Organizational Coordination and Patient Experiences of Specialty Care Integration

Patients report high information coordination between rostered primary care physicians and specialists: A cross-sectional study

Our study aimed to describe patient experience of information coordination between their primary care physician and specialists and to examine the associations between their experience and their personal and primary care characteristics. We conducted a cross-sectional study of Ontario residents rostered to a primary care physician and visited a specialist physician in the previous 12 months by linking population-based health administrative data to the Health Care Experience Survey collected between 2013 and 2020. We described respondents' sociodemographic and health care utilization characteristics and their experience of information coordination between their primary care physician and specialists. We measured the adjusted association between patient-reported measures of information coordination before and after respondents received care from a specialist physician and their type of primary care model. 1,460 out 20,422 (weighted 7.5%) of the respondents reported that their specialist physician did not have basic medical information about their visit from their primary care physician in the previous 12 months. 2,298 out of 16,442 (weighted 14.9%) of the respondents reported that their primary care physician seemed uninformed about the care they received from the specialist. Females, younger individuals, those with a college or undergraduate level of education, and users of walk-in clinics had a higher likelihood of reporting a lack of information coordination between the primary care and specialist physicians. Only respondents rostered to an enhanced fee-for-service model had a higher odds of reporting that the specialist physician did not have basic medical information about their visit compared to those rostered to a Family Health Team (OR 1.22, 95% Cl 1.12-1.40). We found no significant association between respondent's type of primary care model and that their primary care physician was uninformed about the care received from the specialist physician. In this population-based health study, respondents reported high information coordination between their primary care physician and specialists. Except for respondents rostered to an enhanced fee-for-service model of care, we did not find any difference in information coordination across other primary care models.

Content validity of patient-reported measures evaluating experiences of the quality of transitions in healthcare settings-a scoping review

No reviews so far have been conducted to define the constructs of patient-experienced quality in healthcare transitions or to identify existing generic measures of patients' experience of the quality within healthcare transitions. Our aim was to identify domains relevant for people experiencing healthcare transitions when evaluating the quality of care they have received, map the comprehensiveness of existing patient-reported experience measures (PREM), and evaluate the PREMs' content validity. The method was guided by the Joanna Briggs Institutes' guidance for scoping reviews. The search was performed on 07 December 2021 and updated 27 May 2024, in the electronic databases Medline (Ovid), Embase (Ovid), and Cinahl (EBSCO). The search identified 20,422 publications, and 190 studies were included for review. We identified 30 PREMs assessing at least one aspect of adults' experience of transitions in healthcare. Summarising the content, we consider a model with two domains, organisational and human-relational, likely to be adequate. However, a more comprehensive analysis and adequate definition of the construct is needed. None of the PREMs were considered content valid.

Patient-reported outcome and experience domains for diagnostic excellence: a scoping review to inform future measure development

PURPOSE

"Diagnostic excellence," as a relatively new construct centered on the diagnostic process and its health-related outcomes, can be refined by patient reporting and its measurement. We aimed to explore the scope of patient-reported outcome (PRO) and patient-reported experience (PRE) domains that are diagnostically relevant, regardless of the future diagnosed condition, and to review the state of measurement of these patient-reported domains.

METHODS

We conducted an exploratory analysis to identify these domains by employing a scoping review supplemented with internal expert consultations, 24-member international expert convening, additional environmental scans, and the validation of the domains' diagnostic relevance via mapping these onto patient diagnostic journeys. We created a narrative bibliography of the domains illustrating them with existing measurement examples.

RESULTS

We identified 41 diagnostically relevant PRO and PRE domains. We classified 10 domains as PRO, 28 as PRE, and three as mixed PRO/PRE. Among these domains, 19 were captured in existing instruments, and 20 were captured only in qualitative studies. Two domains were conceptualized during this exploratory analysis with no examples identified of capturing these domains. For 27 domains, patients and care partners report on a specific encounter; for 14 domains, reporting relates to an entire diagnostic journey over time, which presents particular measurement opportunities and challenges.

CONCLUSION

The multitude of PRO and PRE domains, if measured rigorously, would allow the diagnostic excellence construct to evolve further and in a manner that is patient-centered, prospectively focused, and concentrates on effectiveness and efficiency of diagnostic care on patients' well-being.

