Selecting a change and evaluating its impact on the performance of a complex adaptive health care delivery system

The Tennessee Heart Health Network effectiveness study: A stepped wedge cluster randomized controlled trial to assess the effectiveness of statewide quality improvement cooperative participation on cardiovascular outcomes

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of premature morbidity and mortality in the United States and Tennessee ranks among the highest in CVD events. While patient-centered outcomes research (PCOR) evidence-based approaches that reach beyond the traditional doctor-patient visit hold promise to improve CVD care and prevent serious complications, most primary care providers lack time, knowledge, and infrastructure to implement these proven approaches. Statewide primary care quality improvement (QI) collaboratives hold potential to help address primary care needs, however, little is known regarding their effectiveness in improving uptake of PCOR evidence-based population health approaches and improving CVD outcomes. This study describes the design and implementation of a stepped-wedge cluster randomized controlled trial to assess the effectiveness of participation in a statewide quality improvement cooperative (The Tennessee Heart Health Network [TN-HHN]) on cardiovascular outcomes.

METHODS/DESIGN

The TN-HHN Effectiveness Study randomized 77 practices to 4 waves (i.e., clusters), with each wave beginning three months after the start of the prior wave and lasting for 18 months. All practice clusters received one of three Network interventions, and outcomes are measured for each three months both in the control phase and the intervention phase. Primary outcomes include Center for Medicare and Medicaid Services measures for aspirin use, blood pressure control, cholesterol control, and smoking cessation (ABCS).

CONCLUSIONS

This trial, upon its conclusion, will allow us to assess the effect of participation in a statewide quality improvement cooperative on cardiovascular outcomes as well as key contributors to successful practice transformation.

The methodology of the Agile Nudge University

Introduction

The Agile Nudge University is a National Institute on Aging-funded initiative to engineer a diverse, interdisciplinary network of scientists trained in Agile processes.

Methods

Members of the network are trained and mentored in rapid, iterative, and adaptive problem-solving techniques to develop, implement, and disseminate evidence-based nudges capable of addressing health disparities and improving the care of people living with Alzheimer's disease and other related dementias (ADRD).

Results

Each Agile Nudge University cohort completes a year-long online program, biweekly coaching and mentoring sessions, monthly group-based problem-solving sessions, and receives access to a five-day Bootcamp and the Agile Nudge Resource Library.

Discussion

The Agile Nudge University is evaluated through participant feedback, competency surveys, and tracking of the funding, research awards, and promotions of participating scholars. The Agile Nudge University is compounding national innovation efforts in overcoming the gaps in the ADRD discovery-to-delivery translational cycle.

A whole-of-health system approach to improving care of frail older persons

The population is aging, with frailty emerging as a significant risk factor for poor outcomes for older people who become acutely ill. We describe the development and implementation of the Frail Older Persons' Collaborative Program, which aims to optimise the care of frail older adults across healthcare systems in Queensland. Priority areas were identified at a co-design workshop involving key stakeholders, including consumers, multidisciplinary clinicians, senior Queensland Health staff and representatives from community providers and residential aged care facilities. Locally developed, evidence-based interventions were selected by workshop participants for each priority area: a Residential Aged Care Facility acute care Support Service (RaSS); improved early identification and management of frail older persons presenting to hospital emergency departments (GEDI); optimisation of inpatient care (Eat Walk Engage); and enhancement of advance care planning. These interventions have been implemented across metropolitan and regional areas, and their impact is currently being evaluated through process measures and system-level outcomes. In this narrative paper, we conceptualise the healthcare organisation as a complex adaptive system to explain some of the difficulties in achieving change within a diverse and dynamic healthcare environment. The Frail Older Persons' Collaborative Program demonstrates that translating research into practice and effecting change can occur rapidly and at scale if clinician commitment, high-level leadership, and adequate resources are forthcoming.

Coincidence Analysis: A Novel Approach to Modeling Nurses' Workplace Experience

OBJECTIVES

The purpose of this study is to identify combinations of workplace conditions that uniquely differentiate high, medium, and low registered nurse (RN) ratings of appropriateness of patient assignment during daytime intensive care unit (ICU) work shifts.

