Enhancing diabetes care through care coordination, telemedicine, and education: Evaluation of a rural pilot program

OBJECTIVE

To provide a comprehensive evaluation of a grant-funded pilot diabetes care program. Rural adult patients living with poorly controlled diabetes were targeted for care.

DESIGN AND SAMPLE

Retrospective study using a purposive sample of patients at select primary care sites with a glycated hemoglobin (A1C) greater than 8%. Interventions included nurse care management, telemedicine endocrinology consults, as well as diabetes self-management education (DSME), to enhance disease management and prevention of complications.

MEASURES

Pre/post labs, DSME test scores, hospital claims data, satisfaction surveys, and a focus group were evaluated.

RESULTS

Fifty-nine adults, 21-76 years of age, participated. Interventions demonstrated statistically significant reduction in A1C (10.10 vs. 9.27; p value = 0.002); DSME test score improvement (76.23 vs. 96.04; p < 0.05) and reduced hospital utilization (Emergency Department use 0.86 vs. 0.40; p value = 0.04; inpatient admissions 0.09 vs. 0.02; p value = 0.02). Patients and providers indicated strong satisfaction with the program components. Less hospital utilization reduced emergency department costs by 51.4% and inpatient costs by 96%. A rural community advisory network indicated satisfaction in delivery of program activities and outcome measures.

CONCLUSIONS

This rural model shows potential for improving diabetes control, access to specialty care through telemedicine, and reduction of health care utilization costs.

Developing Partnerships to Improve School Nursing: The Domino Effect

School nursing is a rewarding but difficult job. As professionals, we need to better understand how our work fits in the larger context of schools and influences not just health but also academia and the school environment. This article explains how school nurses can use systems-level thinking and interprofessional collaboration to facilitate their goals and provides five practice steps that can be undertaken immediately to begin making the change.

Nurse Navigation Program: Outcomes From a Breast Cancer Center in Brazil

BACKGROUND

Nurse navigators play a major role in the care provided to patients with cancer within the healthcare system.

OBJECTIVES

This study aims describe the outcomes of a pioneering nurse navigation program established in a breast cancer center in a private, nonprofit hospital in Porto Alegre, Brazil.

METHODS

This is a cross-sectional, retrospective, descriptive study based on electronic health records. Descriptive statistics were used for data analysis.

FINDINGS

Data from 263 patients participating in the navigation program and hospital quality indicators showed a reduction in the time elapsed from diagnosis to the start of treatment from 24 days in 2014 to 18 days in 2017. Of 153 patients who responded to a patient satisfaction survey, 97% were satisfied or very satisfied with the care provided by the nurse navigator.

Bereaved Parents More Satisfied With the Care Given to Their Child With Severe Spinal Muscular Atrophy Than Nonbereaved

BACKGROUND AND AIMS

Children with severe spinal muscular atrophy have complex care needs due to progressive muscle weakness, eventually leading to respiratory failure. To design a care system adapted to families' needs, more knowledge about parents' experience of care and its coordination between settings is required. This study explores (1) whether parents felt that health professionals took every opportunity to help the child feel as good as possible, (2) parents' satisfaction with various care settings, and (3) parents' satisfaction with coordination between settings.

METHODS

Data derive from nationwide Swedish and Danish surveys of bereaved and nonbereaved parents of children with severe spinal muscular atrophy born between 2000 and 2010 in Sweden and 2003 and 2013 in Denmark (N = 95, response rate = 84%). Descriptive statistics and content analysis were used.

RESULTS

Although most of the parents reported that care professionals had taken every opportunity to help the child feel as good as possible, one-third reported the opposite. Bereaved parents were significantly more satisfied with care than nonbereaved (81% vs 29%). The children received care at many different locations, for all of which parents rated high satisfaction. However, some were dissatisfied with care coordination, describing lack of knowledge and communication among staff, and how they as parents had to take the initiative in care management.

CONCLUSIONS

This study highlights the importance of improving disease-specific competence, communication and knowledge exchange among staff. For optimal care for these children and families, parents should be included in dialogues on care and staff should be more proactive and take care management initiatives.

Patient Experiences with Chronic Care Management Services and Fees: a Qualitative Study

BACKGROUND

As of 2015, the Centers for Medicare & Medicaid Services (CMS) pays for chronic care management (CCM) services for Medicare beneficiaries with two or more chronic conditions. CMS requires eligible providers to first obtain patients' verbal (and, prior to 2017, written) consent, to ensure that patients who participate in CCM services understand their rights and agree to any applicable cost sharing. CCM providers must also enhance patients' access to continuous and coordinated care, including ongoing care management.

OBJECTIVE

To understand patients' perceptions of the consent process, their reasons for choosing to participate, and their experiences receiving CCM services.

DESIGN

Qualitative study using semi-structured interviews with Medicare beneficiaries who had two or more CCM claims submitted by an eligible provider. Beneficiaries were selected from a sampling frame of Medicare claims submitted between January and September 2015.

KEY RESULTS

Most patients reported no concerns about being asked to participate in CCM. The majority of patients had secondary insurance (or Medicaid) that covered any coinsurance for CCM and therefore could not say with certainty whether they would participate if they had to pay for CCM services out-of-pocket. Reasons for participating included having insurance that covered the copay and peace of mind about having access to the CCM team. Patients reported multiple benefits of participating in CCM services, including better access to their primary care team, improved continuity of care, and improved care coordination. Most patients reported no downside to participating in CCM services, although some felt they were relatively healthy and questioned whether they needed CCM services.

CONCLUSIONS

These findings on patients' experiences participating in CCM services during the first 9 months of the policy's implementation can help providers and policymakers understand their perceived benefits and unintended consequences. Our findings also have implications for providers when approaching patients about CCM services.

Care coordination experiences of people with traumatic brain injury and their family members in the 4-years after injury: a qualitative analysis

TITLE

Care coordination experiences of people with traumatic brain injury and their family members 4-years after injury: A qualitative analysis.

AIM

To explore experiences of care coordination in the first 4-years after severe traumatic brain injury (TBI).

METHODS

A qualitative study nested within a population-based longitudinal cohort study. Eighteen semi-structured telephone interviews were conducted 48-months post-injury with six adults living with severe TBI and the family members of 12 other adults living with severe TBI. Participants were identified through purposive sampling from the Victorian State Trauma Registry. A thematic analysis was undertaken.

RESULTS

No person with TBI or their family member reported a case manager or care coordinator were involved in assisting with all aspects of their care. Many people with severe TBI experienced ineffective care coordination resulting in difficulty accessing services, variable quality in the timing, efficiency and appropriateness of services, an absence of regular progress evaluations and collaboratively formulated long-term plans. Some family members attempted to fill gaps in care, often without success. In contrast, effective care coordination was reported by one family member who advocated for services, closely monitored their relative, and effectively facilitated communication between services providers.

CONCLUSION

Given the high cost, complexity and long-term nature of TBI recovery, more effective care coordination is required to consistently meet the needs of people with severe TBI.