Coordinated Care Experiences Among Middle-Aged and Older Adults With Multiple Chronic Conditions: Characteristics, Correlates, and Consequences for Health and Healthcare Utilization

BACKGROUND AND OBJECTIVES

Although coordinated care (CC) seeks to improve patient experiences and ultimately health outcomes, evidence from empirical research on the impacts of CC is mixed. This study examined the relationship between CC and healthcare outcomes over a 4-year period among older adults with multiple chronic conditions.

RESEARCH DESIGN AND METHODS

This observational cohort study is based on data from the 2016-2020 Health and Retirement Study. Analysis is limited to respondents with 2+ chronic conditions who completed an experimental module on CC in 2016 (n = 906). Three domains of CC were assessed: perceptions, informal (family/friends) and formal (healthcare staff) tangible support, and technical support (using a "patient portal"). The longitudinal relationship between CC and health (e.g., pain, functioning, and self-rated health [SRH]) and healthcare (e.g., doctor visits, hospitalization, and care satisfaction) outcomes was investigated using mixed-effects models.

RESULTS

Better perceptions of CC were associated with lower odds of ADL limitations (Odds ratio [OR] = 0.91; 95% CI = 0.84-0.99) and greater satisfaction with care (B = 0.04, 95% CI = 0.02-0.06). Receipt of more informal tangible support was associated with 1.34 higher odds of ADL limitations (95% CI = 1.19-1.51) and 1.74 higher odds of hospitalization (95% CI = 1.07-1.21). Use of technical support was associated with better SRH and greater satisfaction with care.

DISCUSSION AND IMPLICATIONS

The longitudinal relationship between CC and health is multifaceted. Although positive perceptions and more technical support have beneficial effects on health outcomes, higher utilization of tangible support may reflect a higher demand among older adults with more complex healthcare needs.

Hospital Unit Type and Professional Roles as a Predictor of Relational Coordination in an Army Medical Center

BACKGROUND AND OBJECTIVES

High-quality communication and relationships are associated with quality of care. Workflow differences across hospital units can impede communication and relationships among health care professionals. Relational coordination (RC) is a process of communication supported by shared goals, shared knowledge, and mutual respect and is associated with quality of care and better performance outcomes in civilian hospitals. However, RC has not been explored in military hospitals. The objective of our study was to determine whether RC differs between hospital units and professional roles. Specifically, we examined RC differences by unit type for nurses, resident physicians, and physicians working in an Army Medical Center.

METHODS

We conducted an exploratory analysis of a secondary question from a cross-sectional study using a convenience sample of active-duty and civilian licensed practical nurses (LPNs), registered nurses (RNs), physician residents, and physicians (n = 289). We received institutional review board approval from the study site. Data were collected from January 2020 to March 2020, and participants completed a 47-item survey regarding their experiences of RC in various hospital units. We used t tests and one-way analyses of variance to explore bivariate relationships between RC and other study variables, as well as multiple regression to explore whether RC varied by unit type. We controlled for education and experience by including them in the model because these variables may influence perceptions of nurse-physician RC and their interactions with each other.

RESULTS

Seventy percent of participants were civilian (n = 203), 75% RNs (n = 217), and 78% female (n = 216). The mean age of respondents was 40 years (SD = 11.7), and the mean experience level was 11.9 years (SD = 9.5). RC was not associated with unit type. Total RC and between-role RC were associated with professional role. Physicians reported higher RC (β = .45, P = .01), and LPNs reported lower RC (β = -.06, P = .01). Education and experience were associated with RC. Participants with less experience reported higher RC (β = -.01, P = .00), and participants with graduate degrees reported lower RC (β = -.62, P = .00).

CONCLUSIONS

We recommend hospital leaders consider interventions to build interprofessional relationships, including interdisciplinary meetings, huddles, and structured communication tools. Improving RC among health care professionals is a cost-effective and unique way to enhance communication and collaboration among health care professionals across hospital units.

How external and agency characteristics are related to coordination in homecare - findings of the national multicenter, cross-sectional SPOTnat study

BACKGROUND

Homecare client services are often distributed across several interdependent healthcare providers, making proper care coordination essential. However, as studies exploring care coordination in the homecare setting are scarce, serious knowledge gaps exist regarding how various factors influence coordination in this care sector. To fill such gaps, this study's central aim was to explore how external factors (i.e., financial and regulatory mechanisms) and homecare agency characteristics (i.e., work environment, workforce, and client characteristics) are related to care coordination in homecare.