METHODS

A collective case study design and coincidence analysis were employed to identify combinations of workplace conditions that link directly to high, medium, and low RN perception of appropriateness of patient assignment at a mid-shift time point. RN members of the study team hypothesized a set of 55 workplace conditions as potential difference makers through the application of theoretical and empirical knowledge. Conditions were derived from data exported from electronic systems commonly used in nursing care.

RESULTS

Analysis of 64 cases (25 high, 24 medium, and 15 low) produced three models, one for each level of the outcome. Each model contained multiple pathways to the same outcome. The model for "high" appropriateness was the simplest model with two paths to the outcome and a shared condition across pathways. The first path comprised of the absence of overtime and a before-noon patient discharge or transfer, and the second path comprised of the absence of overtime and RN assignment to a single ICU patient.

CONCLUSION

Specific combinations of workplace conditions uniquely distinguish RN perception of appropriateness of patient assignment at a mid-shift time point, and these difference-making conditions provide a foundation for enhanced observability of nurses' work experience during hospital work shifts. This study illuminates the complexity of assessing nursing work system status by revealing that multiple paths, comprised of multiple conditions, can lead to the same outcome. Operational decision support tools may best reflect the complex adaptive nature of the work systems they intend to support by utilizing methods that accommodate both causal complexity and equifinality.

Design and Development of a Community-Based, Interdisciplinary, Collaborative Dementia Care Program

OBJECTIVE

To describe the design, development, and baseline characteristics of enrollees of a home-based, interdisciplinary, dyadic, pilot dementia care program.

DESIGN

Single-arm, dementia care intervention in partnership with primary care providers delivered by Health Coaches to persons with dementia and caregiver "dyads" and supervised by an interdisciplinary team.

SETTING

Home- and virtual-based dyad support.

PARTICIPANTS

Persons with mild cognitive impairment or dementia diagnosis and/or who were prescribed antidementia medications; had an identified caregiver willing to participate; were under the care of a partner primary care provider; and had health insurance through the affiliated accountable care organization (Banner Health Network).

INTERVENTION

Provision of personalized dementia education and support in the home or virtually by Health Coaches supported by an interdisciplinary team.

MEASUREMENTS

Cognition, function, mood, and behavior of persons with dementia; caregiver stress and program satisfaction; primary care provider satisfaction.

RESULTS

Served dyads from three primary care clinics with a total of 87 dyads enrolled between December 2018 and June 2020.

CONCLUSION

A pilot Dementia Care Partners demonstrated feasibility and suggested acceptability, and high satisfaction among primary care providers and caregivers.

An integrated primary care-based programme of PRE-Pregnancy cARE to improve pregnancy outcomes in women with type 2 Diabetes (The PREPARED study): protocol for a multi-method study of implementation, system adaptation and performance

BACKGROUND

The number of women of childbearing age with Type 2 diabetes(T2DM) is increasing, and they now account for > 50% of pregnancies in women with pre-existing diabetes. Diabetes pregnancies without adequate pre-pregnancy care have higher risk for poor outcomes (miscarriages, birth-defects, stillbirths) and are associated with increased complications (caesarean deliveries, macrosomic babies, neonatal intensive-care admissions). The risks and costs of these pregnancies can be reduced with pregnancy preparation (HbA1c, ≤ 6.5%, 5 mg folic acid and stopping potentially harmful medicines). However, 90% of women with T2DM, most of whom are based in primary care, are not adequately prepared for pregnancy. This study will evaluate a programme of primary care-based interventions (decision-support systems; pre-pregnancy care-pathways; pregnancy-awareness resources; professional training; and performance monitoring) to improve pregnancy preparation in women with T2DM.

