Applying models of care for total hip and knee arthroplasty: External validation of a published predictive model to identify extended stay risk prior to lower-limb arthroplasty

OBJECTIVE

This study aimed to externally validate a reported model for identifying patients requiring extended stay following lower limb arthroplasty in a new setting.

DESIGN

External validation of a previously reported prognostic model, using retrospective data.

SETTING

Medium-sized hospital orthopaedic department, Australia.

PARTICIPANTS

Electronic medical records were accessed for data collection between Sep-2019 and Feb-2020 and retrospective data extracted from 200 randomly selected total hip or knee arthroplasty patients.

INTERVENTION

Participants received total hip or knee replacement between 2-Feb-16 and 4-Apr-19. This study was a non-interventional retrospective study.

MAIN MEASURES

Model validation was assessed with discrimination, calibration on both original and adjusted forms of the candidate model. Decision curve analysis was conducted on the outputs of the adjusted model to determine net benefit at a predetermined decision threshold (0.5).

RESULTS

The original model performed poorly, grossly overestimating length of stay with mean calibration of -3.6 (95% confidence interval -3.9 to -3.2) and calibration slope of 0.52. Performance improved following adjustment of the model intercept and model coefficients (mean calibration 0.48, 95% confidence interval 0.16 to 0.80 and slope of 1.0), but remained poorly calibrated at low and medium risk threshold and net benefit was modest (three additional patients per hundred identified as at-risk) at the a-priori risk threshold.

CONCLUSIONS

External validation demonstrated poor performance when applied to a new patient population and would provide limited benefit for our institution. Implementation of predictive models for arthroplasty should include practical assessment of discrimination, calibration and net benefit at a clinically acceptable threshold.

"You don't want to know just about my lungs, you…want to know more about me". Patients and their caregivers' evaluation of a nurse-led COPD supportive care service

AIM

To evaluate a nurse-led model of supportive care in a COPD outpatient service from patient and caregiver perspectives.

DESIGN

Case study methodology.

METHODS

Data were collected from semi-structured interviews with patients (n = 12) and caregivers (n = 7) conducted between April 2020 and September 2022. A purposive sampling strategy was used. Interviews were transcribed verbatim and analysed using content analysis with an inductive approach. COREQ guidelines informed reporting of this study.

RESULTS

Eight categories were identified from the data evaluating of the model of care relating to the most helpful aspects of COPD supportive care and suggested improvements to the model of care. The categories were: guidance with managing symptoms; participating in advance care planning; home visiting; expert advice; continuity and trust; caring; caregiver support and improvements to the model of care.

CONCLUSION

In a nurse-led model of COPD supportive care, what patients and caregivers valued most was expert advice and guidance with symptom management, flexible home visiting, participation in advance care planning, caring and continuity within an ongoing trusted therapeutic relationship. Understanding what patients and caregivers value most is essential in designing and delivering models of care that meet the needs of patients living with chronic, life-limiting illness.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses can lead effective models of supportive care that offer valuable support to patients living with COPD and their caregivers.

The prototype of a frailty learning health system: The HARMONY Model

Introduction

Rapid translation of research findings into clinical practice through innovation is critical to improve health systems and patient outcomes. Access to efficient systems of learning underpinned with real-time data are the future of healthcare. This type of health system will decrease unwarranted clinical variation, accelerate rapid evidence translation, and improve overall healthcare quality.

Methods

This paper aims to describe The HARMONY model (acHieving dAta-dRiven quality iMprovement to enhance frailty Outcomes using a learNing health sYstem), a new frailty learning health system model of implementation science and practice improvement. The HARMONY model provides a prototype for clinical quality registry infrastructure and partnership within health care.

Results

The HARMONY model was applied to the Western Sydney Clinical Frailty Registry as the prototype exemplar. The model networks longitudinal frailty data into an accessible and useable format for learning. Creating local capability that networks current data infrastructures to translate and improve quality of care in real-time.

Conclusion

This prototype provides a model of registry data feedback and quality improvement processes in an inpatient aged care and rehabilitation hospital setting to help reduce clinical variation, enhance research translation capacity, and improve care quality.