Effect of Patient Care Coordination on Hospital Encounters and Related Costs

Given high costs of hospital encounters, providers have increasingly turned to patient-centered health care programs to improve cost-effectiveness and population health for patients with high needs. Yet, evidence is mixed about program effectiveness. This pre-post comparative analysis assessed whether the number of hospital encounters and related costs decreased for patients who received care coordination services funded through Texas's 1115(a) Medicaid waiver incentive-based payment model, under which providers created new programs to improve care quality, population health, and cost-effectiveness. This study compared hospital records for patients who were frequent emergency department users at 4 urban safety net hospitals in Texas and state data for hospital encounters for the calendar years 2013 through 2015. The study included 9061 patients who frequently used emergency departments: 4117 patients who received waiver-funded care coordination services at 2 hospitals and 4944 patients who received usual care at 2 comparison hospitals. Regression models compared changes in patients' hospital use and length of stay for the 2 groups. Patients receiving waiver-funded care coordination had a 19% lower probability of hospitalization after receiving care coordination relative to patients who received usual care, for a mean savings of approximately $1500 per year per patient. Receiving care coordination was not associated with a change in length of stay. Care coordination developed by hospitals to meet the needs of their most vulnerable patients can reduce their use of hospital resources through better preventive care. These findings bolster the business case for care coordination, which may help ensure service continuation.

Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care

OBJECTIVE

To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma.

METHODS

We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine, surgery, anesthesia, and pediatric critical care. Using qualitative content analysis, we identified PL goals, characteristics, and patient-related information from these interviews and the hospital's PL etiquette document of guideline.

RESULTS

We identified five goals of the PL (to document the patient's problems, to make sense of the patient's problems, to make decisions about the care plan, to know who is involved in the patient's care, and to communicate with others), seven characteristics of the PL (completeness, efficiency, accessibility, multiple users, organized, created before arrival, and representing uncertainty), and 22 patient-related information elements (e.g., injuries, vitals). Physicians' suggested criteria for a PL varied across services with respect to goals, characteristics, and patient-related information.

CONCLUSION

Physicians involved in pediatric trauma care described the electronic PL as ideally more than a list of a patient's medical diagnoses and injuries. The information elements mentioned are typically found in other parts of the patient's electronic record besides the PL, such as past medical history and labs. Future work is needed to evaluate the optimal design of the PL so that users with emergent cases, such as pediatric trauma, have access to key information related to the patient's immediate problems.

Practice Capacity to Address Patients' Social Needs and Physician Satisfaction and Perceived Quality of Care

Recent studies have explored clinician impacts of health care-based interventions that respond to patients' social and economic needs. These studies were limited by available clinician data. We used the Commonwealth International Health Policy Survey of 890 primary care physicians to examine associations between clinic capacity to respond to patients' social needs and physician satisfaction, stress, and perceived medical care quality. Results suggest that perceived capacity to address social needs is strongly associated with both clinician satisfaction and perceived medical care quality. Our findings add to a growing literature on the potential return on investment of clinical interventions to address social needs.

Cross-Cultural Adaptation And Pilot Testing Of The Cancer Care Coordination Questionnaire For Patients (CCCQ-P) In Chinese And Arabic Languages

BACKGROUND

The Cancer Care Coordination Questionnaire for Patients (CCCQ-P) has been designed to measure patients' experience of this crucial aspect of their cancer care. Migrants are at particular risk of receiving poorly coordinated cancer care due to challenges in communication as well as unfamiliarity with the health system and roles of health professionals. The aim of this study was to cross-culturally adapt and pilot test the CCCQ-P in Chinese and Arabic languages.

METHODS

This study followed an established five-stage process for cross-cultural adaptation of self-report measures. The CCCQ-P was forward and back-translated into Arabic, Simplified Chinese, and Traditional Chinese languages by two independent translators. An expert committee review panel appraised the translations, resulting in a pre-final version in the target languages. Face validity, content validity, and consistency of the translated CCCQ-P were then assessed in a sample of bilingual former cancer patients and health professionals. In addition, structured interviews were conducted to explore the meaning of each question and responses to participants.

RESULTS

Thirteen health professionals (7 Chinese, 6 Arabic) and 19 former cancer patients (11 Chinese, 8 Arabic) participated in the face validation. Across both language groups, participants agreed that the cross-culturally adapted and translated versions had clear instructions and response options that were appropriate and understandable. All items were considered important and significant to the tool and so no item was removed. Complex medical words caused some differences in preferred terminology in Arabic and Chinese; however, participants agreed that the meaning of the questions and response options was not lost.

CONCLUSION

The Arabic, Simplified Chinese, and Traditional Chinese cross-culturally adapted and piloted versions of the CCCQ-P are useful tools to measure patients' experience of cancer care coordination. Further validation and psychometric testing of the instrument are warranted.

eHealth Engagement as a Response to Negative Healthcare Experiences: Cross-Sectional Survey Analysis

Background

eHealth provides individuals with new means of accessing health information and communicating with providers through online channels. Prior evidence suggests that patients use eHealth to find information online when they receive care that is low in patient centeredness. However, it is unclear how other problems with the healthcare-delivery system motivate the use of eHealth, how these problems relate to different kinds of eHealth activities, and which populations are most likely to use eHealth when they receive low-quality care.

Objective

We aimed to determine how two types of negative care experiences—low patient centeredness and care coordination problems—motivate the use of different eHealth activities, and whether more highly educated individuals, who may find these tools easier to use, are more likely to use eHealth following negative experiences than less highly educated individuals.

Methods

Using nationally representative data from the 2017 Health Information National Trends Survey, we used factor analysis to group 25 different eHealth activities into categories based on the correlation between respondents’ reports of their usage. Subsequently, we used multivariate negative binomial generalized linear model regressions to determine whether negative healthcare experiences predicted greater use of these resulting categories. Finally, we stratified our sample based on education level to determine whether the associations between healthcare experiences and eHealth use differed across groups.

Results

The study included 2612 individuals. Factor analysis classified the eHealth activities into two categories: provider-facing (eg, facilitating communication with providers) and independent (eg, patient-driven information seeking and communication with non-providers). Negative care experiences were not associated with provider-facing eHealth activity in the overall population (care coordination: P=.16; patient centeredness: P=.57) or among more highly educated respondents (care coordination: P=.73; patient centeredness: P=.32), but respondents with lower education levels who experienced problems with care coordination used provider-facing eHealth more often (IRR=1.40, P=.07). Individuals engaged in more independent eHealth activities if they experienced problems with either care coordination (IRR=1.15 P=.01) or patient-centered communication (IRR=1.16, P=.01). Although care coordination problems predicted independent eHealth activity across education levels (higher education: IRR=1.13 P=.01; lower education: IRR=1.19, P=.07), the relationship between low perceived patient centeredness and independent activity was limited to individuals with lower education levels (IRR=1.25, P=.02).

Conclusions

Individuals use a greater number of eHealth activities, especially activities that are independent of healthcare providers, when they experience problems with their healthcare. People with lower levels of education seem particularly inclined to use eHealth when they have negative healthcare experiences. To maximize the potential for eHealth to meet the needs of all patients, especially those who are traditionally underserved by the healthcare system, additional work should be performed to ensure that eHealth resources are accessible and usable to all members of the population.

