58%-12.19%), and the prevalence of high psychological distress by 1.76 percentage points (95% interval 1.35-2.32 percentage points). Scenario testing demonstrated that increasing service capacity growth rate by 20% or standard telehealth had substantially lower impacts. This pattern of results was replicated under post–COVID-19 conditions with technology-enabled care coordination being the only tested scenario, which was forecast to reduce the negative impact of the pandemic on mental health and suicide.

Conclusions

The use of technology-enabled care coordination is likely to improve mental health and suicide outcomes. The substantially lower effectiveness of targeting individual components of the mental health system (ie, increasing service capacity growth rate by 20% or standard telehealth) reiterates that strengthening the whole system has the greatest impact on patient outcomes. Investments into more of the same types of programs and services alone will not be enough to improve outcomes; instead, new models of care and the digital infrastructure to support them and their integration are needed.

Care Coordination Needs of Families of Children with Down Syndrome: A Scoping Review to Inform Development of mHealth Applications for Families

Care coordination is a critical component of health management aimed at linking care providers and health-information-involved care management. Our intent in this scoping review was to identify care coordination needs of families of children with Down syndrome (DS) and the strategies they used to meet those needs, with the goal of contributing to the evidence base for developing interventions by using an mHealth application (mHealth apps) for these families. Using established guidelines for scoping reviews, we searched five databases, yielding 2149 articles. Following abstract and full-text review, we identified 38 articles meeting our inclusion criteria. Studies incorporated varied in regard to research designs, samples, measures, and analytic approaches, with only one testing an intervention by using mHealth apps. Across studies, data came from 4882 families. Common aspects of families' care coordination needs included communication and information needs and utilization of healthcare resources. Additional themes were identified related to individual, family, and healthcare contextual factors. Authors also reported families' recommendations for desirable characteristics of an mHealth apps that addressed the design of a personal health record, meeting age-specific information needs, and ensuring access to up-to-date information. These results will further the development of mHealth apps that are tailored to the needs of families with a child with DS.

Team-Based Approach to Managing Postpartum Screening of Women with Gestational Diabetes for Type 2 Diabetes

INTRODUCTION

Approximately 6% of pregnant women develop gestational diabetes mellitus (GDM), which is a strong risk factor for developing type 2 diabetes mellitus. It is recommended that women with GDM complete a 75-g oral glucose tolerance test (OGTT) 4 to 12 weeks postpartum to screen for type 2 diabetes. A 3-month retrospective chart review in 2 patient-centered medical homes found that postpartum screening for type 2 diabetes was performed in only 39% of eligible women, despite recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the American Diabetes Association. Thus, a quality improvement project was initiated to improve the postpartum type 2 diabetes screening rate.

PROCESS

This quality improvement project involved an education session that described current ACOG recommendations for diabetes screening. The education session included a pretest and posttest that evaluated participants' understanding about development of type 2 diabetes after GDM. A team-based postpartum guideline designed to enable women to complete a 75-g OGTT at the 4-to-12-week postpartum appointment was implemented. A postintervention chart review was conducted to determine the postintervention rate of type 2 diabetes screening.

OUTCOME

The mean pretest score for the clinical team was 57%, and the mean posttest score was 99%. Postpartum screening for women with GDM was improved from 39% of women for whom screening was indicated to 77% with the implementation of the team-based guideline.

DISCUSSION

The quality improvement project results demonstrated that improved understanding of ACOG recommendations combined with the implementation of a team-based guideline significantly improved postpartum screening for type 2 diabetes. Team-based management of care, including education of team members about the rationale for change, may also improve outcomes in other quality improvement projects.

The Checkpoint Program: Collaborative Care to Reduce the Reliance of Frequent Presenters on ED

Introduction:

Growing pressures upon Emergency Departments [ED] call for new ways of working with frequent presenters who, although small in number, place extensive demands on services, to say nothing of the costs and consequences for the patients themselves. EDs are often poorly equipped to address the multi-dimensional nature of patient need and the complex circumstances surrounding repeated presentation. Employing a model of intensive short-term community-based case management, the Checkpoint program sought to improve care coordination for this patient group, thereby reducing their reliance on ED.

Method:

This study employed a single group interrupted time series design, evaluating patient engagement with the program and year-on-year individual differences in the number of ED visits pre and post enrolment. Associated savings were also estimated.

Results:

Prior to intervention, there were two dominant modes in the ED presentation trends of patients. One group had a steady pattern with ≥7 presentations in each of the last four years. The other group had an increasing trend in presentations, peaking in the 12 months immediately preceding enrolment. Following the intervention, both groups demonstrated two consecutive year-on-year reductions. By the second year, and from an overall peak of 22.5 presentations per patient per annum, there was a 53% reduction in presentations. This yielded approximate savings of $7100 per patient.

Discussion:

Efforts to improve care coordination, when combined with proactive case management in the community, can impact positively on ED re-presentation rates, provided they are concerted, sufficiently intensive and embed the principles of integration.

Conclusion:

The Checkpoint program demonstrated sufficient promise to warrant further exploration of its sustainability. However, health services have yet to determine the ideal organisational structures and funding arrangements to support such initiatives.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey

BACKGROUND

Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness.

OBJECTIVE

Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care.

RESEARCH DESIGN

Cross-sectional analysis of responses to a 2018 mailed survey.

SUBJECTS

VHA outpatients with homeless experiences.

MEASURES

Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey.

RESULTS

Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61).