A nurse-led, telehealth-driven hepatitis C management initiative in regional Victoria: Cascade of care from referral to cure

INTRODUCTION

Elimination of hepatitis C virus stands as an unresolved World Health Organization target, and is associated with complications including cirrhosis and hepatocellular carcinoma. Hepatitis C virus management has been revolutionised following the widespread availability of direct-acting antiviral agents in Australia since 2016; however, large proportions of the population remain untreated. Telehealth-based service delivery is an accessible and effective alternative, and we aimed to assess qualitative and clinical outcomes in a clinical nurse consultant-led regional telehealth model.

METHODS

A prospective cohort analysis of all patients referred to a Victorian regional hospital's hepatitis C virus telehealth clinic between 1 April 2017 and 10 June 2020 was conducted. Data were collated from outpatient and electronic medical records.

RESULTS

Fifty-five out of 71 referred patients were booked, with 44 patients (80%) attending at least one appointment. A history of alcohol use disorder and psychiatric comorbidity was seen in 25 (54%) and 24 (52%) patients, respectively. Twenty-one out of 24 (88%) eligible patients had direct-acting antiviral agent treatment and 14 out of 21 (67%) successfully completed the treatment. An average of 46.5 km, 54.6 min and $AUD30.70 was saved per patient for each visit. Observed benefits included: increased medical engagement, adherence to and completion of HCV treatment and cirrhosis monitoring. Telehealth-driven hepatocellular carcinoma surveillance was successful in the cirrhotic subgroup.

CONCLUSION

Clinical nurse consultant-led hepatitis C virus management via telehealth allows access to marginalised regional populations. Clinical outcomes were comparable to other cohorts with additional cost-benefit, efficiency gains and carbon footprint reduction amongst a previously unreported regional Victorian hepatitis C virus population.

Care models for patients with heart failure at home: A systematic review

AIMS

The aim of this study is to evaluate the relative merits of various heart failure models of care with regard to a variety of outcomes.

DESIGN

Systematic review.

DATA SOURCES

Five databases including PubMed, Web of Science, Medline, Embase and Science Direct were searched from the inception date of databases to August 20, 2022.

REVIEW METHODS

This review used the Cochrane Collaboration's 'Risk of Bias' tool to assess quality. Only randomised controlled trails were included in this review that assessed all care models in the management of adults with heart failure. A categorical summary of the pattern of the papers was found, followed by extraction of outcome indicators.

RESULTS

Twenty articles (19 studies) were included. Seven examined nurse-led care, two examined multidisciplinary specialist care, nine (10 articles) examined patient self-management, and one examined nurse and physiotherapist co-led care. Regarding outcomes, this review examined how well the four models performed with regard to quality of life, health services use, HF self-care, and anxiety and depression for heart failure patients. The model of patient self-management showed more beneficial results than nurse-led care, multidisciplinary specialist care, and nurse and physiotherapist co-led care in reducing hospital days, improving symptoms, promoting self-care behaviours of HF patients, enhancing the quality of life, and strengthening self-care ability.

CONCLUSIONS

This systematic review synthesises the different care models and their relative effectiveness. Four different models of care were summarised. Of these models, the self-management model demonstrated better outcomes.

IMPACT

The self-management model is more effective in increasing self-management behaviours and self-management abilities, lowering the risk of hospitalisation and death, improving quality of life, and relieving anxiety and depression than other models.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no funding to remunerate a patient/member of the public for this review.

Opportunistic Treatment of Hepatitis C Infection Among Hospitalized People Who Inject Drugs (OPPORTUNI-C): A Stepped Wedge Cluster Randomized Trial

BACKGROUND

We aimed to evaluate the efficacy of opportunistic treatment of hepatitis C virus (HCV) infection among hospitalized people who inject drugs (PWID).

METHODS

We performed a pragmatic, stepped wedge cluster randomized trial recruiting HCV RNA positive individuals admitted for inpatient care in departments of internal medicine, addiction medicine, and psychiatry at three hospitals in Oslo, Norway. Seven departments were sequentially randomized to change from control conditions (standard of care referral to outpatient care) to intervention conditions (immediate treatment initiation). The primary outcome was treatment completion, defined as dispensing the final package of the prescribed treatment within six months after enrolment.