Transitional Care: Methods and Processes for Transitioning Older Adults With Cancer in a Postacute Setting

BACKGROUND

The concept of transitional care and the methods and processes to efficiently and effectively transition patients between a variety of care settings remains a continuous healthcare goal. Despite the numerous transitional care models that have been developed and implemented in a myriad of healthcare settings, increasing healthcare costs and substandard patient outcomes persist.

OBJECTIVES

This article will examine the topic of older adults with cancer when transitioned to a skilled nursing setting and the challenges they may face along the care continuum. In addition, it will look at the continuity of care between the hospital and skilled nursing facility, as well as explore some of the clinical difficulties experienced by older adult patients with cancer in the postacute care setting.

METHODS

Keyword searches were conducted in a selected literature review of CINAHL®, Ovid, PubMed, and Google Scholar databases.

FINDINGS

Successful transitional care models are built around effective communication and often include an interprofessional team approach and/or a nurse navigator to aid in the effective execution of medical treatment and patient care plans.

Referral patterns and implementation costs of the Partners in Recovery initiative in Gippsland: learnings for the National Disability Insurance Scheme

OBJECTIVE:

The purpose of this paper is to provide some learnings for the NDIS from the referral pattern and cost of implementing the Partners in Recovery initiative of Gippsland.

METHOD:

Information on referral areas made for each consumer was collated from support facilitators. Cost estimates were determined using budget estimates, administrative costs and a literature review and are reported from a government perspective.

RESULTS:

Sixty-three per cent of all referrals were made to organisations that provided multiple types of services. Thirty-one per cent were to Mental Health Community Support Services. Eighteen per cent of referrals were made to clinical mental health services. The total cost of providing the service for a consumer per year (set-up and ongoing) was estimated to be AUD$15,755 and the ongoing cost per year was estimated to be AUD$13,434. The cost of doing nothing is likely to cost more in the longer term, with poor mental health outcomes such as hospital admission, unemployment benefits, prison, homelessness and psychiatric residential care.

CONCLUSIONS:

Supporting recovery in persons with Severe and Persistent Mental Illness is likely to be economically more beneficial than not doing so. Recovery can be better supported when frequently utilised services are co-located. These might be some learnings for the NDIS.

Evaluation of a hepatitis C clinical care coordination programme's effect on treatment initiation and cure: A surveillance-based propensity score matching approach

Hepatitis C (HCV) is a viral infection that if left untreated can severely damage the liver. Project INSPIRE was a 3 year HCV care coordination programme in New York City (NYC) that aimed to address barriers to treatment initiation and cure by providing patients with supportive services and health promotion. We examined whether enrolment in Project INSPIRE was associated with differences in HCV treatment and cure compared with a demographically similar group not enrolled in the programme. INSPIRE participants in 2015 were matched with a cohort of HCV-infected persons identified in the NYC surveillance registry, using full optimal matching on propensity scores and stratified by INSPIRE enrolment status. Conditional logistic regression was used to assess group differences in the two treatment outcomes. Two follow-up sensitivity analyses using individual pair-matched sets and the full unadjusted cohort were also conducted. Treatment was initiated by 72% (790/1130) of INSPIRE participants and 36% (11 960/32 819) of study-eligible controls. Among initiators, 65% (514/790) of INSPIRE participants compared with 47% (5641/11 960) of controls achieved cure. In the matched analysis, enrolment in INSPIRE increased the odds of treatment initiation (OR: 5.25, 95% CI: 4.47-6.17) and cure (OR: 2.52, 95% CI: 2.00-3.16). Results from the sensitivity analyses showed agreement with the results from the full optimal match. Participation in the HCV care coordination programme significantly increased the probability of treatment initiation and cure, demonstrating that care coordination for HCV-infected individuals improves treatment outcomes.

Facilitators and Barriers to Interdisciplinary Communication between Providers in Primary Care and Palliative Care

BACKGROUND

Community-based palliative care (CBPC) plays an integral role in addressing the complex care needs of older adults with serious chronic illnesses, but is premised on effective communication and collaboration between primary care providers (PCPs) and the providers of specialty palliative care (SPC). Optimal strategies to achieve the goal of coordinated care are ill-defined.

OBJECTIVE

The objective of this study was to understand the facilitators and barriers to optimal, coordinated interdisciplinary provision of CBPC.

METHODS

This was a qualitative study using a constructivist grounded theory approach. Thirty semistructured interviews were conducted with primary and palliative care interdisciplinary team members in academic and community settings.

RESULTS

Major categories emerging from the data that positively or negatively influence optimal provision of coordinated care included feedback loops and interactions; clarity of roles; knowledge of palliative care, and workforce and structural constraints. Facilitators were frequent in-person, e-mail, or electronic medical record-based communication; defined role boundaries; and education of PCPs to distinguish elements of generalist palliative care (GPC) and more complex elements or situations requiring SPC. Barriers included inadequate communication that prevented a shared understanding of patients' needs and goals of care, limited time in primary care to provide GPC, and limited workforce in SPC.

CONCLUSIONS

Our findings suggest that processes are needed that promote communication, including structured communication strategies between PCPs and SPC providers, clarification of role boundaries, enrichment of nonspecialty providers' competence in GPC, and enhanced access to CBPC.

Use of Chronic Care Management Codes for Medicare Beneficiaries: a Missed Opportunity?

BACKGROUND

Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions.

OBJECTIVE

Characterize use of the Chronic Care Management (CCM) code in New England in 2015.

DESIGN

Retrospective observational analysis.

PARTICIPANTS

All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015.

INTERVENTION

None.

MAIN MEASURES

The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services.

KEY RESULTS

Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model.

CONCLUSIONS

The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare's most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.

Medical assistance in dying for cancer patients one year after legalization: a collaborative approach at a comprehensive cancer centre

Medical assistance in dying (maid) is a new medical service in Canada. Access to maid for patients with advanced cancer can be daunting during periods of declining health near the end of life. In this report, we describe a collaborative approach between the centralized coordination service and a regional cancer centre as an effective strategy for enabling interdisciplinary care delivery and enhancing patient-centred care at the end of the patient's cancer journey.

Care Coordination for Children and Youth With Special Health Care Needs: National Survey Results

We analyzed findings from the 2009-2010 National Survey of Children with Special Health Care Needs to identify associations between families with children and youth with special health care needs (CYSHCN) reporting adequate care coordination (CC) with family-provider relations, shared decision making (SDM), and child outcomes. Eligible subjects were the 98% of families asked about CC, service use, and communication. Bivariate analysis using χ² tests were performed on binary outcome variables to determine the strength of the associations between CC and independent and dependent variables. Weighted, multivariate logistic regression models were constructed to assess independent associations of adequate CC with child outcomes and associations of SDM on adequate CC. Among families of CYSHCN asked about CC, 72% reported receiving help with CC. Of these, 55% reported receiving adequate CC. Family report of adequate CC was favorably associated with family-provider relations, child outcomes, and report of provider participation in SDM.

Application of the Medical Neighborhood to Children with Severe Obesity

BACKGROUND

Growth in the prevalence of severe pediatric obesity and tertiary care pediatric weight management programs supports the application of chronic disease management models to the care of children with severe obesity. One such model, the medical neighborhood, aims to optimize care coordination between primary and tertiary care by applying principles of the Patient-Centered Medical Home to all providers.