METHODS

The study aims to optimise the programme interventions and estimate their impact on pregnancy preparation, pre-pregnancy care uptake and pregnancy outcomes. To evaluate this multimodal intervention, we will use a multi-method research design following Complex Adaptive Systems (CAS) theory, refining the interventions iteratively during the study. Thirty GP practices with ≥ 25 women with T2DM of reproductive age (18-45 years) from two South London boroughs will be exposed to the intervention. This will provide > 750 women with an estimated pregnancy incidence of 80-100 to study. The research involves: a clinical audit of processes and outcomes; a process evaluation informing intervention feasibility, implementation, and behaviour change; and a cost-consequences analysis informing future economic evaluation. Performance data will be collected via audits of GP systems, hospital antenatal clinics and pregnancy outcomes. Following CAS theory, we will use repeated measurements to monitor intervention impact on pregnancy preparation markers at 4-monthly intervals over 18-months. We will use performance and feasibility data to optimise intervention effects iteratively. The target performance for the intervention is a 30% increase in the proportion of women meeting pre-pregnancy care criteria.

DISCUSSION

The primary output will be development of an integrated programme of interventions to improve pregnancy preparation, pre-pregnancy care uptake, and reduce adverse pregnancy outcomes in women with T2DM. We will also develop an implementation plan to support the introduction of the interventions across the NHS.

TRIAL REGISTRATION

ISRCTN47576591 ; February 8, 2022.

State of Science: Bridging the Science-Practice Gap in Aging, Dementia and Mental Health

The workforce available to care for older adults has not kept pace with the need. In response to workforce limitations and the growing complexity of healthcare, scientists have tested new models of care that redesign clinical practice. This article describes why new models of care in aging, dementia, and mental health diffuse inadequately into the healthcare systems and communities where they might benefit older adults. We review a general framework for the diffusion of innovations and highlight the importance of other features of innovations that deter or facilitate diffusion. Although scientists often focus on generating evidence-based innovations, end-users apply their own criteria to determine an innovation's value. In 1962, Rogers suggested six features of an innovation that facilitate or deter diffusion suggested: relative advantage, compatibility with the existing environment, ease or difficulty of implementation, trial-ability or ability to "test drive", adaptability, and observed effectiveness. We describe examples of models of care in aging, dementia and mental health that enjoy a modicum of diffusion into practice and place the features of these models in the context of deterrents and facilitators for diffusion. Developers of models of care in aging, dementia, and mental health typically fail to incorporate the complexities of health systems, the barriers to diffusion, and the role of emotion into design considerations of new models. We describe agile implementation as a strategy to facilitate the speed and scale of diffusion in the setting of complex adaptive systems, social networks, and dynamic macroenvironments.

Developing the Agile Implementation Playbook for Integrating Evidence-Based Health Care Services Into Clinical Practice

Problem

Despite the more than $32 billion the National Institutes of Health has invested annually, evidence-based health care services are not reliably implemented, sustained, or distributed in health care delivery organizations, resulting in suboptimal care and patient harm. New organizational approaches and frameworks that reflect the complex nature of health care systems are needed to achieve this goal.

Approach

To guide the implementation of evidence-based health care services at their institution, the authors used a number of behavioral theories and frameworks to develop the Agile Implementation (AI) Playbook, which was finalized in 2015. The AI Playbook leverages these theories in an integrated approach to selecting an evidence-based health care service to meet a specific opportunity, rapidly implementing the service, evaluating its fidelity and impact, and sustaining and scaling up the service across health care delivery organizations. The AI Playbook includes an interconnected eight-step cycle: (1) identify opportunities; (2) identify evidence-based health care services; (3) develop evaluation and termination plans; (4) assemble a team to develop a minimally viable service; (5) perform implementation sprints; (6) monitor implementation performance; (7) monitor whole system performance; and (8) develop a minimally standardized operating procedure.

Outcomes

The AI Playbook has helped to improve care and clinical outcomes for intensive care unit survivors and is being used to train clinicians and scientists in AI to be quality improvement advisors.

Next Steps

The authors plan to continue disseminating the details of the AI Playbook and illustrating how health care delivery organizations can successfully leverage it.