METHODS

This analysis was part of a national multicentre, cross-sectional study in the Swiss homecare setting that included a stratified random sample of 88 Swiss homecare agencies. Data were collected between January and September 2021 through agency and employee questionnaires. Using our newly developed care coordination framework, COORA, we modelled our variables to assess the relevant components of care coordination on the structural, process, and outcome levels. We conducted both descriptive and multilevel regression analyses-with the latter adjusting for dependencies within agencies-to explore which key factors are associated with coordination.

RESULTS

The final sample size consisted of 1450 employees of 71 homecare agencies. We found that one explicit coordination mechanism ("communication and information exchange" (beta = 0.10, p <.001)) and four implicit coordination mechanisms-"knowledge of the health system" (beta = -0.07, p <.01), "role clarity" (beta = 0.07, p <.001), "mutual respect and trust" (beta = 0.07, p <.001), and "accountability, predictability, common perspective" (beta = 0.19, p <.001)-were significantly positively associated with employee-perceived coordination. We also found that the effects of agency characteristics and external factors were mediated through coordination processes.

CONCLUSION

Implicit coordination mechanisms, which enable and enhance team communication, require closer examination. While developing strategies to strengthen implicit mechanisms, the involvement of the entire care team is vital to create structures (i.e., explicit mechanisms) that enable communication and information exchange. Appropriate coordination processes seem to mitigate the association between staffing and coordination. This suggests that they support coordination even when workload and overtime are higher.

Determining the core content of a digital survivorship care plan for melanoma survivors: a multistakeholder Delphi consensus study

Increasing melanoma incidence and improved survival emphasize the importance of survivorship care plans (SCPs). We conducted a multistakeholder Delphi study to achieve consensus on core melanoma SCP content. Of the 44 potential elements, 24 (55%) reached consensus for inclusion. Notably, melanoma survivors and healthcare providers differed in their preferences, with survivors prioritizing coordination improvements and healthcare providers emphasizing psychosocial care. Exploring and overcoming these differences in opinions and including the consented elements as a basis in the design of the SCP can facilitate its implementation in practice and lead to survivorship care tailored to stakeholders’ needs.

Creating Whole Person Health Care Systems: Understanding Employee Perceptions of VAs Whole Health Cultural Transformation

Objective: Whole person health care, like that being implemented in the U.S. Veterans Health Administration (VHA), involves person-centered approaches that address what matters most to patients to achieve well-being beyond the biomedical absence of disease. As whole health (WH) approaches expand, their integration into clinical practice is predicated on health care employees reconceptualizing practice beyond find-it-fix-it medicine and embracing WH as a new philosophy of care. This study examined employee perspectives of WH and their integration of this approach into care. Design: We conducted a survey with responses from 1073 clinical and 800 nonclinical employees at 5 VHA WH Flagship sites about their perceptions and use of a WH approach. We used descriptive statistics to examine employees' support for WH and conducted thematic analysis to qualitatively explore their perceptions about this approach from free-text comments supplied by 475 respondents. Results: On structured survey items, employees largely agreed that WH was a valuable approach but were relatively less likely to have incorporated it into practice or report support within their organization for WH. Qualitative comments revealed varying conceptualizations of WH. While some respondents understood that WH represented a philosophical shift in care, many characterized WH narrowly as services. These conceptualizations contributed to lower perceived relevance, skepticism, and misgivings that WH diverted needed resources away from existing clinical services. Organizational context including leadership messaging, siloed structures, and limited educational opportunities reinforced these perceptions. Conclusions: Successfully transforming the culture of care requires a shift in mindset among employees and leadership alike. Employees' depictions didn't always reflect WH as a person-centered approach designed to engage patients to enhance their health and well-being. Without consistent leadership messaging and accessible training, opportunities to expand understandings of WH are likely to be missed. To promote WH transformation, additional attention is needed for employees to embrace this approach to care.

Primary care referral patterns for patients with asthma: analysis of real-world data

OBJECTIVE

To identify features related to management of patients prior to referral from primary care physicians (PCPs) to pulmonologists and allergists.

METHODS

This is an analysis of patient claims data from Symphony Health (2013-2018). To characterize referrals, a longitudinal cohort included 12 months with no asthma claims prior to the index date, followed by 36 months of observation. We also assessed a cross-sectional cohort for 12 months at the end of the observational period to characterize disease control and treatment patterns. Referral was defined as the first appearance of a claim from an allergist or pulmonologist for a patient's initial visit for asthma. Descriptive statistics were used to analyze the data.