METHODS

An exploration of the literature was performed describing effective programs, approaches, and coordinated care models applied to pediatric weight management and other chronic conditions.

RESULTS

Though there was a paucity of literature discovered with applications specific to pediatric weight management, relevant disease management and care coordination approaches were found. Proposed applications to the care of children with severe obesity can be made.

CONCLUSION

The application of the medical neighborhood framework, with its inclusion of healthcare and community partners, may optimize the management of children with severe obesity.

Aboriginal experiences of cancer and care coordination: Lessons from the Cancer Data and Aboriginal Disparities (CanDAD) narratives

BACKGROUND

Aboriginal people with cancer experience worse outcomes than other Australians for a range of complex and interrelated reasons. A younger age at diagnosis, higher likelihood of more advanced cancer or cancer type with poorer prognosis, geographic isolation and cultural and language diversity mean that patient pathways are potentially more complex for Aboriginal people with cancer. In addition, variation in the quality and acceptability of care may influence cancer outcomes.

OBJECTIVE

This study sought to understand how care coordination influences Aboriginal people's experiences of cancer treatment.

METHODS

Interviews with 29 Aboriginal patients or cancer survivors, 11 carers and 22 service providers were carried out. Interviews were semi-structured and sought to elicit experiences of cancer and the health-care system. The manifest content of the cancer narratives was entered onto a cancer pathway mapping tool and underlying themes were identified inductively.

RESULTS

The practice of cancer care coordination was found to address the needs of Aboriginal patients and their families/carers in 4 main areas: "navigating the health system"; "information and communication"; "things to manage at home"; and "cultural safety".

CONCLUSIONS

The CanDAD findings indicate that, when the need for cancer care coordination is met, it facilitated continuity of care in a range of ways that may potentially improve cancer outcomes. However, the need remains unmet for many. Findings support the importance of dedicated care coordination to enable Aboriginal people to receive adequate and appropriate patient-centred care, so that the unacceptable disparity in cancer outcomes between Aboriginal and non-Aboriginal people can be addressed.

Unmet Need for Care Coordination Among Children with Special Health Care Needs

Socioeconomic disparities in access to care coordination have been noted among children with special health care needs (CSHCN). Following recent policy developments and technological innovation, care coordination has become more widespread, possibly leading to reduced disparity in care coordination access. This study investigates whether child and household characteristics remain associated with unmet need for care coordination among CSHCN. CSHCN (aged <18 years) requiring ≥2 types of health services in the past year were identified in the 2016 National Survey of Children's Health (NSCH). Care coordination was defined as help with arranging the child's care among different doctors or services. Children were classified as not needing care coordination, receiving sufficient care coordination (met need), or needing but not receiving care coordination (unmet need). Weighted multinomial logistic regression examined the association of child characteristics with this outcome. The analysis included 5622 children with no need for care coordination, 1466 with a met need, and 980 with unmet needs. Children with mental health conditions were more likely to have unmet rather than met needs for care coordination (odds ratio = 4.1; 95% confidence interval: 2.7, 6.1; P < 0.001). After multivariable adjustment, race/ethnicity, income, family structure, insurance coverage, place of birth, and use of English in the home were not associated with having unmet rather than met needs for care coordination. Among CSHCN, the latest data from NSCH reveal no evidence of previously described socioeconomic disparities in access to care coordination. Nevertheless, unmet needs for care coordination remain prevalent, especially among children with mental health conditions.

Enhancing Rural Population Health Care Access and Outcomes Through the Telehealth EcoSystem™ Model

The article highlights the Telehealth EcoSystem™ model, a holistic cross-sector approach for socioeconomic revitalization, connectivity, interoperability and technology infrastructure development to address health equity for rural underserved communities. Two guiding frameworks, Community & Economic Development (CED) and Collective Impact, provided the foundation for the Telehealth EcoSystem™ model. Public and private organizational capacities are addressed by comprehensive healthcare and social service delivery through stakeholder engagement and collaborative decision-making processes. A focus is maintained on economic recovery and policy reforms that enhance population health outcomes for individuals and families who have economic challenges.

The Telehealth EcoSystem™ utilizes an intranet mechanism that enables a range of technologies and electronic devices for health informatics and telemedicine initiatives. The relevance of the intranet to the advancement of health informatics is highlighted. Best practices in digital connectivity, HIPAA requirements, electronic health records (EHRs), and eHealth applications, such as patient portals and mobile devices, are emphasized. Collateral considerations include technology applications that expand public health services.

The ongoing collaboration between a social science research corporation, a regional community foundation and an open access telecommunications carrier is a pivotal element in the sequential development and implementation of the Telehealth EcoSystem™ model in the rural southeastern region community.

College-Bound: Transition Planning Strategies for Students With Type 1 Diabetes

Transition planning is mandated for students who receive special education services; however, it is not required for students with chronic conditions. Students with chronic conditions nearing graduation would benefit from more intensive attention to their post-high school self-care needs and responsibilities. Students with type 1 diabetes must be able to understand the necessary self-care of one of the most complicated and intensive chronic conditions yet there are no evidence-based strategies for how to help students transition from the support provided at school to independence at graduation. The need for a student with type 1diabetes to independently manage their diabetes is even greater as the student leaves home for college. School nurses, who are also certified diabetes educators, created a support group for seniors with type 1 diabetes. The group focused on life after high school and provided the students with a detailed checklist to help improve knowledge and prepare students for the transition to college. Participants felt better prepared to move on to college armed with their checklist and other resources to help when away from home.

"Dealing with the Hospital has Become too Difficult for Us to Do Alone" - Developing an Integrated Care Program for Children with Medical Complexity (CMC)

INTRODUCTION

Children with medical complexity (CMC) require highly specialised care, often from multiple providers and over many years. This paper describes the first 18 months of development of the Kids Guided Personalised Services (GPS) Integrated Care Program (the Program). This Program aims to improve health care experience; communication and to streamline provision of care.

DISCUSSION

Key enablers across the Program were put in place and 5 individual project streams were used to implement change. An extensive formative evaluation process was undertaken to truly understand all perspectives in developing the Program.

CONCLUSION/KEY LESSONS

This Program supports families who are caring for CMC by developing shared care models that bring together local health services with the tertiary hospitals. The methodology used has resulted in comprehensive system change and transformation; reduced presentations to the Emergency Department (ED), avoidable admissions and travel time. A challenge remains in meaningfully engaging primary health care providers.

Integrated Care in Chronic Obstructive Pulmonary Disease and Rehabilitation

Individuals with advanced chronic obstructive pulmonary disease (COPD) often have complex medical problems that require more than simple pharmacological therapy to optimize outcomes. Comprehensive care is necessary to meet the substantial burdens, not just from the primary respiratory disease process itself, but also those imposed by its systemic manifestations and comorbidities. These problems are intensified in the peri-exacerbation period, especially for newly discharged patients. Pulmonary rehabilitation, with its interdisciplinary, patient-centered and holistic approach to management, and integrated care, adding coordination or transition of care to the chronic care model, are useful approaches to meeting these complex issues.