Using the agile implementation model to reduce central line-associated bloodstream infections

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are among the most common hospital-acquired infections and can lead to increased patient morbidity and mortality rates. Implementation of practice guidelines and recommended prevention bundles has historically been suboptimal, suggesting that improvements in implementation methods could further reductions in CLABSI rates. In this article, we describe the agile implementation methodology and present details of how it was successfully used to reduce CLABSI.

METHODS

We conducted an observational study of patients with central line catheters at 2 adult tertiary care hospitals in Indianapolis from January 2015 to June 2017.

RESULTS

The intervention successfully reduced the CLABSI rate from 1.76 infections per 1,000 central line days to 1.24 (rate ratio = 0.70; P = .011). We also observed reductions in the rates of Clostridium difficile and surgical site infections, whereas catheter-associated urinary tract infections remained stable.

CONCLUSIONS

Using the AI model, we were able to successfully implement evidence-based practices to reduce the rate of CLABSIs at our facility.

Present Algorithms and Future Treatments for Alzheimer's Disease

An estimated 47 million people live with Alzheimer's disease (AD) and other forms of dementia worldwide. Although no disease-modifying treatments are currently available for AD, earlier diagnosis and proper management of the disease could have considerable impact on patient and caregiver quality of life and functioning. Drugs currently approved for AD treat the cognitive, behavioral, and functional symptoms of the disease and consist of three cholinesterase inhibitors (ChEIs) and the N-methyl-D-aspartate receptor antagonist memantine. Treatment of patients with mild to moderate AD is generally initiated with a ChEI. Patients who show progression of symptoms while on ChEI monotherapy may be switched to another ChEI and/or memantine can be added to the treatment regimen. In recent years, putative disease-modifying therapies have emerged that aim to slow the progression of AD instead of only addressing its symptoms. However, many therapies have failed in clinical trials in patients with established AD, suggesting that, once developed, disease-modifying agents may need to be deployed earlier in the course of illness. The goal of this narrative literature review is to discuss present treatment algorithms and potential future therapies in AD.

Longitudinal multiple case study on effectiveness of network-based dementia care towards more integration, quality of care, and collaboration in primary care

INTRODUCTION

This study aimed to provide insight into the merits of DementiaNet, a network-based primary care innovation for community-dwelling dementia patients.

METHODS

Longitudinal mixed methods multiple case study including 13 networks of primary care professionals as cases. Data collection comprised continuously-kept logs; yearly network maturity score (range 0-24), yearly quality of care assessment (quality indicators, 0-100), and in-depth interviews.

RESULTS

Networks consisted of median nine professionals (range 5-22) covering medical, care and welfare disciplines. Their follow-up was 1-2 years. Average yearly increase was 2.03 (95%-CI:1.20-2.96) on network maturity and 8.45 (95%-CI:2.80-14.69) on quality indicator score. High primary care practice involvement and strong leadership proved essential in the transition towards more mature networks with better quality of care.

DISCUSSION

Progress towards more mature networks favored quality of care improvements. DementiaNet appeared to be effective to realize transition towards network-based care, enhance multidisciplinary collaboration, and improve quality of dementia care.

The application of systems thinking concepts, methods, and tools to global health practices: An analysis of case studies

OBJECTIVES

This review of systems thinking (ST) case studies seeks to compile and analyse cases from ST literature and provide practitioners with a reference for ST in health practice. Particular attention was given to (1) reviewing the frequency and use of key ST terms, methods, and tools in the context of health, and (2) extracting and analysing longitudinal themes across cases.

METHODS

A systematic search of databases was conducted, and a total of 36 case studies were identified. A combination of integrative and inductive qualitative approaches to analysis was used.

RESULTS

Most cases identified took place in high-income countries and applied ST retrospectively. The most commonly used ST terms were agent/stakeholder/actor (n = 29), interdependent/interconnected (n = 28), emergence (n = 26), and adaptability/adaptation (n = 26). Common ST methods and tools were largely underutilized. Social network analysis was the most commonly used method (n = 4), and innovation or change management history was the most frequently used tool (n = 11). Four overarching themes were identified; the importance of the interdependent and interconnected nature of a health system, characteristics of leaders in a complex adaptive system, the benefits of using ST, and barriers to implementing ST.