CONCLUSIONS

Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

Development of a specialty intensity score to estimate a patient's need for care coordination across physician specialties

BACKGROUNDS AND AIMS

This article develops a Specialty Intensity Score, which uses patient diagnosis codes to estimate the number of specialist physicians a patient will need to access. Conceptually, the score can serve as a proxy for a patient's need for care coordination across doctors. Such a measure may be valuable to researchers studying care coordination practices for complex patients. In contrast with previous comorbidity scores, which focus primarily on mortality and utilization, this comorbidity score approximates the complexity of a patient's the interaction with the health care system.

METHODS

We use 2015 inpatient claims data from the Centers for Medicare and Medicaid Services to model the relationship between a patient's diagnoses and physician specialty usage. We estimate usage of specialist doctors by using a least absolute shrinkage and selection operator Poisson model. The Specialty Intensity Score is then constructed using this predicted specialty usage. To validate our score, we test its power to predict the occurrence of patient safety incidents and compare that with the predictive power of the Charlson comorbidity index.

RESULTS

Our model uses 127 of the 279 International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis subchapters to predict specialty usage, thus creating the Specialty Intensity Score. This score has significantly greater power in predicting patient safety complications than the widely used Charlson comorbidity index.

CONCLUSION

The Specialty Intensity Score developed in this article can be used by health services researchers and administrators to approximate a patient's need for care coordination across multiple specialist doctors. It, therefore, can help with evaluation of care coordination practices by allowing researchers to restrict their analysis of outcomes to the patients most impacted by those practices.

Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review

BACKGROUND

In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care.

OBJECTIVES

We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes.

RESEARCH DESIGN

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review.

RESULTS

Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery.

CONCLUSIONS

This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.

Improving Care for Patients Living with Prolonged Incurable Cancer

The number of patients that can no longer be cured but may expect to live with their cancer diagnosis for a substantial period is increasing. These patients with 'prolonged incurable cancer' are often overlooked in research and clinical practice. Patients encounter problems that are traditionally seen from a palliative or survivorship perspective but this may be insufficient to cover the wide range of physical and psychosocial problems that patients with prolonged incurable cancer may encounter. Elements from both fields should, therefore, be delivered concordantly to further optimize care pathways for these patients. Furthermore, to ensure future high-quality care for this important patient population, enhanced clinical awareness, as well as further research, are urgently needed.

Interprofessional Collaboration in School-Based Settings, Part 3: Implementation of IC Through Case Scenarios

This article is the last in a series of three that discusses the importance of interprofessional collaboration (IC) between the school nurse and other school-based and community professionals and provides a succinct recap on the importance of IC along with illustrating how IC can successfully be implemented in the school setting through case scenarios. The case scenarios will depict how the school nurse works interprofessionally with school healthcare professionals, community healthcare professionals, and school staff to provide a comprehensive, collaborative approach.

Medicare's Care Management Codes Might Not Support Primary Care As Expected

To enhance compensation for primary care activities that occur outside of face-to-face visits, the Centers for Medicare and Medicaid Services recently introduced new billing codes for transitional care management (TCM) and chronic care management (CCM) services. Overall, rates of adoption of these codes have been low. To understand the patterns of adoption, we compared characteristics of the practices that billed for these services to those of the practices that did not and determined the extent to which a practice other than the beneficiary's usual primary care practice billed for the services. Larger practices and those using other novel billing codes were more likely to adopt TCM or CCM. Over a fifth of all TCM claims and nearly a quarter of all CCM claims were billed by a practice that was not the beneficiary's assigned primary care practice. Our results raise concerns about whether these codes are supporting primary care as originally expected.

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis

The beneficial impact of primary care, focused on all aspects of a patient's health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower use of emergency care and hospitalization for ambulatory care-sensitive conditions, and decreased early mortality. Although the importance of primary care and care coordination at the primary care/specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving in-center maintenance hemodialysis remains ill-defined. In this perspective article, we will describe: (1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among these patients; (2) the key challenges to delivery of primary care in these complex cases, including suboptimal care coordination between nephrology and primary care providers, the intensity of dialysis care, and the limited capacity of nephrologists and primary care providers to meet the broad health needs of hemodialysis patients; (3) potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and (4) future research requirements to improve primary care delivery for this high-risk population.

Feasibility of a Voice-Enabled Medical Diary App (SpeakHealth) for Caregivers of Children With Special Health Care Needs and Health Care Providers: Mixed Methods Study

Background

Children with special health care needs (CSHCN) require more than the usual care management and coordination efforts from caregivers and health care providers (HCPs). Health information and communication technologies can potentially facilitate these efforts to increase the quality of care received by CSHCN.

Objective

In this study, we aim to assess the feasibility of a voice-enabled medical diary app (SpeakHealth) by investigating its potential use among caregivers and HCPs.

Methods

Following a mixed methods approach, caregivers of CSHCN were interviewed (n=10) and surveyed (n=86) about their care management and communication technology use. Only interviewed participants were introduced to the SpeakHealth app prototype, and they tested the app during the interview session. In addition, we interviewed complex care HCPs (n=15) to understand their perception of the value of a home medical diary such as the SpeakHealth app. Quantitative data were analyzed using descriptive statistics and correlational analyses. Theoretical thematic analysis was used to analyze qualitative data.