RESULTS

The majority of patients with asthma were managed by PCPs (60%), followed by pulmonologists (16%) and allergists (8%). Forty-three percent had uncontrolled asthma. Only 8% were referred to specialists within the first 24 months after initial diagnosis, of which 76% were seen by pulmonologists and 24% by allergists. Referrals resulted in treatment change in 55%-68% of the cases. Patients who received a referral were more likely to be on oral corticosteroids (OCS) and/or have more hospitalizations/ED visits.

CONCLUSIONS

About one-third of the patients managed by PCPs received intermittent and/or chronic OCS prior to referral, which may be an indication of uncontrolled disease. The referral patterns in this analysis illustrate underutilization of specialists in the consultation and management of patients with uncontrolled asthma.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

BACKGROUND

The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process.

METHODS

A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis.

RESULTS

A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified.

CONCLUSIONS

Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.

Adaptations to relational facilitation for two national care coordination programs during COVID-19

Background

Adaptations to implementation strategies are often necessary to support adoption and scale-up of evidence-based practices. Tracking adaptations to implementation strategies is critical for understanding any impacts on outcomes. However, these adaptations are infrequently collected. In this article we present a case study of how we used a new method during COVID-19 to systematically track and report adaptations to relational facilitation, a novel implementation strategy grounded in relational coordination theory. Relational facilitation aims to assess and improve communication and relationships in teams and is being implemented to support adoption of two Quadruple Aim Quality Enhancement Research Initiative (QA QUERI) initiatives: Care Coordination and Integrated Case Management (CC&ICM) and the Transitions Nurse Program for Home Health Care (TNP-HHC) in the Veterans Health Administration (VA).

Methods

During 2021-2022, relational facilitation training, activities and support were designed as in-person and/or virtual sessions. These included a site group coaching session to create a social network map of care coordination roles and assessment of baseline relationships and communication between roles. Following this we administered the Relational Coordination Survey to assess the relational coordination strength within and between roles. COVID-19 caused challenges implementing relational facilitation, warranting adaptations. We tracked relational facilitation adaptations using a logic model, REDCap tracking tool based on the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) with expanded Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) dimensions, and member checking. Adaptations were analyzed descriptively and for themes using matrix content analysis.

Results

COVID-19's impact within the VA caused barriers for implementing relational facilitation, warranting eight unique adaptations to the implementation strategy. Most adaptations pertained to changing the format of relational facilitation activities (n = 6; 75%), were based on external factors (n = 8; 100%), were planned (n = 8; 100%) and initiated by the QA QUERI implementation team (n = 8; 100%). Most adaptations impacted adoption (n = 6; 75%) and some impacted implementation (n = 2; 25%) of the CC&ICM and TNP-HHC interventions.

Discussion

Systematically tracking and discussing adaptations to relational facilitation during the COVID-19 pandemic enhanced engagement and adoption of two VA care coordination interventions. The impact of these rapid, early course adaptations will be followed in subsequent years of CC&ICM and TNP-HHC implementation.

Experiences of care coordination among older adults in the United States: Evidence from the Health and Retirement Study

INTRODUCTION

The goal of this study was to examine variation in patient experiences and perceptions of care coordination across sociodemographic and health factors.

METHODS

Data come from the 2016 Health and Retirement Study (N = 1, 216). Three domains of coordination were assessed: 1) Perceptions (e.g., patient impressions of provider-provider communication), 2) Tangible supports (e.g., meeting with a care coordinator, being accompanied to appointments), and 3) Technical supports (e.g., use of a "patient portal"). Logistic regression was used to quantify the frequency of each domain and examine variation by racial minority status, socioeconomic status, and health status.

RESULTS

Approximately 42% of older adults perceived poor care coordination, including 14.8% who reported receiving seemingly conflicting advice from different providers. Only one-third had ever met with a formal care coordinator, and 40% were occasionally accompanied to appointments. Although racial minorities were less likely to have access to technical supports, they were more likely to use them. Better perceived coordination was associated with higher care satisfaction (Odds Ratio: 1.43, 95% CI: 1.27-1.61).

CONCLUSIONS

Important gaps in care coordination remain for older adults.

PRACTICE IMPLICATIONS

Providers should consider assessing patient perceptions of care coordination to address these gaps in an equitable manner.