CONCLUSIONS

This review revealed that while much has been written about the potential benefits of applying ST to health, it has yet to completely transition from theory to practice. There is however evidence of the practical use of an ST lens as well as specific methods and tools. With clear examples of ST applications, the global health community will be better equipped to understand and address key health challenges.

Home is where the future is: The BrightFocus Foundation consensus panel on dementia care

INTRODUCTION

A national consensus panel was convened to develop recommendations on future directions for home-based dementia care (HBDC).

METHODS

The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus-based recommendations.

RESULTS

The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed.

DISCUSSION

HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.

Systems thinking in public health: a bibliographic contribution to a meta-narrative review

Background

Research across the formal, natural and social sciences has greatly expanded our knowledge about complex systems in recent decades, informing a broadly inclusive, cross-disciplinary conceptual framework referred to as Systems Thinking (ST). Its use in public health is rapidly increasing, although there remains a poor understanding of how these ideas have been imported, adapted and elaborated by public health research networks worldwide.

Method

This review employed a mixed methods approach to narrate the development of ST in public health. Tabulated results from a literature search of the Web of Science Core Collection database were used to perform a bibliometric analysis and literature review. Annual publication counts and citation scores were used to analyse trends and identify popular and potential 'landmark' publications. Citation network and co-authorship network diagrams were analysed to identify groups of articles and researchers in various network roles.

Results

Our search string related to 763 publications. Filtering excluded 208 publications while citation tracing identified 2 texts. The final 557 publications were analysed, revealing a near-exponential growth in literature over recent years. Half of all articles were published after 2010 with almost a fifth (17.8%) published in 2014. Bibliographic analysis identified five distinct citation and co-authorship groups homophilous by common geography, research focus, inspiration or institutional affiliation.

As a loosely related set of sciences, many public health researchers have developed different aspects of ST based on their underlying perspective. Early studies were inspired by Management-related literature, while later groups adopted a broadly inclusive understanding which incorporated related Systems sciences and approaches.

Conclusion

ST is an increasingly popular subject of discussion within public health although its understanding and approaches remain unclear. Briefly tracing the introduction and development of these ideas and author groups in public health literature may provide clarity and opportunities for further learning, research and development.

Analysing a Chinese Regional Integrated Healthcare Organisation Reform Failure using a Complex Adaptive System Approach

Introduction:

China’s organised health system has remained outdated for decades. Current health systems in many less market-oriented countries still adhere to traditional administrative-based directives and linear planning. Furthermore, they neglect the responsiveness and feedback of institutions and professionals, which often results in reform failure in integrated care. Complex adaptive system theory (CAS) provides a new perspective and methodology for analysing the health system and policy implementation.

Methods:

We observed the typical case of Qianjiang’s Integrated Health Organization Reform (IHO) for 2 years to analyse integrated care reforms using CAS theory. Via questionnaires and interviews, we observed 32 medical institutions and 344 professionals. We compared their cooperative behaviours from both organisational and inter-professional levels between 2013 and 2015, and further investigated potential reasons for why medical institutions and professionals did not form an effective IHO. We discovered how interested parties in the policy implementation process influenced reform outcome, and by theoretical induction, proposed a new semi-organised system and corresponding policy analysis flowchart that potentially suits the actual realisation of CAS.

Results:

The reform did not achieve its desired effect. The Qianjiang IHO was loosely integrated rather than closely integrated, and the cooperation levels between organisations and professionals were low. This disappointing result was due to low mutual trust among IHO members, with the main contributing factors being insufficient financial incentives and the lack of a common vision.