RESULTS

A total of 200 HCV RNA positive individuals were enrolled between 1 October 2019 and 31 December 2021 (mean age 47.4 years, 72.5% male, 60.5% injected past 3 months, 20.4% cirrhosis). Treatment completion was accomplished by 67 of 98 (68.4% [95% confidence interval {CI}: 58.2-77.4]) during intervention conditions and by 36 of 102 (35.3% [95% CI: 26.1-45.4]) during control conditions (risk difference 33.1% [95% CI: 20.0-46.2]; risk ratio 1.9 [95% CI: 1.4-2.6]). The intervention was superior in terms of treatment completion (adjusted odds ratio [aOR] 4.8 [95% CI: 1.8-12.8]; P = .002) and time to treatment initiation (adjusted hazard ratio [aHR] 4.0 [95% CI: 2.5-6.3]; P < .001). Sustained virologic response was documented in 60 of 98 (61.2% [95% CI: 50.8-70.9]) during intervention and in 66 of 102 (64.7% [95% CI: 54.6-73.9]) during control conditions.

CONCLUSIONS

An opportunistic test-and-treat approach to HCV infection was superior to standard of care among hospitalized PWID. The model of care should be considered for broader implementation. Clinical Trials Registration. NCT04220645.

A Virtual Hospital Model of Care for Low Back Pain, Back@Home: Protocol for a Hybrid Effectiveness-Implementation Type-I Study

BACKGROUND

Low back pain (LBP) was the fifth most common reason for an emergency department (ED) visit in 2020-2021 in Australia, with >145,000 presentations. A total of one-third of these patients were subsequently admitted to the hospital. The admitted patient care accounts for half of the total health care expenditure on LBP in Australia.

OBJECTIVE

The primary aim of the Back@Home study is to assess the effectiveness of a virtual hospital model of care to reduce the length of admission in people presenting to ED with musculoskeletal LBP. A secondary aim is to evaluate the acceptability and feasibility of the virtual hospital and our implementation strategy. We will also investigate rates of traditional hospital admission from the ED, representations and readmissions to the traditional hospital, demonstrate noninferiority of patient-reported outcomes, and assess cost-effectiveness of the new model.

METHODS

This is a hybrid effectiveness-implementation type-I study. To evaluate effectiveness, we plan to conduct an interrupted time-series study at 3 metropolitan hospitals in Sydney, New South Wales, Australia. Eligible patients will include those aged 16 years or older with a primary diagnosis of musculoskeletal LBP presenting to the ED. The implementation strategy includes clinician education using multimedia resources, staff champions, and an "audit and feedback" process. The implementation of "Back@Home" will be evaluated over 12 months and compared to a 48-month preimplementation period using monthly time-series trends in the average length of hospital stay as the primary outcome. We will construct a plot of the observed and expected lines of trend based on the preimplementation period. Linear segmented regression will identify changes in the level and slope of fitted lines, indicating immediate effects of the intervention, as well as effects over time. The data will be fully anonymized, with informed consent collected for patient-reported outcomes.

RESULTS

As of December 6, 2023, a total of 108 patients have been cared for through Back@Home. A total of 6 patients have completed semistructured interviews regarding their experience of virtual hospital care for nonserious back pain. All outcomes will be evaluated at 6 months (August 2023) and 12 months post implementation (February 2024).

CONCLUSIONS

This study will serve to inform ongoing care delivery and implementation strategies of a novel model of care. If found to be effective, it may be adopted by other health districts, adapting the model to their unique local contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50146.

Models of Care in Providing Comprehensive Healthcare on Cancer Survivors: A Scoping Review with a TIDieR Checklist Analysis

BACKGROUND

The study's aim is to identify the models of care used to provide survivorship care plans (SCPs) to cancer survivors in healthcare services, describing what kind of professionals are involved, in which settings and timings, and their feasibility.

METHODS

The Joanna Briggs Institute methodology for scoping reviews is followed. Studies that considered the SCPs applying different models of care, in any healthcare setting on any adult cancer survivors who completed oncological treatments, have been included. Pubmed, Embase, Cochrane Library, Scopus, and Cinahal were searched from 2013 to 2023 with these keywords: "Survivorship Care Plan", "Oncology", and "Program". The study selection process was reported with the PRISMA-ScR. A total of 325 records were identified, 42 were screened, and, ultimately, 23 articles were included.

RESULTS

The models of care include: SCP standardization in hospitals; self-support oriented; consultation-based; primary or specialist direct referral; shared care; a multimodal approach. Multidisciplinary teams were involved in the SCP models of care. The settings were private clinics or cancer centers. One-hour SCP interventions were most frequently delivered through in-person visits, by telephone, or online.