Results

The survey results indicated a positive attitude toward voice-enabled technology and features; however, there was no strong correlation among the measured items. The caregivers identified communication, information sharing, tracking medication, and appointments as fairly and highly important features of the app. Qualitative analysis revealed the following two overarching themes: enablers and barriers in care communication and enablers and barriers in communication technologies. The subthemes included parent roles, care communication technologies, and challenges. HCPs found the SpeakHealth app to be a promising tool for timely information collection that could be available for sharing information with the health system. Overall, the findings demonstrated a variety of needs and challenges for caregivers of CSHCN and opportunities for voice-enabled, interactive medical diary apps in care management and coordination. Caregivers fundamentally look for better information sharing and communication with HCPs. Health care and communication technologies can potentially improve care communication and coordination in addressing the patient and caregiver needs.

Conclusions

The perspectives of caregivers and providers suggested both benefits and challenges in using the SpeakHealth app for medical note-taking and tracking health events at home. Our findings could inform researchers and developers about the potential development and use of a voice-enabled medical diary app.

A descriptive study on reasons for prolonged hospital stay in a tertiary hospital in Singapore

BACKGROUND

Our health care is facing with the challenges of bed crunch and increasing number of patients with prolonged hospital stay.

AIMS

This study aimed to determine factors contributing to the prolonged hospital stay in a tertiary hospital in Singapore.

METHODS

A random sample of 600 medical records of patients' staying in hospital for more than 21 days was retrieved. The reasons for their prolonged hospital stay were categorized into 'medically unfit' and 'medically fit'.

RESULTS

The top three reasons for prolonged hospital stay among the 'medically unfit' group were ongoing medical treatment, surgical interventions and receiving intravenous chemotherapy/radiotherapy. The top three reasons for the 'medically fit' group were waiting for community hospital bed, waiting for a new caregiver and undecided on discharge disposition.

CONCLUSION

The results inform health care stakeholders in planning measures to minimize the incidence of unnecessary prolonged hospitalization for optimal health care resource utilization.

IMPLICATIONS OF NURSING MANAGEMENT

Ineffective discharge planning can lead to serious adverse outcomes such as hospital readmission and prolonged hospital stay. Patient navigators have a crucial role in facilitating safe, smooth and timely discharge of patients from acute care hospital to community. Understanding the reasons behind extended hospitalization is essential in order to better provide support.

Experiences with health care practitioners among advanced cancer patients and their family caregivers: A longitudinal dyadic study

BACKGROUND

Assessing patient and caregiver experiences with care is central to improving care quality. The authors assessed variations in the experiences of advanced cancer patients and their caregivers with physician communication and care coordination by patient and caregiver factors.

METHODS

The authors surveyed 600 patients with a stage IV solid malignancy and 346 caregivers every 3 months for more than 2 years. Patients entered the cohort any time during their stage IV trajectory. The analytic sample was restricted to patient-caregiver dyads (n = 299). Each survey assessed patients' experiences with physician communication and care coordination; patients' symptom burden; caregivers' quality of life; and patients' and caregivers' anxiety, financial difficulties, and perceptions of treatment goals. An actor-partner interdependence framework was used for analysis.

RESULTS

Patients reported better physician communication (average marginal effect [AME], 6.04; 95% confidence interval [CI], 3.82 to 8.26) and care coordination (AME, 8.96; 95% CI, 6.94 to 10.97) than their caregivers. Patients reported worse care coordination when they (AME, -0.56; 95% CI, -1.07 to -0.05) or their caregivers (AME, -0.58; 95% CI, -0.97 to -0.19) were more anxious. Caregivers reported worse care coordination when they were anxious (AME, -1.62; 95% CI, -2.02 to -1.23) and experienced financial difficulties (AME, -2.31; 95% CI, -3.77 to -0.86). Correct understanding of the treatment goal (vs being uncertain) was associated with caregivers reporting physician communication as better (AME, 3.67; 95% CI, 0.49 to 6.86) but with patients reporting it as worse (AME, -3.29; 95% CI, -6.45 to -0.14).

CONCLUSIONS

Patients' and caregivers' reports of physician communication and care coordination vary with aspects of their own and each other's well-being and with their perceptions of treatment goals. These findings may have implications for improving patients' and caregivers' reported experiences with health care practitioners.

Usability of Electronic Health Record-Generated Discharge Summaries: Heuristic Evaluation

BACKGROUND

Obtaining accurate clinical information about recent acute care visits is extremely important for outpatient providers. However, documents used to communicate this information are often difficult to use. This puts patients at risk of adverse events. Elderly patients who are seen by more providers and have more care transitions are especially vulnerable.

OBJECTIVE

This study aimed to (1) identify the information about elderly patients' recent acute care visits needed to coordinate their care, (2) use this information to assess discharge summaries, and (3) provide recommendations to help improve the quality of electronic health record (EHR)-generated discharge summaries, thereby increasing patient safety.

METHODS

A literature review, clinician interviews, and a survey of outpatient providers were used to identify and categorize data needed to coordinate care for recently discharged elderly patients. Based upon those data, 2 guidelines for creating useful discharge summaries were created. The new guidelines, along with 17 previously developed medical documentation usability heuristics, were applied to assess 4 simulated elderly patient discharge summaries.

RESULTS

The initial research effort yielded a list of 29 items that should always be included in elderly patient discharge summaries and a list of 7 "helpful, but not always necessary" items. Evaluation of 4 deidentified elderly patient discharge summaries revealed that none of the documents contained all 36 necessary items; between 14 and 18 were missing. The documents each had several other issues, and they differed significantly in organization, layout, and formatting.

