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Chan B, Edwards ST, Srikanth P, Mitchell M, Devoe M, Nicolaidis C, Kansagara D, Korthuis PT, Solotaroff R, Saha S. Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness: The SUMMIT Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2342012. [PMID: 37948081 PMCID: PMC10638646 DOI: 10.1001/jamanetworkopen.2023.42012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. Objective To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. Design, Setting, and Participants The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. Intervention The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. Main Outcomes and Measures The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. Results This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. Conclusions and Relevance The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. Trial Registration ClinicalTrials.gov Identifier: NCT03224858.
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Affiliation(s)
- Brian Chan
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Central City Concern, Portland, Oregon
| | - Samuel T. Edwards
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Priya Srikanth
- Biostatistics Design Program, Oregon Health & Science University, Portland
| | | | - Meg Devoe
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Central City Concern, Portland, Oregon
| | - Christina Nicolaidis
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- School of Social Work, Portland State University, Portland, Oregon
| | - Devan Kansagara
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - P. Todd Korthuis
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University–Portland State University, Portland
| | | | - Somnath Saha
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
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Weightman AL, Kelson MJ, Thomas I, Mann MK, Searchfield L, Willis S, Hannigan B, Smith RJ, Cordiner R. Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis. CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1329. [PMID: 37206622 PMCID: PMC10189499 DOI: 10.1002/cl2.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority. Objectives To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact. Search Methods We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies. Selection Criteria We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation. Data Collection and Analysis We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data. Main Results We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings. Case Management and Housing Outcomes Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches. Case Management and Mental Health Outcomes The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817). Case Management and Other Outcomes Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment. Case Management Components For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services. Characteristics of Persons Experiencing Homelessness No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3. The Broader Context of Delivery of Case Management Programmes Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice. Cost Effectiveness The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed. Authors' Conclusions Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.
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Affiliation(s)
| | - Mark J. Kelson
- Department of Mathematics and Statistics, Faculty of Environment, Science and EconomyUniversity of ExeterExeterUK
| | - Ian Thomas
- Wales Institute of Social and Economic Research and Data (WISERD)Cardiff UniversityCardiffUK
| | - Mala K. Mann
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Lydia Searchfield
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Simone Willis
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
| | - Ben Hannigan
- Mental Health Nursing, School of Healthcare SciencesCardiff UniversityCardiffUK
| | | | - Rhiannon Cordiner
- Specialist Unit for Review Evidence (SURE)Cardiff UniversityCardiffUK
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Zuchowski I, McLennan S. A Systematic Review of Social Work in General Practice: Opportunities and Challenges. JOURNAL OF EVIDENCE-BASED SOCIAL WORK (2019) 2023:1-41. [PMID: 37264677 DOI: 10.1080/26408066.2023.2202665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE This study identified the nature of social work practice in primary health care and described the reported patient outcomes, benefits, challenges, and enablers of social work in general practice [GP] settings. METHOD A systematic literature review applying the Prisma framework was conducted. RESULTS A total of 26 studies met the inclusion criteria. Social work practice in GP assists in delivering positive health outcomes for patients, improved patient care, offers value for money, and supports interdisciplinary teams. Identified challenges include funding impediments, organizational barriers, and a lack of understanding of and undervaluing the social work role. DISCUSSION AND CONCLUSIONS The review outlined the benefits of social work practice in GP practices; however, these must be further evidenced. Funding for social workers in primary health care was identified as a challenge when it was lacking, and as an enabler when it was available. Further research to evidence the patient outcomes and overall benefits, the fiscal value of social work and funding pathways in primary health care is recommended.