Discussion and Conclusions:

The traditional organised health system is old-fashioned. Rather than being completely organised or adaptive, the health system is currently more similar to a semi-organised system. Medical institutions and professionals operate in a middle ground between complete adherence to administrative orders from state-run health systems and completely adapting to the market. Thus, decision-making, implementation and analysis of health policies should also be updated according to this current standing. The simplest way to manage this new system is to abandon linear top-down orders and patiently wait for an explicit picture of IHO mechanisms to be revealed after complete and spontaneous negotiation between IHO allies is reached. In the meantime, bottom-up feedback from members should be paid attention to, and common benefits and fluid information flow should be prioritised in building a successful IHO.

Development of an adaptive, personalized, and scalable dementia care program: Early findings from the Care Ecosystem

Katherine Possin and colleagues report on the implementation, development, and early findings of the Care Ecosystem, an adaptive, personalized, and scalable dementia care program.

Addressing antimicrobial resistance in China: policy implementation in a complex context

The effectiveness of antibiotics in treating bacterial infections is decreasing in China because of the widespread development of resistant organisms. Although China has enacted a number of regulations to address this problem, but the impact is very limited. This paper investigates the implementation of these regulations through the lens of complex adaptive systems (CAS). It presents the findings from reviews of relevant policy documents and published papers. The paper identifies different types of agent and explores their interaction with regard to the use of antibiotics and their responses to changes of the regulations. It focuses particularly on the impact of perverse financial incentives on overall patterns of use of antibiotics. Implications for the possibilities of nonlinear results, interactive relationships, and new pathways of policy implementation are discussed. The paper concludes that policy-makers need to better understand the objectives, incentives and potential adaptive behaviors of the agents when they implement interventions to improve antibiotic use and reduce the risk of emergence of resistant organisms.

A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults

BACKGROUND

Healthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person's life that centers on meeting a person's health goals and needs will result in optimal aging.

METHODS/DESIGN

This is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person's life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months.

DISCUSSION

Evidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system's transformation of person-focused, primary care for older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02283723.

The Indiana University Center for Healthcare Innovation and Implementation Science: Bridging healthcare research and delivery to build a learning healthcare system

In the United States, it is estimated that 75,000 deaths every year could be averted if the healthcare system implemented high quality care more effectively and efficiently. Patient harm in the hospital occurs as a consequence of inadequate procedures, medications and other therapies, nosocomial infections, diagnostic evaluations and patient falls. Implementation science, a new emerging field in healthcare, is the development and study of methods and tools aimed at enhancing the implementation of new discoveries and evidence into daily healthcare delivery. The Indiana University Center for Healthcare Innovation and Implementation Science (IU-CHIIS) was launched in September 2013 with the mission to use implementation science and innovation to produce great-quality, patient-centered and cost-efficient healthcare delivery solutions for the United States of America. Within the first 24 months of its initiation, the IU-CHIIS successfully scaled up an evidence-based collaborative care model for people with dementia and/or depression, successfully expanded the Accountable Care Unit model positively impacting the efficiency and quality of care, created the first Certificate in Innovation and Implementation Science in the US and secured funding from National Institutes of Health to investigate innovations in dementia care. This article summarizes the establishment of the IU-CHIIS, its impact and outcomes and the lessons learned during the journey.

CE: critical care recovery center: an innovative collaborative care model for ICU survivors

OVERVIEW

Five million Americans require admission to ICUs annually owing to life-threatening illnesses. Recent medical advances have resulted in higher survival rates for critically ill patients, who often have significant cognitive, physical, and psychological sequelae, known as postintensive care syndrome (PICS). This growing population threatens to overwhelm the current U.S. health care system, which lacks established clinical models for managing their care. Novel innovative models are urgently needed. To this end, the pulmonary/critical care and geriatrics divisions at the Indiana University School of Medicine joined forces to develop and implement a collaborative care model, the Critical Care Recovery Center (CCRC). Its mission is to maximize the cognitive, physical, and psychological recovery of ICU survivors. Developed around the principles of implementation and complexity science, the CCRC opened in 2011 as a clinical center with a secondary research focus. Care is provided through a pre-CCRC patient and caregiver needs assessment, an initial diagnostic workup visit, and a follow-up visit that includes a family conference. With its sole focus on the prevention and treatment of PICS, the CCRC represents an innovative prototype aimed at modifying post-critical illness morbidities and improving the ICU survivor's quality of life.