CONCLUSIONS

Variations in content and structure of discharge summaries in the United States make them unnecessarily difficult to use. Standardization would benefit both patients, by lowering the risk of care transition-related adverse events, and outpatient providers, by helping reduce frustration that can contribute to burnout. In the short term, acute care providers can help improve the quality of their discharge summaries by working with EHR vendors to follow recommendations based upon this study. Meanwhile, additional human factors work should determine the most effective way to organize and present information in discharge summaries, to facilitate effective standardization.

User-centered design of a longitudinal care plan for children with medical complexity

OBJECTIVE

To determine the content priorities and design preferences for a longitudinal care plan (LCP) among caregivers and healthcare providers who care for children with medical complexity (CMC) in acute care settings.

MATERIALS AND METHODS

We conducted iterative one-on-one design sessions with CMC caregivers (ie, parents/legal guardians) and providers from 5 groups: complex care, primary care, subspecialists, emergency care, and care coordinators. Audio-recorded sessions included content categorization activities, drawing exercises, and scenario-based testing of an electronic LCP prototype. We applied inductive content analysis of session materials to elicit content priorities and design preferences between sessions. Analysis informed iterative prototype revisions.

RESULTS

We conducted 30 design sessions (10 with caregivers, 20 with providers). Caregivers expressed high within-group variability in their content priorities compared to provider groups. Emergency providers had the most unique content priorities among clinicians. We identified 6 key design preferences: a familiar yet customizable layout, a problem-based organization schema, linked content between sections, a table layout for most sections, a balance between unstructured and structured data fields, and use of family-centered terminology.

DISCUSSION

Findings from this study will inform enhancements of electronic health record-embedded LCPs and the development of new LCP tools and applications. The design preferences we identified provide a framework for optimizing integration of family and provider content priorities while maintaining a user-tailored experience.

CONCLUSION

Health information platforms that incorporate these design preferences into electronic LCPs will help meet the information needs of caregivers and providers caring for CMC in acute care settings.

Patient-Centered Outcomes in an Interdisciplinary Clinic for Complex Children with Autism

OBJECTIVE

To compare the perspectives of caregivers of children with autism receiving care at the Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program, an interdisciplinary clinic that provides primary care and behavioral/mental health services for patients with autism and other developmental disabilities, with those responding to the 2016 National Survey of Children's Health (NSCH). We focused on ratings related to shared decision-making, care coordination, family-centered care, and care within a medical home.

METHODS

We administered a subset of items from the 2016 NSCH to caregivers of children with autism enrolled in HOME and compared responses with the same items from a nationally representative group of caregivers of children with autism who completed the 2016 NSCH. We compared the proportions that reported receiving shared decision-making, care coordination, family-centered care, care within a medical home, and unmet needs among the 2 study groups using Poisson regression, controlling for age, sex, race/ethnicity, payor, autism severity, and intellectual disability (ID).

RESULTS

Compared with the NSCH cohort (n = 1151), children enrolled in HOME (n = 129) were older, more often female, had severe autism, and had co-occurring ID. Caregivers perceived that children receiving care within HOME more often received family-centered, coordinated care within a medical home compared with a national sample of children with autism. HOME enrollees also reported increased access to behavioral treatments and adult transition services with less financial burden compared with the national sample.

CONCLUSION

An interdisciplinary clinic model may best serve children with autism, especially those with higher severity symptoms and co-occurring conditions.

Covid-19: A critical time for cross-sector social work care management

Covid-19 has profoundly impacted social work and has exposed the existing inequities in the health care system in the United States. Social workers play a critical role in the pandemic response for historically marginalized communities and for those who find themselves needing support for the first time. Innovative approaches to care management, including the Center for Health and Social Care Integration (CHaSCI) Bridge Model of transitional care provides a foundation from which social workers can rise to meet these new challenges.

Vagueness and Ambiguity in Communication of Case Management: A Content Analysis in the Australian National Disability Insurance Scheme

Case management (CM) is an integrated care strategy, characterised by a set of actions to support person-centred planning, coordination of health and social services. Decades of CM, organisational psychology and occupational research highlight how vagueness and ambiguity in role communication can create role conflict and job stress, negatively impacts staff turnover, intra-organisational collaboration, job performance, and that poor communication of CM impedes policy, quality analysis service development and practice. We conducted a detailed top-down hierarchical, quality analysis of communication about CM roles and responsibilities in a Scheme for people with disability in Australia. The study used content analysis methods and the main actions as defined in a validated CM taxonomy (Appendix 1). We systematically searched and analysed 53 Scheme policy and practice documents of CM from 2013-2019. The results showed poor role communication with vagueness, ambiguity, gaps in the description of CM roles and responsibilities. Poor role communication has contributed to negative experiences and outcomes of CM actions of planning and coordination, as reported by CM users in many Scheme-related parliamentary inquiries, research, formal complaints, and decision appeals. The results reinforce the importance of an ontological approach in communication of CM roles and actions and provides learnings for integrated care roles across countries and contexts.

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

Introduction:

Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination. This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare.

Methodology:

We followed Arksey and O’Malley’s methodological framework for scoping reviews. We carried out a systematic search across CINAHL, MEDLINE, Scopus and ProQuest. Only empirical studies were included. We performed a thematic analysis using deductive (the American Nurses Association Framework) and inductive approaches. Findings were discussed with a group of experts.