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Affiliation(s)
- Ines Zuchowski
- Social Work and Human Services, College of Arts, Society and Education, James Cook University, Douglas, Townsville, Queensland, Australia
| | - Simoane McLennan
- Social Work and Human Services, College of Arts, Society and Education, James Cook University, Douglas, Townsville, Queensland, Australia
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Rodis JL, Irwin AN, Valentino AS, Erdmann AM. Pharmacist care in Federally Qualified Health Centers: A narrative review. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Adriane N. Irwin
- Oregon State University College of Pharmacy Corvallis Oregon USA
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Löwe C, Mark P, Sommer S, Weltermann B. Collaboration between general practitioners and social workers: a scoping review. BMJ Open 2022; 12:e062144. [PMID: 36691249 PMCID: PMC9171253 DOI: 10.1136/bmjopen-2022-062144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/08/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Aim of the study is to present an overview of collaboration structures and processes between general practitioners and social workers, the target groups addressed as well the quality of available scientific literature. DESIGN A scoping review following the guidelines of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). INCLUDED SOURCES AND ARTICLES According to a pre-published protocol, three databases (PubMed, Web of Science, DZI SoLit) were searched using the participant-concept-context framework. The searches were performed on 21 January 2021 and on 10 August 2021. Literature written in English and German since the year 2000 was included. Two independent researchers screened all abstracts for collaboration between general practitioners and social workers. Articles selected were analysed regarding structures, processes, outcomes, effectiveness and patient target groups. RESULTS A total of 72 articles from 17 countries were identified. Collaborative structures and their routine differ markedly between healthcare systems: 36 publications present collaboration structures and 33 articles allow an insight into the processual routines. For all quantitative studies, a level of evidence was assigned. Various measurements are used to determine the effectiveness of collaborations, for example, hospital admissions and professionals' job satisfaction. Case management as person-centred care for defined patient groups is a central aspect of all identified collaborations between general practitioners and social workers. CONCLUSION This scoping review showed evidence for benefits on behalf of patients, professionals and healthcare systems by collaborations between general practitioners and social workers, yet more rigorous research is needed to better understand the impact of these collaborations. TRIAL REGISTRATION NUMBER www.osf.io/w673q.
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Affiliation(s)
- Cornelia Löwe
- University Hospital / Institute of General Practice and Family Medicine, Rheinische Friedrich-Wilhelms-Universitat Bonn, Bonn, Germany
| | - Patrick Mark
- University Hospital / Institute of General Practice and Family Medicine, Rheinische Friedrich-Wilhelms-Universitat Bonn, Bonn, Germany
| | - Samira Sommer
- University Hospital / Institute of General Practice and Family Medicine, Rheinische Friedrich-Wilhelms-Universitat Bonn, Bonn, Germany
| | - Birgitta Weltermann
- University Hospital / Institute of General Practice and Family Medicine, Rheinische Friedrich-Wilhelms-Universitat Bonn, Bonn, Germany
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Social work involvement in palliative care heart failure research: a review of recent literature. Curr Opin Support Palliat Care 2020; 14:3-8. [PMID: 31895064 DOI: 10.1097/spc.0000000000000482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of the review is to examine the findings of empirical studies of palliative care interventions for patients with heart failure in which a social worker was identified as a key member of the interprofessional clinical team. RECENT FINDINGS Our systematic review of the empirical literature from January 2016 to August 2019 found five palliative care interventions with heart failure patients that cited involvement of a social worker as a key team member. The reviewed studies highlighted social workers' roles in the areas of psychosocial assessments and support, advance care planning, and patient-medical team communication. SUMMARY Palliative social workers possess the knowledge and skills to provide expertise in psychological, social, and cultural care within palliative care domains of practice. Given this primary and critical role, more studies that include the assessment of outcomes linked to the social worker's role should be pursued. Our review unearthed several important studies that highlight the role of the palliative social workers in heart failure models of care.
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Peckens S, Adelman MM, Ashcraft AM, Xiang J, Sheppard B, King DE. Improving Chronic Obstructive Pulmonary Disease (COPD) Symptoms Using a Team-Based Approach. J Am Board Fam Med 2020; 33:978-985. [PMID: 33219076 PMCID: PMC8366582 DOI: 10.3122/jabfm.2020.06.200176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. METHODS To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients' self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149). RESULTS Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms. CONCLUSION An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.