Implementation of a heart failure quality initiative in a skilled nursing facility: lessons learned

Skilled nursing facilities (SNFs) are organizations that represent complex adaptive systems, offering barriers to the implementation of quality improvement (QI) initiatives. The current article describes the authors' efforts to use the approach of reflective adaptive process to implement a new model of care (i.e., the Skilled Heart Unit Program) for effective heart failure (HF) care in one SNF. A team of stakeholders from the local hospital system and a local SNF was convened to design and implement this new model. Evaluation of the implementation processes confirmed the value of the implementation approach, which centered on team-based approaches, staff engagement, and flexibility of processes to respect the SNF's needs and culture. Interviews with facility staff and the administrator revealed their perceptions that the strategy resulted in better HF care, enhanced teamwork between staff and clinicians, and improved staff job satisfaction. This work provides a unique blueprint of strategic QI implementation for patients with HF in the SNF setting.

Development of a facilitation curriculum to support primary care transformation: the "coach medical home" curriculum

BACKGROUND

In an effort to improve patient care, retain high-quality primary care providers, and control costs, primary care practices across the United States are transforming to patient-centered medical homes. This is no small task. Practice facilitation, also called "coaching," is increasingly being used to support system change; however, there is limited guidance for these programs.

OBJECTIVE

To develop an evidence-based curriculum to help practice coaches guide broad-scale transformation efforts in primary care.

METHODS

We gathered evidence about effective practice transformation coaching from 25 published programs and 8 expert interviews. Given limited published information, we drew extensively on our experience as leaders and coaches in the Safety Net Medical Home Initiative. Using these data, and with input from a User Group, we identified 6 curricular topics and created learning objectives and curricular content related to these topics.

RESULTS

The Coach Medical Home curriculum guides coaches in the following areas: getting started with a practice; recognition and payment; sequencing changes; measurement; learning communities; and sustainability and spread.

CONCLUSIONS

Coach Medical Home is a publically available web-based curriculum that provides tools, resources, and guidance for practice transformation support programs, including practice facilitators and learning community organizers.

Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts

Background

This paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals.

Methods

The study draws on several sources of data including a review of official policy documents and academic papers and in-depth interviews with key policy actors at national level and at a sample of localities.

Results

The study identifies three major transition points associated with changes in broad development strategy and demonstrates how the adaptation of large numbers of actors to these contextual changes had a major impact on the performance of the health system. Further, it documents how the Ministry of Health viewed its role as both an advocate for the interests of health facilities and health workers and as the agency responsible for ensuring that government health system objectives were met. It is argued that a major reason for the resilience of the health system and its ability to adapt to rapid economic and institutional change was the ability of the Ministry to provide overall strategy leadership. Additionally, it postulates that a number of interest groups have emerged, which now also seek to influence the pathway of health system development.

Conclusions

This history illustrates the complex and political nature of the management of health system development and reform. The paper concludes that governments will need to increase their capacity to analyze the health sector as a complex system and to manage change processes.

Applying complexity theory: a review to inform evaluation design

Complexity theory has increasingly been discussed and applied within evaluation literature over the past decade. This article reviews the discussion and use of complexity theory within academic journal literature. The aim is to identify the issues to be considered when applying complexity theory to evaluation. Reviewing 46 articles, two groups of themes are identified. The first group considers implications of applying complexity theory concepts for defining evaluation purpose, scope and units of analysis. The second group of themes consider methodology and method. Results provide a starting point for a configuration of an evaluation approach consistent with complexity theory, whilst also identifying a number of design considerations to be resolved within evaluation planning.