Results:

Thirty-four articles were included in the synthesis. Overall, nursing care coordination activities were synthesized into three categories: those targeting the patient, family and caregivers; those targeting health and social care teams; and those bringing together patients and professionals. Interpersonal communication and information transfer emerged as cross-cutting activities that support every other activity. Our results also brought to light the nurses’ contribution to care coordination efforts for patients with complex needs as well as critical components that should be present in every care coordination intervention for this clientele. These include an increased intensity and frequency of activities, relational continuity of care, and home visits.

Conclusion:

With the growing complexity of patient’s needs, efforts must be directed towards enabling the primary healthcare level to effectively play its substantial role in care coordination. This includes finding primary care employment models that would facilitate multidisciplinary teamwork and the delivery of integrated care, and guarantee the delivery of intensive yet efficient coordinated care.

Caregiver outcomes of a dementia care program

The University of California, Los Angeles Alzheimer's and Dementia Care (ADC) program enrolls persons living with dementia (PLWD) and their family caregivers as dyads to work with nurse practitioner dementia care specialists to provide coordinated dementia care. At one year, despite disease progression, overall the PLWDs' behavioral and depressive symptoms improved. In addition, at one-year, overall caregiver depression, strain, and distress related to behavioral symptoms also improved. However, not all dyads enrolled in the ADC program showed improvement in these outcomes. We conducted a mixed qualitative-quantitative study to explore why some participants did not benefit and what could be changed in this and other similar dementia management programs to increase the percentage who benefit. Semi-structured interviews (N=12) or surveys (N=41) were completed with 53 caregivers by telephone, mail and online. Seven areas for potential program improvement were identified from the first 12 interviews. These included: recommendations that did not match caregivers' perceived care needs, barriers to accessing care and utilizing resources, differing care needs based on stage of dementia, needing services not offered by the ADC, needing more education or support, behavioral recommendations that the caregiver felt did not work, and poor rapport of the dementia expert with caregivers. Despite having been identified as having had no clinical benefit from participating in the program, most caregivers (85%) reported that the program was very beneficial or extremely beneficial. Respondents identified the close, longitudinal relationship and access to a dementia care expert as particularly beneficial. This dichotomy highlights that perceived benefit for most of the interviewed caregivers was not captured with the formal instruments used by the program.

Women's experience with receiving advice on diet and Self-Monitoring of blood glucose for gestational diabetes mellitus: a qualitative study

OBJECTIVE

We aimed to explore how women with gestational diabetes mellitus (GDM) experience advice about diet and self-monitoring of blood glucose received in primary health care (PHC) and secondary health care (SHC) with a focus on how women perceived the care coordination and collaboration between healthcare professionals.

DESIGN, SETTING AND SUBJECTS

Individual interviews were conducted with 12 pregnant women diagnosed with GDM. Six women had immigrant backgrounds, and six were ethnic Norwegian. Women received GDM care in the area of Oslo, Norway. Interviews were analysed using thematic analysis.

RESULTS

Women described feeling shocked when they were diagnosed with GDM and feeling an immediate need for information about the consequences and management of GDM. Most of the women felt that their general practitioner (GP) had too little knowledge about GDM. Women with an immigrant background felt that the PHC midwives provided them with sufficient dietary advice related to GDM. Ethnic Norwegian women appreciated receiving more individually tailored dietary advice in SHC. Self-monitoring of blood glucose influenced women's daily lives; however, they perceived the training in PHC and SHC as adequate. The women experienced poor collaboration between healthcare professionals in PHC and SHC, which implied that they sometimes had to initiate follow-up steps in their GDM care by themselves.

CONCLUSIONS

Ideally, women diagnosed with GDM should meet healthcare professionals with sufficient knowledge about GDM as soon as possible after being diagnosed. The collaboration between healthcare professionals involved in the care of women with GDM should be improved to avoid having women feel that they need to coordinate their own care.KEY POINTSCurrent awareness•The management of gestational diabetes mellitus requires appropriate follow-up by healthcare professionalsMain statements•Pregnant women's need for information about the consequences and management of gestational diabetes mellitus was highest immediately after diagnosis•Women perceived that they received more individually tailored information about diet and self-monitoring of blood glucose in secondary health care compared to primary health care•Women felt that general practitioners had insufficient knowledge about gestational diabetes mellitus•Based on our results, care coordination and collaboration between healthcare professionals involved in the care of women with gestational diabetes mellitus should be improved.

Homecare nurses guide goals for care and care transitions in serious illness: A grounded theory of relationship-based care

AIMS

To identify the process that homecare nurses use when recognizing serious illness, engaging patients and families in goals-for-care discussions and guiding transitions to comfort-focused care.

DESIGN

Constructivist grounded theory.

METHODS

Semi-structured focus group interviews of 31 homecare Registered Nurses were recorded and transcribed (June-August 2019). Line-by-line coding using the constant comparative method until saturation was achieved and a grounded theory was identified. Credibility, transferability, and confirmability establish study rigor.

RESULTS

A grounded theory of relationship-based care. Nurses cogitate and act when recognizing serious illness. They have difficult conversations and support care transitions with wisdom and knowing, by identifying changes in illness trajectories and being informed and alert to diminishing quality of life. Nurses are skilled at engaging patients, families, and the team and accommodate care in the home for as long as possible, while manoeuvring through complex systems of care; ultimately relinquishing and guiding care to other providers and settings. However, nurses feel inadequately prepared and frustrated with a fragmented healthcare system and lack of collaboration among the team.