CONCLUSIONS

Implementing SCPs is feasible in healthcare contexts, but with challenges, like time and resource management. Patient-centered programs promoting coordinated care are promising models of care.

Physiotherapists' experiences of implementation of the BetterBack model of care for low back pain in primary care - a focus group interview study

INTRODUCTION

The BetterBack model of care (MoC), a best practice physiotherapy MoC for low back pain (LBP), was implemented in Swedish primary care to improve management of patients with LBP and provide patients with support tools to better self-manage episodes of LBP.

PURPOSE

The objective was to describe how physiotherapists in primary care experienced the implementation of the BetterBack MoC for LBP.

METHODS

Focus group interviews were conducted with physiotherapists in 2018-2019, 14-18 months after the introduction of the BetterBack MoC. Data were analyzed using qualitative content analysis.

RESULTS

Five focus group interviews with 23 (15 female and 8 male) physiotherapists, age range 24-61 years were analyzed. A supportive organization and adaptation to the local culture, combined with health care professionals' attitudes and collaboration between physiotherapists emerged as important factors for a successful implementation and for long-term sustainability of the MoC. Physiotherapists had differing opinions if the implementation led to change in clinical practice. Improved confidence in how to manage patients with LBP was expressed by physiotherapists.

CONCLUSIONS

Several barriers and facilitators influence the implementation of a best practice physiotherapy MoC for LBP in primary care, which need to be considered in future implementation and sustainability processes.

Dissemination of the Women-Centred HIV Care Model: A Multimodal Process and Evaluation

BACKGROUND

Using data from a national cohort study and focus groups, the Women-Centred HIV Care (WCHC) Model was developed to inform care delivery for women living with HIV.

METHODS

Through an evidence-based, integrated knowledge translation approach, we developed 2 toolkits based on the WCHC Model for service providers and women living with HIV in English and French (Canada's national languages). To disseminate, we distributed printed advertising materials, hosted 3 national webinars and conducted 2 virtual capacity-building training series.

RESULTS

A total of 315 individuals attended the webinars, and the average WCHC knowledge increased by 29% (SD 4.3%). In total, 131 service providers engaged in 22 virtual capacity-building training sessions with 21 clinical cases discussed. Learners self-reported increased confidence in 15/15 abilities, including the ability to provide WCHC. As of December 2023, the toolkits were downloaded 7766 times.

CONCLUSIONS

We successfully developed WCHC toolkits and shared them with diverse clinical and community audiences through various dissemination methods.

Treatable traits models of care

Treatable traits is a personalized approach to the management of respiratory disease. The approach involves a multidimensional assessment to understand the traits present in individual patients. Traits are phenotypic and endotypic characteristics that can be identified, are clinically relevant and can be successfully treated by therapy to improve clinical outcomes. Identification of traits is followed by individualized and targeted treatment to those traits. First proposed for the management of asthma and chronic obstructive pulmonary disease (COPD) the approach is recommended in many other areas of respiratory and now immunology medicine. Models of care for treatable traits have been proposed in different diseases and health care setting. In asthma and COPD traits are identified in three domains including pulmonary, extrapulmonary and behavioural/lifestyle/risk-factors. In bronchiectasis and interstitial lung disease, a fourth domain of aetiological traits has been proposed. As the core of treatable traits is personalized and individualized medicine; there are several key aspects to treatable traits models of care that should be considered in the delivery of care. These include person centredness, consideration of patients' values, needs and preferences, health literacy and engagement. We review the models of care that have been proposed and provide guidance on the engagement of patients in this approach to care.

Perspectives on chronic musculoskeletal pain management among healthcare professionals in Bhutan: A qualitative study

INTRODUCTION

Musculoskeletal pain disorders continue to be one of the leading causes of disability worldwide. Best practice care recommends patient-centred biopsychosocial models of care. Little is known about the chronic musculoskeletal pain management in low- and middle-income countries.

OBJECTIVES

To explore the management of chronic musculoskeletal pain by healthcare professionals in Bhutan.

METHODS

This study employed a qualitative design involving 19 Bhutanese healthcare professionals managing chronic musculoskeletal pain in Bhutan. We collected data using a semi-structured interview guide. Thematic analysis was done manually.