Reducing ICU Length of Stay: The Impact of a Multidisciplinary Perioperative Pathway in Vestibular Schwannoma

Objective This study was aimed to evaluate the impact of a multidisciplinary perioperative pathway on length of stay (LOS) and postoperative outcomes after vestibular schwannoma surgery.

Setting This study was conducted in a tertiary skull base center.

Main Outcome Measures The impact of the pathway on intensive care unit (ICU) LOS was evaluated as the primary outcome measure of the study. Overall resource LOS, postoperative complications, and readmission rates were also evaluated as secondary outcome measures.

Methods Present study is a retrospective review.

Results A universally adopted perioperative pathway was developed to include standardization of preoperative education and expectations, intraoperative anesthetic delivery, postoperative nursing education, postoperative rehabilitation, and utilization of stepdown and surgical floor units after ICU stay. Outcomes were measured for 95 consecutive adult patients who underwent surgical resection for vestibular schwannoma (40 cases before implementation of the perioperative pathway and 55 cases after implementation). There were no significant differences in the two groups with regard to tumor size, operative time, or medical comorbidities. The mean ICU LOS decreased from 2.1 in the preimplementation group to 1.6 days in the postimplementation group (p = 0.02). There were no significant differences in overall resource LOS postoperative complications or readmission rates between groups.

Conclusion Multidisciplinary, perioperative neurotologic pathways can be effective in lowering ICU LOS in patients undergoing vestibular schwannoma surgery without compromising quality of care. Further research is needed to continue to sustain and continuously improve these and other measures, while continuing to provide high-quality care to this patient population.

A Multi-site Case Study of Care Coordination Between Primary Care and Specialty Care

BACKGROUND

Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care.

OBJECTIVES

We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers.

RESEARCH DESIGN

Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care (PC)-mental health (MH) and PC-medical/surgical specialty care.

SUBJECTS

Physicians, nurses and other clinicians in PC, cardiology, and MH (N=102) in 8 Veterans Affairs medical centers.

RESULTS

We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. PC-MH coordination was reported as better than PC-medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between PC-MH than between PC-specialty care.

DISCUSSION

We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.

"Beyond Just a Supplement": Administrators' Visions for the Future of Virtual Primary Care Services

PURPOSE

The COVID-19 pandemic resulted in unprecedented adoption and implementation of virtual primary care services, and little is known about whether and how virtual care services will be provided after the pandemic ends. We aim to identify how administrators at health care organizations perceive the future of virtual primary care services.

METHODS

In March-April of 2021, we conducted semistructured qualitative phone interviews with administrators at 17 health care organizations that ranged from multi-state nonfederal delivery systems to single-site primary care practices. Organizations differed in size, structure, ownership, and geography. We explore how health care administrators anticipate their organization will offer virtual primary care services after the COVID-19 pandemic subsides.

RESULTS

All interviewed administrators expected virtual primary care services to persist after the pandemic. We categorize expected impact of future virtual services as limited (n = 4); targeted to a narrow set of clinical encounters (n = 5); and a major shift in primary care delivery (n = 8). The underlying motivation expressed by administrators for providing virtual care services was to remain financially stable and competitive. This motivation can be seen in the 3 main goals described for their anticipated use of virtual services: (1) optimizing medical services; (2) enhancing the patient experience; and (3) increasing loyalty among patients.

CONCLUSIONS

Health care organizations are considering how virtual primary care services can be used to improve patient outcomes, access to care, and convenience of care. To implement and sustain virtual primary care services, health care organizations will need long-term support from regulators and payers.

What Affects Adoption of Specialty Palliative Care in Intensive Care Units: A Qualitative Study

CONTEXT

Although many patients with critical illness may benefit from involvement of palliative care specialists, adoption of these services in the intensive care unit (ICU) is variable.

OBJECTIVE

To characterize reasons for variable buy-in for specialty palliative care in the ICU, and identify factors associated with routine involvement of specialists in appropriate cases.

METHODS

Qualitative study using in-depth, semi-structured interviews with ICU attendings, nurses, and palliative care clinicians, purposively sampled from eight ICUs (medical, surgical, cardiothoracic, neurological) with variable use of palliative care services within two urban, academic medical centers. Interviews were transcribed and coded using an iterative and inductive approach with constant comparison.