CONCLUSION

This study identifies a grounded theory to support clinical decision-making and position homecare nurses as leaders in guiding goal care discussions and transitions to comfort-focused care. These findings reinforce the importance of developing health policy that ensures care continuity in serious illness. Further research is needed to improve relationships across care settings and enhance training for the delivery of comfort-focused care in the home as changing needs emerge during serious illness management.

The Impact of Telephonic Follow-Up Within 2 Business Days Postdischarge on 30-Day Readmissions for Patients With Heart Failure

BACKGROUND

Heart failure (HF) is a chronic condition associated with high rates of hospital readmissions. The prevalence and costs of HF are expected to rise dramatically by 2030 (Heidenreich,et al., 2013).

OBJECTIVE

A 24-month, retrospective study was conducted using electronic medical record (EMR) chart review, seeking to identify if postdischarge follow-up phone calls decreased 30-day readmissions in individuals with HF.

METHODS

The study included 705 adult participants who were admitted to the hospital for HF. Some received a postdischarge call within 2 business days of discharge, and some did not.

RESULTS

Participants who received the postdischarge call were less likely to be readmitted (20.1%) than participants who did not receive a postdischarge call (28.8%; p = .007). Participants who received the postdischarge call were more likely to have a follow-up visit within 14 days (70.1%) than participants who did not receive a postdischarge call (30.2%; p < .001).

CONCLUSIONS

The findings from this study may help to drive future transitional care strategies for individuals diagnosed with HF.

IMPLICATIONS FOR NURSING

Nurse-led transitional care interventions offer potential solutions to ensure safe, effective hospital discharges.

Think globally, act locally: Quality improvement as a catalyst for COVID-19 related care during the transitional years

The COVID-19 pandemic has posed distinctive challenges to adolescents and young adults living with spina bifida, especially those from ethic minority populations. With this public health challenge in mind, developing a customized electronic health record to leverage registry data to promote and quantify COVID-19 vaccination uptake among this population is feasible. We provide a brief description of our activities in customizing an electronic health record to track vaccination uptake among adolescents and young adults with spina bifida (AYASB); and the lessons learned, in hopeful support of those scaling-up vaccination delivery across the globe for AYASB as they transition to adult-centered care. Thus, as providers think globally and act locally, COVID-19 immunization efforts can be implemented while providing culturally appropriate transition policies and services for individuals with neurodevelopmental disabilities.

The Patient-centered Medical Home as an Intervention Strategy for Diabetes Mellitus: A Systematic Review of the Literature

BACKGROUND

Poorly managed diabetes mellitus increases health care expenditures and negatively impacts health outcomes. There are 34 million people living with diabetes in the United States with a direct annual medical cost of $237 billion. The patient-centered medical home (PCMH) was introduced to transform primary care by offering team-based care that is accessible, coordinated, and comprehensive. Although the PCMH is believed to address multiple gaps in delivering care to people living with chronic diseases, the research has not yet reported clear benefits for managing diabetes.

OBJECTIVE

The study reviews the scientific literature about diabetes mellitus outcomes reported by PCMHs, and understands the impact of team-based care, interdisciplinary communication, and care coordination strategies on the clinical, financial, and health-related outcomes.

METHODS

The systematic review was performed according to the Cochrane method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight databases were systematically searched for articles. The Oxford Centre for Evidence-based Medicine Levels of evidence and the Critical Appraisal Skills Programme systematic review checklist were used to evaluate the studies.

RESULTS

The search resulted in 596 articles, of which 24 met all the inclusion criteria. Care management resulted in more screenings and better preventive care. Pharmacy-led interventions and technology were associated with positive clinical outcomes, decreased utilization, and cost savings. Most studies reported decreased emergency room visits and less inpatient admissions.

CONCLUSION

The quality and strength of the outcomes were largely inconclusive about the overall effectiveness of the PCMH. Defining and comparing concepts across studies was difficult as universal definitions specific to the PCMH were not often applied. More research is needed to unpack the care model of the PCMH to further understand how the individual key components, such as care bundles, contribute to improved outcomes. Further evaluations are needed for team-based care, communication, and care coordination with comparisons to patient, clinical, health, and financial outcomes.

Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team

Objectives: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions-FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population. Methods: We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population. Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 - 1.75) and hospital days per year (16.83, CI 1.76 - 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization. Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.

Agreement of Provider and Parent Perceptions of Complex Care Medical Homes After a Care Management Intervention

INTRODUCTION

Children with medical complexity frequently lack coordinated and family-centered care and are best cared for in a medical home.

METHOD

We assessed concordance between provider and family perceptions of care management improvements during a prospective, 3-year study of nine complex care clinics and 42 primary care clinics. Using a pre-post design, we compared provider and parent perceptions of changes in care coordination and family-centered care responses using paired t tests, Spearman rank correlations, and linear regression.

RESULTS

Provider scores significantly increased in every domain (range: 14.1 points [data management], 23.0 points [chronic care management]; p < .001). Parent perceptions improved only for shared decision making improved significantly (2.2 points, p < .01).

DISCUSSION

These results indicate that it is possible to improve the medical home for children with medical complexity through a quality improvement initiative, but that provider perception of the improvement may be greater than parents' perceptions.