Care Coordination Between the Nephrology Nurse and the Payor: Working Together to Bridge the Gaps in Care for Patients with Kidney Disease

Integrated care management is a key buzz phrase in health care. Most providers, nurse practitioners, nurses, and payors believe their area of expertise, such as direct patient care or insurance companies, has integrated nursing plans and forgotten about opportunities to collaborate outside of their immediate area. However, collaboration between nurses in dialysis clinics, physicians, nurse practitioners, and case managers from payors, such as insurance companies, is often missing. This collaboration can result in better patient outcomes and in meeting goals for the patient, the provider, and the payor, including maximizing value-based purchasing opportunities.

Care Coordination as Imagined, Care Coordination as Done: Findings from a Cross-national Mental Health Systems Study

Introduction:

Care coordination is intended to ensure needs are met and integrated services are provided. Formalised processes for the coordination of mental health care arrived in the UK with the introduction of the care programme approach in the early 1990s. Since then the care coordinator role has become a central one within mental health systems.

Theory and methods:

This paper contrasts care coordination as work that is imagined with care coordination as work that is done. This is achieved via a critical review of policy followed by a qualitative analysis of interviews, focusing on day-to-day work, conducted with 28 care coordinators employed in four NHS organisations in England and two in Wales.

Findings:

Care coordination is imagined as a vehicle for the provision of collaborative, recovery-focused, care. Those who practise care coordination are concerned with the quality of their relationships with service users and the tailoring of services, but limits exist to collaboration and open discussion. Care coordinators describe doing necessary work connecting people and the system of care. However, this work also brings significant administrative demands, is subject to performance management which distorts its primary purpose, and in a context of scarce resources promotes generic professional roles.

Conclusion:

Care coordination must be done. However, it is not consistently being done in the way policymakers imagine, and in the real world of work can be done differently.

Exploration of the Personal Health Record as a Tool for Spinal Cord Injury Health Self-Management and Coordination of Care

Background: A personal health record (PHR) is a collection of electronic health data drawn from multiple sources but managed by the patient. The PHR is a strategy that enables patients to be proactive in the coordination of their care. Objective: The purpose of this clinical improvement study was to discover what worked, what did not work, and what could be improved in the initial implementation of MyPHR, a PHR tailored to patients with spinal cord injury (SCI), to make it a useful tool for care coordination and health self-management. Methods: Five individuals with chronic (>1 year) SCI carried out trial use of MyPHR. Twelve hours of interactions, including screen navigation and think-aloud reflection, were recorded and analyzed using formative research, a qualitative method and type of case study research. Results: Two key themes emerged to guide the implementation of PHR technology: selectivity in the identification of information for the patient to track, and continual support and communication with the clinical team. Conclusion: Given the volume of electronic data available to patients with SCI, the data identified to import, manage, and keep current in a PHR have to be thoughtfully selected to make sure the patient is convinced of the worth of this data record and is willing to invest the time and effort it will take to maintain it. A PHR should be implemented with a deliberate focus on its function as a tool that patients and providers use together to expand communication as they work toward their common goal of optimizing health after SCI.

Effects of Early Dual-Eligible Special Needs Plans on Health Expenditure

OBJECTIVE

To examine the effects of the penetration of dual-eligible special needs plans (D-SNPs) on health care spending.

DATA SOURCES/STUDY SETTING

Secondary state-level panel data from Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011.

STUDY DESIGN

A difference-in-difference strategy that adjusts for dual-eligibles' demographic and socioeconomic characteristics, state health resources, beneficiaries' health risk factors, Medicare/Medicaid enrollment, and state- and year-fixed effects.

DATA COLLECTION/EXTRACTION METHODS

Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee-for-service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System.

PRINCIPAL FINDINGS

Results indicate that D-SNPs penetration was associated with reduced Medicare spending per dual-eligible beneficiary. Specifically, a 1 percent increase in D-SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D-SNPs penetration and Medicaid or total spending.

CONCLUSION

Involving Medicaid services in D-SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual-eligible beneficiaries. Starting from 2013, D-SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D-SNPs on health care spending. More research is needed to examine the impact of D-SNPs on dual-eligible spending.

Building Bridges for Asthma Care: Reducing school absence for inner-city children with health disparities

BACKGROUND

Children with asthma are at increased risk for experiencing health and educational disparities because of increased school absence. School nurses are well positioned to support asthma management and improve school attendance.

OBJECTIVE

We sought to implement and assess the effect of the Building Bridges for Asthma Care Program on improving school attendance and measures of asthma control.

METHODS

Children with asthma (age, 5-14 years) in the Denver Public School System (n = 240) and the Hartford Public School System (n = 223) were enrolled in the Building Bridges Program during the 2013-2014 and 2014-2015 school years and followed until the end of the second school year. The primary outcome was school absence, with secondary outcomes, including asthma control, measured based on Childhood Asthma Control Test or the Asthma Control Test scores and rescue inhaler use.

RESULTS

Participants experienced a 22% absolute decrease in school absenteeism, the number of children with an Asthma Control Test/Childhood Asthma Control Test score of less than the control threshold of 20 decreased from 42.7% to 28.8%, and bronchodilator use greater than 2 times per week decreased from 35.8% to 22.9% (all changes were significant, P < .01).

CONCLUSIONS

Children enrolled in the Building Bridges for Asthma Care Program experienced reduced school absence and improved asthma control.

A scoping review of patient-sharing network studies using administrative data

There is a robust literature examining social networks and health, which draws on the network traditions in sociology and statistics. However, the application of social network approaches to understand the organization of health care is less well understood. The objective of this work was to examine approaches to conceptualizing, measuring, and analyzing provider patient-sharing networks. These networks are constructed using administrative data in which pairs of physicians are considered connected if they both deliver care to the same patient. A scoping review of English language peer-reviewed articles in PubMed and Embase was conducted from inception to June 2017. Two reviewers evaluated article eligibility based upon inclusion criteria and abstracted relevant data into a database. The literature search identified 10,855 titles, of which 63 full-text articles were examined. Nine additional papers identified by reviewing article references and authors were examined. Of the 49 papers that met criteria for study inclusion, 39 used a cross-sectional study design, 6 used a cohort design, and 4 were longitudinal. We found that studies most commonly theorized that networks reflected aspects of collaboration or coordination. Less commonly, studies drew on the strength of weak ties or diffusion of innovation frameworks. A total of 180 social network measures were used to describe the networks of individual providers, provider pairs and triads, the network as a whole, and patients. The literature on patient-sharing relationships between providers is marked by a diversity of measures and approaches. We highlight key considerations in network identification including the definition of network ties, setting geographic boundaries, and identifying clusters of providers, and discuss gaps for future study.

Dialysis Dependence Predicts Complications, Intensive Care Unit Care, Length of Stay, and Skilled Nursing Needs in Elective Primary Total Knee and Hip Arthroplasty

BACKGROUND

Limited data describe risks and perioperative resource needs of total joint arthroplasty (TJA) in dialysis-dependent patients.

METHODS

Retrospective multiple cohort analysis of dialysis-dependent American College of Surgeons National Surgical Quality Improvement Program patients undergoing primary elective total hip and knee arthroplasty compared to non-dialysis-dependent controls from 2005 to 2015. Relative risks (RRs) of 30-day adverse events were determined by multivariate regression adjusting for baseline differences.