Building a multidisciplinary team for burn treatment - Lessons learned from the Montreal tendon transfer experience

Multidisciplinary teams (MDTs) represent a recognized component of care in the treatment of complex conditions such as burns. However, most institutions do not provide adequate support for the formation of these teams. Furthermore, the majority of specialists lack the managerial skills required to create a team and have difficulties finding the proper tools. Our objective is to provide an insight for health care professionals, who wish to form a MDT for burn treatment, on the challenges that are likely to be faced, and to identify key elements that may facilitate the establishment of such a project. The setting for this was a plastic surgery department and rehabilitation center at a national reference center. A qualitative analysis was performed on all correspondences related to our tetraplegia project, from 2006 to 2008. To guide our thematic analysis, we used a form of systems theory known as the complexity theory. The qualitative analysis was performed using the NVivo software (Version 8.0 QSR International Melbourne, Australia). Lastly, the data was organized in chronologic order. Three main themes emerged from the results: knowledge acquisition, project organizational setup and project steps design. These themes represented respectively 24%, 50% and 26% of all correspondences. Project steps design and knowledge acquisition correspondences increased significantly after the introduction of the mentor team to our network. We conclude that an early association with a mentor team is beneficial for the establishment of a MDT.

Collaborative transdisciplinary team approach for dementia care

Alzheimer's disease (AD) has high economic impact and places significant burden on patients, caregivers, providers and healthcare delivery systems, fostering the need for an evaluation of alternative approaches to healthcare delivery for dementia. Collaborative care models are team-based, multicomponent interventions that provide a pragmatic strategy to deliver integrated healthcare to patients and families across a wide range of populations and clinical settings. Healthcare reform and national plans for AD goals to integrate quality care, health promotion and preventive services, and reduce the impact of disease on patients and families reinforcing the need for a system-level evaluation of how to best meet the needs of patients and families. We review collaborative care models for AD and offer evidence for improved patient- and family-centered outcomes, quality indicators of care and potential cost savings.

Connecting research discovery with care delivery in dementia: the development of the Indianapolis Discovery Network for Dementia

BACKGROUND

The US Institute of Medicine has recommended an integrated, locally sensitive collaboration among the various members of the community, health care systems, and research organizations to improve dementia care and dementia research.

METHODS

Using complex adaptive system theory and reflective adaptive process, we developed a professional network called the "Indianapolis Discovery Network for Dementia" (IDND). The IDND facilitates effective and sustainable interactions among a local and diverse group of dementia researchers, clinical providers, and community advocates interested in improving care for dementia patients in Indianapolis, Indiana.

RESULTS

The IDND was established in February 2006 and now includes more than 250 members from more than 30 local (central Indiana) organizations representing 20 disciplines. The network uses two types of communication to connect its members. The first is a 2-hour face-to-face bimonthly meeting open to all members. The second is a web-based resource center (http://www.indydiscoverynetwork.org ). To date, the network has: (1) accomplished the development of a network website with an annual average of 12,711 hits per day; (2) produced clinical tools such as the Healthy Aging Brain Care Monitor and the Anticholinergic Cognitive Burden Scale; (3) translated and implemented the collaborative dementia care model into two local health care systems; (4) created web-based tracking software, the Enhanced Medical Record for Aging Brain Care (eMR-ABC), to support care coordination for patients with dementia; (5) received more than USD$24 million in funding for members for dementia-related research studies; and (6) adopted a new group-based problem-solving process called the "IDND consultancy round."

CONCLUSION

A local interdisciplinary "think-tank" network focused on dementia that promotes collaboration in research projects, educational initiatives, and quality improvement efforts that meet the local research, clinical, and community needs relevant to dementia care has been built.

Next-generation phenotyping of electronic health records

The national adoption of electronic health records (EHR) promises to make an unprecedented amount of data available for clinical research, but the data are complex, inaccurate, and frequently missing, and the record reflects complex processes aside from the patient's physiological state. We believe that the path forward requires studying the EHR as an object of interest in itself, and that new models, learning from data, and collaboration will lead to efficient use of the valuable information currently locked in health records.

Implementing innovative models of dementia care: The Healthy Aging Brain Center

BACKGROUND

Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers.

OBJECTIVE

To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis.

METHODS

We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC).

RESULTS

Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs.

CONCLUSION

The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.