Spina bifida care, education, and research: A multidisciplinary community in a global context

Worldwide neural tube defects, such as encephalocele and spina bifida (SB), remain a substantial cause of the global burden of disease; and in the US, Latinos consistently have a higher birth prevalence of SB compared with other ethnic groups. From limited access and fragmented care, to scarcely available adult services, many are the challenges that besiege those living with SB. Thus, to provide inclusion and active involvement of parents of children and adults with SB from all communities, innovative approaches will be required, such as community-based participatory research and culturally competent learning collaboratives. Promisingly, the Spina Bifida Community-Centered Research Agenda was developed by the community of people living with SB through the Spina Bifida Association (SBA). Additionally, the SBA will host the Fourth World Congress on Spina Bifida Research and Care in March of 2023. Just as the SBA is clearly committed to this population, the Journal of Pediatric Rehabilitation Medicine will continue to serve as a catalyst for SB care, education, and research across the SB population in a global context.

Increasing the Focus on Children's Complex and Integrated Care Needs: A Position Paper of the European Academy of Pediatrics

There is wide variation in terminology used to refer to children living with complex needs, across clinical, research and policy settings. It is important to seek to reconcile this variation to support the effective development of programmes of care for this group of children and their families. The European Academy of Pediatrics (EAP) established a multidisciplinary Working Group on Complex Care and the initial work of this group examined how complex care is defined in the literature. A scoping review was conducted which yielded 87 papers with multiple terms found that refer to children living with complex needs. We found that elements of integrated care, an essential component of care delivery to these children, were repeatedly referred to, though it was never specifically incorporated into a term to describe complex care needs. This is essential for practice and policy, to continuously assert the need for integrated care where a complex care need exists. We propose the use of the term Complex and Integrated Care Needs as a suitable term to refer to children with varying levels of complexity who require continuity of care across a variety of health and social care settings.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting

Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained, direct caregivers to manage their complex needs safely. These guidelines were developed from a comprehensive review of the literature to provide guidance for the selection of the type of tracheostomy tube (cuffed vs uncuffed), use of communication devices, implementation of daily care bundles, timing of first tracheostomy change, type of humidification used (active vs passive), timing of oral feedings, care coordination, and routine cleaning. Cuffed tracheostomy tubes should only be used for positive-pressure ventilation or to prevent aspiration. Manufacturer guidelines should be followed for cuff management and tracheostomy tube hygiene. Daily care bundles, skin care, and the use of moisture-wicking materials reduce device-associated complications. Tracheostomy tubes may be safely changed at postoperative day 3, and they should be changed with some regularity (at a minimum of every 1-2 weeks) as well as on an as-needed basis, such as when an obstruction within the lumen occurs. Care coordination can reduce length of hospital and ICU stay. Published evidence is insufficient to support recommendations for a specific device to humidify the inspired gas, the use of a communication device, or timing for the initiation of feedings.

Applying Care Coordination Principles to Reduce Cardiovascular Disease Risk Factors in People With Serious Mental Illness: A Case Study Approach

People with serious mental illness (SMI) have a 2-3-fold higher mortality than the general population, much of which is driven by largely preventable cardiovascular disease. One contributory factor is the disconnect between the behavioral and physical health care systems. New care models have sought to integrate physical health care into primary mental health care settings. However, few examples of successful care coordination interventions to improve health outcomes with the SMI population exist. In this paper, we examine challenges faced in coordinating care for people with SMI and explore pragmatic, multi-disciplinary strategies for overcoming these challenges used in a cardiovascular risk reduction intervention shown to be effective in a clinical trial.

Stakeholder perspectives: Communication, care coordination, and transitions in care for children with medical complexity

PURPOSE

The purpose of this study was to obtain feedback on communication, care coordination, and transitions in care for hospitalized children with medical complexity (CMC).

DESIGN AND METHODS

This descriptive, mixed-methods study used online surveys with forced-choice and open-ended questions to obtain stakeholder feedback. Stakeholders included parents, healthcare providers, and nurses. Participants over 18 years of age were recruited from a Midwest children's hospital inpatient unit dedicated to care of CMC. Quantitative data were analyzed using t-tests and one-way analysis of variance. Qualitative description was used to analyze responses to open-ended questions.

RESULTS

Parents' ratings of communication, care coordination, and transitions in care were generally high. Transitions from other facilities to the emergency department and unit received lower ratings. Providers and nurses gave high ratings to overall care, communication among providers and nurses on the patient unit, and experiences with discharge; however, between unit communication and unit-based coordination received lower ratings. Providers and nurses had higher ratings for discharge preparation than parents (p ≤ .001). Three themes were identified in responses to the open-ended questions: establishing balanced and collaborative relationships between the care team and families, taking a proactive approach to care coordination, and the importance of an inclusive, interdisciplinary, and centralized approach to care coordination and communication.

PRACTICE IMPLICATIONS

Collaboration among all stakeholders is needed to achieve coordinated care, inclusive communication, and transitions with positive outcomes during hospitalization. Parents identified a need for consistent communication from care teams, with the primary inpatient team taking a lead role. Including parents in care coordination and transitions in care is key, as they are the experts in their children's health and well-being.

Pediatric care coordination and risk tiering: Moving beyond claims data

PURPOSE

The goal of this study was to evaluate the performance of a pediatric stratification tool that incorporates health and non-medical determinants to identify children and youth with special health care needs (CYSHCN) patients according to increasing levels of complexity and compare this method to existing tools for pediatric populations.

METHODS

This retrospective cohort study examined pediatric patients aged 0 to 21 years who received care at our institution between 2012 and 2015. We used the St. Luke's Children's Acuity Tool (SLCAT) to evaluate mean differences in dollars billed, number of encounters, and number of problems on the problem list and compared the SLCAT to the Pediatric Chronic Conditions Classification System version2 (CCCv2).