RESULTS

We identified three types of specialty palliative care adoption in ICUs, representing different phases of buy-in. The "nascent" phase was characterized by the need for education about palliative care services and clarification of which patients may be appropriate for involvement. During the key "transitional" phase, use of specialists depended on development of "comfort and trust", which centered on four aspects of the ICU-palliative care clinician relationship: 1) increasing familiarity between clinicians; 2) navigating shared responsibility with primary clinicians; 3) having a collaborative approach to care; and 4) having successful experiences. In the "mature" phase, ICU and palliative care clinicians worked to strengthen their existing collaboration, but further adoption was limited by the availability and resources of the palliative care team.

CONCLUSION

This conceptual framework identifying distinct phases of adoption may assist institutions aiming to foster sustained adoption of specialty palliative care in an ICU setting.

The clinical and translational research activities at the INT - IRCCS "Fondazione Pascale" cancer center (Naples, Italy) during the COVID-19 pandemic

COVID-19 pandemic following the outbreak in China and Western Europe, where it finally lost the momentum, is now devastating North and South America. It has not been identified the reason and the molecular mechanisms of the two different patterns of the pulmonary host responses to the virus from a minimal disease in young subjects to a severe distress syndrome (ARDS) in older subjects, particularly those with previous chronic diseases (including diabetes) and cancer. The Management of the Istituto Nazionale Tumori - IRCCS "Fondazione Pascale" in Naples (INT-Pascale), along with all Health professionals decided not to interrupt the treatment of those hospitalized and to continue, even if after a careful triage in order not to allow SARS-CoV-2 positive subjects to access, to take care of cancer patients with serious conditions. Although very few (n = 3) patients developed a symptomatic COVID-19 and required the transfer to a COVID-19 area of the Institute, no patients died during the hospitalization and completed their oncology treatment. Besides monitoring of the patients, all employees of the Institute (physicians, nurses, researchers, lawyers, accountants, gatekeepers, guardians, janitors) have been tested for a possible exposure. Personnel identified as positive, has been promptly subjected to home quarantine and subdued to health surveillance. One severe case of respiratory distress has been reported in a positive employees and one death of a family member. Further steps to home monitoring of COVID-19 clinical course have been taken with the development of remote Wi-Fi connected digital devices for the detection of early signs of respiratory distress, including heart rate and oxygen saturation.In conclusion cancer care has been performed and continued safely also during COVID-19 pandemic and further remote home strategies are in progress to ensure the appropriate monitoring of cancer patients.

Concerns of Primary Care Clinicians Practicing in an Integrated Health System: a Qualitative Study

BACKGROUND

Clinician well-being is a major priority for healthcare organizations. However, the impact of workplace environment on clinicians' well-being is poorly understood. Integrated health systems are a particularly relevant type of practice environment to focus on, given the increasing rates of practice consolidation and integration.

OBJECTIVE

To improve understanding of the concerns of primary care clinicians (PCCs) practicing in an integrated health system.

DESIGN

We analyzed free-text comment box responses offered on a national survey about care coordination by 555 PCCs in the Veterans Health Administration, one of the largest integrated health systems in the USA.

PARTICIPANTS

A total of 555 PCCs who left free-text comments on a national survey of care coordination in the VHA (30% out of 1862 eligible respondents). Demographics and coordination scale scores were similar between respondents who left comments vs. those who did not.

APPROACH

The data were coded and analyzed in line with the grounded theory approach. Key themes were identified by team consensus and illustrative quotations were chosen to illustrate each theme.

KEY RESULTS

VHA PCCs described some pressures shared across practice environments, such as prohibitive administrative burden, but also reported several concerns particular to integrated settings, including "dumping" by specialists and moral distress related to a concern for patients. Frustrations due to several aspects of responsibility around referrals may be unique to integrated health systems with salaried clinicians and/or where specialists have the ability to reject referrals.

CONCLUSION

PCCs in integrated health systems feel many of the same pressures as their counterparts in non-integrated settings, but they are also confronted with unique stressors related to these systems' organizational features that restrict clinicians' autonomy. An understanding of these concerns can guide efforts to improve the well-being of PCCs in existing integrated health systems, as well as in practices on their way to integration.

Development and psychometric assessment of a survey to measure specialty care coordination as experienced by primary care providers

OBJECTIVE

To assess the psychometric properties and construct validity of a survey of primary care providers' (PCPs') experience of specialty care coordination, which is a counterpart to our existing survey ("CSC-Specialist") that measures specialists' experience of specialty care coordination.

DATA SOURCES

We surveyed PCPs from Veterans Health Administration medical centers and community-based outpatient clinics nationwide (N = 1576) in April 2018.