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Affiliation(s)
- Shaylee Peckens
- From the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
| | - Megan M Adelman
- From the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
| | - Amie M Ashcraft
- From the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
| | - Jun Xiang
- From the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
| | - Brittany Sheppard
- From the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
| | - Dana E King
- From the Department of Family Medicine, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (SP, MMA, AMA, JX, DEK); School of Pharmacy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown (MMA, BS)
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Delaney RK, Sisco-Taylor B, Fagerlin A, Weir P, Ozanne EM. A systematic review of intensive outpatient care programs for high-need, high-cost patients. Transl Behav Med 2020; 10:1187-1199. [PMID: 33044534 DOI: 10.1093/tbm/ibaa017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Five percent of the patient population accounts for 50% of U.S. healthcare expenditures. High-need, high-cost patients are medically complex for numerous reasons, often including behavioral health needs. Intensive outpatient care programs (IOCPs) are emerging, innovative clinics which provide patient-centered care leveraging multidisciplinary teams. The overarching goals of IOCPs are to reduce emergency department visits and hospitalizations (and related costs), and improve care continuity and patient outcomes. The purpose of this review was to examine the effectiveness of IOCPs on multiple outcomes to inform clinical care. A systematic search of the literature was conducted to identify articles. Six studies were included that varied in rigor of research design, analysis, and measurement of outcomes. Most studies reported results on healthcare utilization (n = 4) and costs (n = 3), with fewer reporting results on patient-reported and health-related outcomes (n = 2). Overall, there were decreasing trends in emergency department visits and hospitalizations. However, results on healthcare utilization varied based on time of follow-up, with shorter follow-up times yielding more significant results. Two of the three studies that evaluated costs found significant reductions associated with IOCPs, and the third was cost-neutral. Two studies reported improvements in patient-reported outcomes (e.g., satisfaction, depression, and anxiety). Overall, these programs reported positive impacts on healthcare utilization and costs; however, few studies evaluated patient characteristics and behaviors (e.g., engagement in care) which may serve as key mechanisms of program effectiveness. Future research should examine patient characteristics, behaviors, and clinic engagement metrics to inform clinical practice.
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Affiliation(s)
- Rebecca K Delaney
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brittany Sisco-Taylor
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Peter Weir
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
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Sundberg G. Solutions to Address Frequent Hospital Attendance. J Patient Cent Res Rev 2020; 7:222-226. [PMID: 32760753 PMCID: PMC7398627 DOI: 10.17294/2330-0698.1786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Affiliation(s)
- Glenda Sundberg
- Department of Family Medicine, Aurora UW Medical Group, Advocate Aurora Health, Milwaukee, WI
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10
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Chan B, Hulen E, Edwards S, Mitchell M, Nicolaidis C, Saha S. "It's Like Riding Out the Chaos": Caring for Socially Complex Patients in an Ambulatory Intensive Care Unit (A-ICU). Ann Fam Med 2019; 17:495-501. [PMID: 31712287 PMCID: PMC6846277 DOI: 10.1370/afm.2464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/13/2019] [Accepted: 05/24/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE High-need high-cost (HNHC) patients consume a large proportion of health resources but often receive suboptimal care in traditional primary care. Intensive ambulatory care interventions attempt to better meet these patients' needs, but we know little about how teams delivering these interventions in clinics serving socially complex patient populations perceive their work. METHODS We performed a qualitative study of multidisciplinary staff experiences at a Federally Qualified Health Center (FQHC) caring for predominantly homeless HNHC patients in the context of an ongoing implementation of an ambulatory intensive care unit (A-ICU) intervention. We conducted semistructured interviews with 9 ambulatory intensive care team members and 6 "usual care" members. We conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS Staff viewed complexity as a combination of social, behavioral, and medical challenges that lead to patient-health care system mismatch. Staff perceive the following as key ingredients in caring for HNHC patients: addressing both psychosocial and clinical needs together; persistence in staying connected to patients through chaotic periods; shared commitment and cohesion among interdisciplinary team members; and flexibility to tailor care to patients' individual situations. Participants' definitions of success focused more on improving patient engagement than reducing utilization or cost. CONCLUSION FQHC staff working with HNHC patients perceive mismatch between the health care system and patients' clinical and social needs as the key driver of poor outcomes for these patients. Intensive ambulatory care teams may bridge mismatch through provision of psychosocial supports, flexible care delivery, and fostering team cohesion to support patient engagement.
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Affiliation(s)
- Brian Chan
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon .,Central City Concern, Portland, Oregon
| | - Elizabeth Hulen
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Sociology, Portland State University, Portland, Oregon
| | - Samuel Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | | | - Christina Nicolaidis
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.,School of Social Work, Portland State University, Portland, Oregon.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, Oregon
| | - Somnath Saha
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
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