RESULTS

Six hundred forty-five (0.2%) dialysis-dependent patients of 342,730 TJA patients were dialysis-dependent and more likely to be dependent, under weight, anemic, hypoalbuminemic, and have cardiopulmonary disease. In total hip arthroplasty patients, dialysis was associated with greater risk of any adverse event (RR = 1.1, P < .001), mortality (RR = 2.8, P = .012), intensive care unit (ICU) care (RR = 9.8, P < .001), discharge to facility (RR = 1.3, P < .001), and longer admission (1.5×, P < .001). In total knee arthroplasty patients, dialysis conferred greater risk of any adverse event (RR = 1.1, P < .001), ICU care (RR = 6.0, P < .001), stroke (RR = 7.6, P < .001), cardiac arrest (RR = 4.8, P = .014), discharge to facility (RR = 1.5, P < .001), readmission (RR = 1.8, P = .002), and longer admission (1.3×, P < .001).

CONCLUSION

Dialysis-dependence is an independent risk factor for 30-day adverse events, ICU care, longer admission, and rehabilitation needs in TJA patients. Thirty days is not sufficient to detect infectious complications among these patients. These findings inform shared decision-making, perioperative resource planning, and risk adjustment under alternative reimbursement models.

Validation of New Care Coordination Quality Measures for Children with Medical Complexity

OBJECTIVES

To validate new caregiver-reported quality measures assessing care coordination services for children with medical complexity (CMC).

METHODS

A cross-sectional analysis of the associations between 20 newly developed Family Experiences with Coordination of Care (FECC) quality measures and 3 validation measures among 1209 caregivers who responded to a telephone or mailed survey from August to November 2013 in Minnesota and Washington. Validation measures included an access composite, a provider rating item, and a care coordination outcome measure, all derived from Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey items. Multivariate regression was used to examine associations between the 3 validation measures and each of the 20 FECC quality measures.

RESULTS

Nineteen of the 20 FECC quality measures were significantly and positively associated with ≥1 of the validation measures. The components of care coordination demonstrating the strongest positive association with provider ratings included: 1) having a care coordinator who was knowledgeable and supportive and advocated for the child's needs (β = 26.4; 95% confidence interval [CI], 20.0-32.8, scaled to reflect change associated with a 0-100 change in the FECC measure score); and 2) receiving a written visit summary that was useful and easy to understand (β = 22.0; 95% CI, 17.1-27.0).

CONCLUSIONS

Nineteen newly developed FECC quality measures demonstrated convergent validity with previously validated CAHPS measures. These new measures are valid for assessing the quality of care coordination services provided to CMC and may be useful for evaluating new models of care focused on improving these services.

Telementoring of primary care providers delivering hepatitis C treatment in New York City: Results from Project INSPIRE

INTRODUCTION

The recent availability of highly effective, easily administered, and relatively nontoxic treatments for hepatitis C virus (HCV) infection provides an opportunity for clinicians to treat HCV in nonspecialist settings with appropriate support. Project INSPIRE provides care coordination to HCV patients and a web-based training program (telementoring) on disease management and treatment by HCV specialists to primary care providers inexperienced in HCV treatment. Weekly telementoring sessions use a didactic and case-based approach to instruct non-HCV providers on how to identify and assess HCV treatment candidates and prescribe appropriate treatment.

METHODS

We used mixed methods to assess the telementoring service, including provider surveys and semistructured interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed to identify dominant themes.

RESULTS

Provider survey responses indicated an increased ability to identify and evaluate HCV treatment candidates and increased confidence in sharing knowledge with peers and patients. Interviews revealed a high degree of satisfaction with the telementoring service and Project INSPIRE overall. The telementoring service was viewed as having enhanced providers' knowledge, confidence, and ability to treat their own HCV-infected patients rather than having to refer them to an HCV specialist with resulting benefits for continuity of care. Providers reported comradery and collegiality with other INSPIRE providers and satisfaction with professional growth from attaining new knowledge and skills via the telementoring service.

CONCLUSIONS

Using readily available web conferencing technology, telementoring can facilitate knowledge transfer between specialists and primary care providers, facilitating continuity of care for patients and increased provider satisfaction.

Hospital and Community Characteristics Associated With Pediatric Direct Admission to Hospital

OBJECTIVES

One quarter of pediatric hospitalizations begin as direct admissions, defined as hospitalization without receiving care in the hospital's emergency department (ED). Direct admission rates are highly variable across hospitals, yet previous studies have not examined reasons for this variation. We aimed to determine the relationships between hospital and community factors and pediatric direct admission rates, and to evaluate the degree to which these characteristics explain variation in risk-adjusted direct admission rates.

METHODS

We conducted a cross-sectional study of the Healthcare Cost and Utilization Project's Kids Inpatient Database, American Hospital Association Database, and Area Health Resource File, including children <18 years of age who were admitted for a medical hospitalization in states contributing data to all data sets. Using hierarchical generalized linear modeling, we generated risk-adjusted direct admission rates and used generalized linear models to assess the association of hospital and community characteristics with these risk-adjusted rates.

RESULTS

We included 211,458 children discharged from 933 hospitals and 26 states; 20.2% were admitted directly. One-fifth of the variance in risk-adjusted direct admission rates was attributed to observed hospital and community factors. The greatest proportion of this explained variance was related to ED volume (37%), volume of pediatric hospitalizations (27%), and size of the pediatrician workforce (12%).

CONCLUSIONS

Direct admission rates were associated with several hospital and community characteristics, but the majority of variation in hospitals' direct admission rates was not explained by these factors. These findings suggest opportunities for diverse hospital types to develop the infrastructure and communication systems necessary to support pediatric direct admissions.

Panel Size, Office Visits, and Care Coordination Events: A New Workload Estimation Methodology Based on Patient Longitudinal Event Histories

Background. Panel size, or the number of patients a primary care physician (PCP) and her care team can feasibly manage as part of a practice, remains a vital question in primary care. Objective. To Illustrate a new methodology for quantifying two types of workload associated with a panel size: 1) the PCP weekly office visit distribution and 2) the weekly distribution of non-PCP events (subspecialty visits, emergency room visits, hospitalizations) that potentially require non–face-to-face coordination. Methods. We assemble granular individual-level histories of events in the health system using the Medical Expenditure Panel Survey from 2011. Using the date on which each event occurred, we create weekly utilization estimates as a function of panel size for the general population and Medicare patients. Results. A PCP with a panel of 2,000 adults approximately representative of the US population can expect to have 93.54 office visits on average each week. A simple model quantifying demand–capacity mismatch suggests that a PCP with a weekly capacity of 80 to 90 appointments will struggle to satisfy this office-visit demand in a timely manner. Furthermore, each week the PCP can expect the same panel to have 9.08 visits to the emergency room, 4.69 hospital inpatient events, and 131.29 office-based visits to non–primary care subspecialists; these events contribute to the non–face-to-face coordination workload, increasing the probability of an overburdened workweek. Both PCP office visit and coordination events are highly concentrated in less than 200 individuals (<10% of the 2,000). Conclusion. Patient-level longitudinal event histories can be retrospectively assembled to quantify patterns of face-to-face office visits and coordination workload associated with a primary care panel.

Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital

OBJECTIVES

To develop pediatric direct admission guidelines and prioritize outcomes to evaluate the safety and effectiveness of hospital admission processes.

STUDY DESIGN

We conducted deliberative discussions at 1 children's hospital and 2 community hospitals, engaging parents of hospitalized children and inpatient, outpatient, and emergency department physicians and nurses to identify shared and dissenting perspectives regarding direct admission processes and outcomes. Discussions were audio-recorded, professionally transcribed, and analyzed using a general inductive approach. We then convened a national panel to prioritize guideline components and outcome measures using a RAND/UCLA Modified Delphi approach.

RESULTS

Forty-eight stakeholders participated in 6 deliberative discussions. Emergent themes related to effective multistakeholder communication, resources needed for high quality direct admissions, written direct admission guidelines, including criteria to identify children appropriate for and inappropriate for direct admission, and families' needs. Building on these themes, Delphi panelists endorsed 71 guideline components as both appropriate and necessary at children's hospitals and community hospitals and 13 outcomes to evaluate hospital admission systems. Guideline components include (1) pre-admission communication, (2) written guidelines, (3) hospital resources to optimize direct admission processes, (4) special considerations for pediatric populations that may be at particular risk of nosocomial infection and/or stress in emergency departments, (5) communication with families referred for direct admission, and (6) quality reviews to evaluate admission systems.

CONCLUSIONS

These direct admission guidelines can be adapted by hospitals and health systems to inform hospital admission policies and protocols. Multistakeholder engagement in evaluation of hospital admission processes may improve transitions of care and health system integration.

Impact of a Web-Based Electronic Health Record on Behavioral Health Service Delivery for Children and Adolescents: Randomized Controlled Trial

Background

Electronic health records (EHRs) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR systems on behavioral health service delivery is scant, especially for children and adolescents.

Objective

The current study evaluated the usability of an EHR developed to support the implementation of the Wraparound care coordination model for children and youth with complex behavioral health needs, and impact of the EHR on service processes, fidelity, and proximal outcomes.

Methods

Thirty-four Wraparound facilitators working in two programs in two states were randomized to either use the new EHR (19/34, 56%) or to continue to implement Wraparound services as usual (SAU) using paper-based documentation (15/34, 44%). Key functions of the EHR included standard fields such as youth and family information, diagnoses, assessment data, and progress notes. In addition, there was the maintenance of a coordinated plan of care, progress measurement on strategies and services, communication among team members, and reporting on services, expenditures, and outcomes. All children and youth referred to services for eight months (N=211) were eligible for the study. After excluding those who were ineligible (69/211, 33%) and who declined to participate (59/211, 28%), a total of 83/211 (39%) children and youth were enrolled in the study with 49/211 (23%) in the EHR condition and 34/211 (16%) in the SAU condition. Facilitators serving these youth and families and their supervisors completed measures of EHR usability and appropriateness, supervision processes and activities, work satisfaction, and use of and attitudes toward standardized assessments. Data from facilitators were collected by web survey and, where necessary, by phone interviews. Parents and caregivers completed measures via phone interviews. Related to fidelity and quality of behavioral health care, including Wraparound team climate, working alliance with providers, fidelity to the Wraparound model, and satisfaction with services.

Results

EHR-assigned facilitators from both sites demonstrated the robust use of the system. Facilitators in the EHR group reported spending significantly more time reviewing client progress (P=.03) in supervision, and less time overall sending reminders to youth/families (P=.04). A trend toward less time on administrative tasks (P=.098) in supervision was also found. Facilitators in both groups reported significantly increased use of measurement-based care strategies overall, which may reflect cross-group contamination (given that randomization of staff to the EHR occurred within agencies and supervisors supervised both types of staff). Although not significant at P<.05, there was a trend (P=.10) toward caregivers in the EHR group reporting poorer shared agreement on tasks on the measure of working alliance with providers. No other significant between-group differences were found.

Conclusions

Results support the proposal that use of EHR systems can promote the use of client progress data and promote efficiency; however, there was little evidence of any impact (positive or negative) on overall service quality, fidelity, or client satisfaction. The field of children’s behavioral health services would benefit from additional research on EHR systems using designs that include larger sample sizes and longer follow-up periods.

Trial Registration

ClinicalTrials.gov NCT02421874; https://clinicaltrials.gov/ct2/show/NCT02421874 (Archived by WebCite at http://www.webcitation.org/6yyGPJ3NA)

Predictors of Coordinated and Comprehensive Care Within a Medical Home for Children With Special Healthcare (CHSCN) Needs

The purpose of this study was to examine predictors of coordinated and comprehensive care within a medical home among children with special health care needs (CSHCN). The latest version of the National Survey of Children with Special Health Care Needs (NS-CSHCN) employed a national random-digit-dial sample whereby US households were screened, resulting in 40,242 eligible respondents. Logistic regression analyses were performed modeling the probability of coordinated, comprehensive care in a medical home based on shared decision-making and other factors. A total of 29,845 cases were selected for inclusion in the model. Of these, 17,390 cases (58.3%) met the criteria for coordinated, comprehensive care in a medical home. Access to a community-based service systems had the greatest positive impact on coordinated, comprehensive care in a medical home. Adequate insurance coverage and being White/Caucasian were also positively associated with the dependent variable. Shared decision-making was reported by 72% of respondents and had a negative, but relatively negligible impact on coordinated, comprehensive care in a medical home. Increasing age, non-traditional family structures, urban residence, and public insurance were more influential, and negatively impacted the dependent variable. Providers and their respective organizations should seek to expand and improve health and support services at the community level.

Disease-specific clinical pathways - are they feasible in primary care? A mixed-methods study

OBJECTIVE

To explore the feasibility of disease-specific clinical pathways when used in primary care.

DESIGN

A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings.

SETTING

Primary care and specialist care collaborating to manage care coordination.

RESULTS

Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year.

CONCLUSIONS

The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care. In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.

Economic Evaluation of Concussion Programs in the State of Idaho: The Collective Potential of Prevention and Clinical Care

Concussion, or mild traumatic brain injury, especially among young children, teenagers, and young adults, is a significant problem in Ada County, Idaho, and the United States. Although much has been learned about concussion, considerable controversy and gaps in knowledge still exist in many areas of research, leading to variation in concussion assessment, treatment, and management protocols. Health systems can positively impact concussion outcomes through community education and outreach, and provision of timely, coordinated, evidence-based clinical care. Collectively, these measures serve to reduce concussion incidence (primary prevention), enable more timely recognition of concussion by parents, coaches, and teachers of youth athletes (secondary prevention), and improve treatment of concussion after it has occurred (tertiary prevention). Using the concussion prevention and clinical care coordination activities of St. Luke's Health System in Idaho as a benchmark, this analysis estimates the economic value of these preventive measures, in particular those preventive measures that target the pediatric population, for Ada County and the state of Idaho, and includes both year of injury and long-term costs of concussion. This study adopts a societal perspective, incorporating savings in direct medical, indirect, and quality of life costs.

Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England

INTRODUCTION

E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care.

METHODS

This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations.