STUDY DESIGN

We developed candidate items through literature review, existing surveys, PCP interviews, and expert opinion. We used exploratory and confirmatory factor analysis to develop scales and multivariable linear regression to determine their association with PCPs' overall experience of coordination.

DATA COLLECTION

The online survey included 23 candidate scale items about specialty care coordination and a single item asking respondents to rate their overall experience of specialty care coordination on a 0-10 scale. All VA PCPs were eligible. We sent survey invitations to PCPs following local Section Chiefs' email introduction (N = 926) and by directly emailing two random samples (N = 400 and N = 6653), overall response rate across the three nonoverlapping samples = 24 percent.

PRINCIPAL FINDINGS

Analyses identified 20 items forming 6 scales with strong psychometric properties and predictive power for overall coordination. Two scales are identical to CSC-Specialist scales: "Communication" (k = 3, α = 0.87) and "Data Transfer" (k = 2, α = 0.92); one is similar: "Relationships and Collaboration" (k = 6, α = 0.90). The three remaining scales address the PCP's unique perspective: "Role Clarity" (k = 3, α = 0.85), "Role Agreement" (k = 3, α = 0.75), and "Making Referrals" (k = 3, α = 0.75). The six scales together explained 67 percent of the variance in PCPs' overall coordination experience with specialists.

CONCLUSIONS

The Coordination of Specialty Care-Primary Care Provider Survey (CSC-PCP) is a novel 20-item survey that can be used in quality improvement or health services research, alone or in combination with the CSC-Specialist, to evaluate coordination of care as experienced by either or both participants.

A Mixed Methods Study of the Association of Non-Veterans Affairs Care With Veterans' and Clinicians' Experiences of Care Coordination

BACKGROUND

Poor coordination between the Department of Veterans Affairs (VA) and non-VA care may negatively impact health care quality. Recent legislation is intended to increase Veterans' access to care, in part through increased use of non-VA care. However, a possible consequence may be diminished patient experiences of coordination.

OBJECTIVE

The objective of this study was to determine VA patients' and clinicians' experiences of coordination across VA and non-VA settings.

DESIGN

Observational mixed methods using patient surveys and clinician interviews. Sampled patients were diagnosed with type 2 diabetes mellitus and either cardiovascular or mental health comorbidities.

PARTICIPANTS AND MEASURES

Patient perspectives on coordination were elicited between April and September 2016 through a national survey supplemented with VA administrative records (N=5372). Coordination was measured with the 8-dimension Patient Perceptions of Integrated Care survey. Receipt of non-VA care was measured through patient self-report. Clinician perspectives were elicited through individual interviews (N=100) between May and October 2017.

RESULTS

Veterans who received both VA and non-VA care reported significantly worse care coordination experiences than Veterans who only receive care in VA. Clinicians report limited information exchange capabilities, which, combined with bureaucratic and opaque procedures, adversely impact clinical decision-making.

CONCLUSIONS

VA is working through a shift in how Veterans receive health care by increasing access to care from non-VA providers. Study findings suggest that VA should prioritize coordination of care in addition to access. This could include requiring monitoring of patient-experienced care coordination, surveys of referring and consulting clinicians, and pilot testing and evaluation of interventions to improve coordination.

VA-Community Dual Care: Veteran and Clinician Perspectives

Many veterans receive care in both community settings and the VA. Recent legislation has increased veteran access to community providers, raising concerns about safety and coordination. This project aimed to understand the benefits and challenges of dual care from the perceptions of both the Veterans their clinicians. We conducted surveys and focus groups of veterans who use both VA and community care in VT and NH. We also conducted a web-based survey and a focus group involving primary care clinicians from both settings. The main measures included (1) reasons that veterans seek care in both settings; (2) problems faced by veterans and clinicians; (3) association of health status and ease of managing care with sites of primary care; and (4) association of veteran rurality with dual care experiences. The primary reasons veterans reported for using both VA and community care were (1) for convenience, (2) to access needed services, and (3) to get a second opinion. Veterans reported that community and VA providers were informed about the others' care more than half the time. Veterans in isolated rural towns reported better overall health and ease of managing their care. VA and community primary care clinicians reported encountering systems problems with dual-care including communicating medication changes, sharing lab and imaging results, communicating with specialists, sharing discharge summaries and managing medication renewals. Both Veterans and their primary clinicians report substantial system issues in coordinating care between the VA and the community, raising the potential for significant patient safety and Veteran satisfaction concerns.