RESULTS

Results indicate that the SLCAT assigned pediatric patients into levels reflective of resource utilization and found that children with highly complex chronic conditions had significantly higher utilization than those with mild and/or moderate complex conditions. The SLCAT found 515 patients not identified by the CCCv2. Nearly half of those patients had a mental/behavioral health diagnosis.

CONCLUSIONS

The findings of this study provide evidence that a tiered classification model that incorporates all aspects of a child's care may result in more accurate identification of CYSHCN. This would allow for primary care provider and care coordination teams to match patients and families with the appropriate amount and type of care coordination services.

Exploring Cancer Registrars' Perceptions of the Quality and Use of Cancer Registry Data for Care Coordination and Other Purposes

BACKGROUND

Hospital cancer registry data are used for a variety of aspects of patient care, yet one of the lesser used purposes of cancer registry data is to improve care coordination.

OBJECTIVES

The purposes of this study were to assess hospital cancer registrars' perceptions of (1) the use of and quality of hospital cancer registry data for care coordination and other purposes; (2) the availability of all needed data for complete hospital cancer registry data collection; and (3) the data collection of COVID-19 effects on cancer patients.

METHODS

A survey was sent to hospital-based members of Cancer Registrars of Illinois between April and June 2020. Survey questions focused on current use and quality of hospital cancer registry data for care coordination as well as items related to COVID-19's effect on cancer patients. The focus of this study was hospital-based registrars, as they are the individuals collecting data directly from primary patient records.

RESULTS

While hospital cancer registry data are being used for many purposes including continuity of care, this study found that providers are not using hospital cancer registry data to its fullest extent. It was also found that hospital cancer registrars have collected valuable data on the impact that COVID-19 has had on cancer patients.

CONCLUSION

Care coordination between providers is especially important for cancer patients who may see multiple providers and visit several facilities. This study found that the hospital cancer registry database contains extremely useful data for cancer patients and practitioners. Further, it was found that the hospital cancer registry is a source of valuable information regarding the impact that COVID-19 has had on cancer patients.

Using Digital Technologies to Facilitate Care Coordination Between Youth Mental Health Services: A Guide for Implementation

Enhanced care coordination is essential to improving access to and navigation between youth mental health services. By facilitating better communication and coordination within and between youth mental health services, the goal is to guide young people quickly to the level of care they need and reduce instances of those receiving inappropriate care (too much or too little), or no care at all. Yet, it is often unclear how this goal can be achieved in a scalable way in local regions. We recommend using technology-enabled care coordination to facilitate streamlined transitions for young people across primary, secondary, more specialised or hospital-based care. First, we describe how technology-enabled care coordination could be achieved through two fundamental shifts in current service provisions; a model of care which puts the person at the centre of their care; and a technology infrastructure that facilitates this model. Second, we detail how dynamic simulation modelling can be used to rapidly test the operational features of implementation and the likely impacts of technology-enabled care coordination in a local service environment. Combined with traditional implementation research, dynamic simulation modelling can facilitate the transformation of real-world services. This work demonstrates the benefits of creating a smart health service infrastructure with embedded dynamic simulation modelling to improve operational efficiency and clinical outcomes through participatory and data driven health service planning.

The Use of Medical and Non-Medical Services by the Elderly during the SARS-CoV-2 Pandemic Differs between General and Specialist Practice: A One-Center Study in Poland

In Poland, there is a lack of documented data on the use of medical and non-medical services by the elderly during the SARS-CoV-2 pandemic. The FIMA questionnaire assesses the use of medical and non-medical services by the elderly. The authors compared the demand for these services during the ongoing pandemic with similar months in 2017. It was confirmed that in the group of 61 surveyed elderly people, the number of individuals who had a medical visit decreased significantly in the three-month period. In the analyzed pandemic period, patients had significantly fewer visits to their general practitioner only. The pandemic had no significant impact on the use of other medical and non-medical services analyzed by FIMA. The limitations may include the small number of respondents, the relatively short period from the beginning of the pandemic covered by the survey, and the nature of the studied patients’ diseases. Further observation of elderly patients’ access to the abovementioned services can improve the efforts of governments and caregivers in this field, which is of particular importance in the group of chronically ill elderly patients.

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

Introduction:

Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations.

Methods:

Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes.

Results:

Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.

Conclusions:

This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Community-Based Participatory Research in Action: The Patient-Centered Medical Home and Neighborhood

Background:

The Morehouse School of Medicine Patient Centered Medical Home and Neighborhood Project was developed to implement a community-based participatory research driven, integrated patient-centered medical home and neighborhood (PCMH) pilot intervention. The purpose of the PCMHN was to develop a care coordination program for underserved, high-risk patients with multiple morbidities served by the Morehouse Healthcare Comprehensive Family Health Clinic.

Measures:

A community needs assessment, patient surveys and provider interviews were administered.

Results:

Among a panel of 367 high-risk patients and potential participants, 93 participated in the intervention and 42 patients completed the intervention. The patients self-reported increased utilization of community support, increased satisfaction with health care options, and increased self-care management ability.

Conclusion:

The results were largely attributable to the efforts of community health workers and targeted community engagement. Lessons learned from implementation and integration of a community-based participatory approach will be used to train clinicians and small practices on how to affect change using a care coordination model for underserved, high-risk patients emphasizing CBPR.

Identifying Caregiver Needs for Children With a Tracheostomy Living at Home

This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.