RESULTS

Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment (n = 44), anti-coagulation/anti-platelet management (n = 33), and EKG interpretation (n = 20). Cardiologists provided answers for the majority (89.6%) of clinical questions. Among the e-consults in which cardiologists did not provide answers or clinical guidance (n = 41), the reasons included missing or insufficient clinical information (n = 18), medical complexity (n = 6), and deferment to the patient's non-VA primary cardiologist (n = 7). Cardiologists recommended that the patients be seen as face-to-face consults for 7.9% of e-consults.

DISCUSSION

Primary care providers are the most frequent requesters of cardiology e-consults, using them primarily to obtain input on clinical questions. Cardiologists did not provide answers for one in ten, owing principally to insufficient available clinical information. Educating PCPs and standardizing the template for requesting e-consultation may help to reduce the number of unanswered e-consults.

FIMA, the questionnaire for health-related resource use in the elderly population: validity, reliability, and usage of the Polish version in clinical practice

Purpose

The purpose of this study was to determine the validity and reliability of the Polish version of the Questionnaire for Health-Related Resource Use in an Elderly Population [Fragebogen zur Inanspruchnahme medizinischer und nicht-medizinischer Versorgungsleistungen im Alter (FIMA)].

Patients and methods

This was a cross-sectional study conducted in a rehabilitation care unit in Poland between January and June of 2017. Sixty-one patients aged ≥65 years who had been admitted to the unit were enrolled into the study. Each participant was evaluated twice: once within 48 hours of admission (T1) and once after 2 weeks (T2).

Results

The translated instrument was understood by most respondents in a selected population and it maintained a reading and comprehension level that was accessible by most respondents, even of a low education level. With the aid of the prevalence-adjusted bias-adjusted kappa (PABAK) and intraclass correlation coefficient (ICC), 100% test–retest reliability for 10 out of the 12 questions that were subjected to analysis was indicated. The most frequent health-related resource uses were appointments at the general practitioner (90.2%) and orthopedist (54.1%), medication (93.4%), and the necessity to have glasses as supportive equipment (70.5%).

Conclusion

The Polish FIMA demonstrated very good test–retest reliability, good validity, and ease of use for elderly people. Further investigation is required. In the future, the routine use of this instrument could be encouraged to assess the use and demand for medical and nonmedical services among the elderly.

Forty years of referrals and outcomes to a UK Child Development Centre (CDC): Has demand plateaued?

AIMS

To explore 40 years of Child Development Centre (CDC) activity and outcomes at Northampton General Hospital 1974-2014.

METHODS

The study comprises 3 data sets: a published report from 1974 to 1999, an internal audit from 2001 to 2004, and more recent data collected from 2005 to 2014. The medical notes of all children who were assessed by the CDC in 2014 were reviewed, along with referral data collected by the CDC manager from this year and the preceding 10 years.

RESULTS

From January 1, 1974 to December 31, 2014, 3,786 children were assessed. The male to female ratio is 2.8:1 from 2005 to 2014. Referrals for behavioural difficulties increased from 10% (10/100 referrals) in 1999-2004 to 17.8% (18/101 referrals) in 2014. Similarly, referrals for social and communication problems, "interaction" increased two and a half fold from 10% (10/100 referrals) in 1999-2004 to 26.7% (27/101 referrals) in 2014. Between 2004 and 2014, numbers of referrals for "developmental delay" halved (22.2% to 12%).

CONCLUSION

We are aware of no other comparable extant UK CDC database. Services should plan for a referral rate of 6.5 per 1,000 preschool children. Between 1974 and 2014, there has clearly been a change in recorded assessment outcomes. From the mid-1980s, this reflects the change to a preschool assessment role and a shift away from purely educational outcome to include medical conditions. Covering 1974-2014, we demonstrate a clear increase in the number of referrals together with an increasing demand for assessments for social interaction and behavioural difficulties. This reflects the increased awareness of these neurodevelopmental difficulties and the changing diagnostic criteria which will now more likely result in an Autistic Spectrum Disorder diagnosis than previously. Together, these two features are most likely to have considerable implications for service development within Child Development Centres (CDCs) and Child Development Teams (CDTs).

Utilizing a Modified Care Coordination Measurement Tool to Capture Value for a Pediatric Outpatient Parenteral and Prolonged Oral Antibiotic Therapy Program

BACKGROUND

Outpatient parenteral or prolonged oral antibiotic therapy (OPAT) programs reduce inpatient healthcare costs by shifting care to outpatient settings. Care coordination (CC) is a necessary component to successfully transition patients. Our objective was to assess outcomes of provider time spent on nonreimbursable CC activities in a pediatric OPAT program.

METHODS

We used a qualitative feasibility pilot design and modified the Care Coordination Measurement Tool. We captured nonreimbursable CC activity and associated outcome(s) among pediatric patients enrolled in OPAT from March 1 to April 30, 2015 (44 work days) at Doernbecher Children's Hospital. We generated summary statistics for this institutional review board-waived QI project.

RESULTS

There were 154 nonreimbursable CC encounters conducted by 2 infectious diseases (ID) providers for 29 patients, ages 17 months-15 years, with complex infections. Total estimated time spent on CC was 54 hours, equivalent to at least 6 workdays. Five patients with complex social issues used 37% of total CC time. Of 129 phone events, 38% involved direct contact with families, pharmacies (13%), primary care providers (13%), and home health nursing (11%). Care coordination prevented 10 emergency room (ER) visits and 2 readmissions. Care coordination led to 16 additional, not previously scheduled subspecialist and 13 primary care visits. The OPAT providers billed for 32 clinic visits during the study period.

CONCLUSIONS

Nonreimbursable CC work by OPAT providers prevented readmissions and ER visits and helped facilitate appropriate healthcare use. The value of pediatric OPAT involvement in patient care would have been underestimated based on reimbursable ID consultations and clinic visits alone.

Reducing the Time from Surgery to Adjuvant Radiation Therapy: An Institutional Quality Improvement Project

Objective The National Comprehensive Cancer Network guidelines recommend an interval between surgery and adjuvant radiation therapy of less than 6 weeks, but only 44% of patients meet this metric nationally. We sought to identify key components of an improvement process focused on starting adjuvant radiation therapy within 6 weeks of surgery. Methods This project used an A3 model to improve a defined process measure. We studied a consecutive sample of 56 patients with oral cavity carcinoma who were treated at our institution with upfront surgical resection followed by adjuvant radiation therapy. Twelve proposed interventions tested during the study period focused on 3 key drivers of delays: delayed dental evaluation and teeth extraction, delayed radiation oncology consults, and inadequate patient engagement. The primary outcome measure was the number of days from surgery to the start of radiation therapy. Results Prior to the intervention, 62% of patients received adjuvant radiation within 6 weeks of surgery. Following the intervention, 73% of patients achieved this metric. The percentage of patients with avoidable delays decreased from 24% to 9%. The percentage of patients with unavoidable delays was relatively constant before and after the intervention (15% and 18%, respectively). Discussion Defining disease-specific metrics is critical to improving care in our head and neck cancer patient population. We demonstrate several key components to develop and improve self-defined metrics. Implications for Practice As we transition to a system of value-based care, structured quality improvement projects can have a measurable impact on cancer patient process measures.