RESULTS

Healthcare professionals reported that patients rely on a combination of home remedies and seek help from local healers and hospitals for chronic musculoskeletal pain management. While healthcare professionals understand chronic musculoskeletal pain as multi-dimensional phenomenon, the primary focus was on identifying and treating structural anomalies. Time constraints, inadequate knowledge and skills, lack of confidence, facilities and expertise were reported as barriers to the effective management of chronic musculoskeletal pain. They proposed a need for clinical guidelines, relevant skills training and creating awareness of chronic musculoskeletal pain.

CONCLUSION

The management of chronic musculoskeletal pain in Bhutan is focused on identifying and treating physical abnormalities. Healthcare professionals consider psychosocial dimensions important but lack any form of actionable interventions in this domain.

Who cares for the carer? Codesigning a carer health and wellbeing clinic for older care partners of older people in Australia

INTRODUCTION

Older carers or 'care partners' of older people experiencing care needs often provide essential support, at times while neglecting their own health and well-being. This is an increasingly frequent scenario due to both demographic changes and policy shifts towards ageing in place. Multiple community stakeholders within the care and support ecosystem hold valuable expertise about the needs of older care partners, and the programme and policy responses that may better support their health and well-being. The aim of this study was to identify the perspectives of stakeholders obtained through the codesign phase of a multicomponent research project investigating new models of care and support for older care partners suitable for the Australian context.

METHODS

Principles of codesign were used to engage a purposeful sample of older care partners, health professionals, researchers, policy makers and health service administrators. Participants took part in a series of three codesign workshops conducted remotely via video conferencing. The workshops were supported with briefing material and generated consensus-based summaries, arriving at a preferred service model.

FINDINGS

This paper reports the research design and structure of the codesign panels, the range of findings identified as important to support the health and well-being of older carers of older people, and the resulting service model principles. The codesigned and preferred model of care is currently being prepared for implementation and evaluation in Australia.

PUBLIC CONTRIBUTION

This study was conducted using codesign methodology, whereby stakeholders including older care partners and others involved in supporting older carers, were integrally involved with design, development, results and conclusions.

Clinicians' Perspective on Implementing Virtual Hospital Care for Low Back Pain: Qualitative Study

BACKGROUND

Alternate "hospital avoidance" models of care are required to manage the increasing demand for acute inpatient beds. There is currently a knowledge gap regarding the perspectives of hospital clinicians on barriers and facilitators to a transition to virtual care for low back pain. We plan to implement a virtual hospital model of care called "Back@Home" and use qualitative interviews with stakeholders to develop and refine the model.

OBJECTIVE

We aim to explore clinicians' perspectives on a virtual hospital model of care for back pain (Back@Home) and identify barriers to and enablers of successful implementation of this model of care.

METHODS

We conducted semistructured interviews with 19 purposively sampled clinicians involved in the delivery of acute back pain care at 3 metropolitan hospitals. Interview data were analyzed using the Theoretical Domains Framework.

RESULTS

A total of 10 Theoretical Domains Framework domains were identified as important in understanding barriers and enablers to implementing virtual hospital care for musculoskeletal back pain. Key barriers to virtual hospital care included patient access to videoconferencing and reliable internet, language barriers, and difficulty building rapport. Barriers to avoiding admission included patient expectations, social isolation, comorbidities, and medicolegal concerns. Conversely, enablers of implementing a virtual hospital model of care included increased health care resource efficiency, clinician familiarity with telehealth, as well as a perceived reduction in overmedicalization and infection risk.

CONCLUSIONS

The successful implementation of Back@Home relies on key stakeholder buy-in. Addressing barriers to implementation and building on enablers is crucial to clinicians' adoption of this model of care. Based on clinicians' input, the Back@Home model of care will incorporate the loan of internet-enabled devices, health care interpreters, and written resources translated into community languages to facilitate more equitable access to care for marginalized groups.

What Is the Pathway to the Best Model of Care for Traumatic Spinal Cord Injury? Evidence-Based Guidance

Introduction

People with traumatic spinal cord injury (tSCI) experience lifelong physical and emotional health impacts, needing specialized care that is complex to navigate. The non-standardized care pathways used by different jurisdictions to address these needs lead to care inequities and poor health outcomes.

Purpose

To develop an evidence-based integrated tSCI Care Pathway, from time of injury to life in the community.

Methods and Analysis

Eighty key partners engaged in planning, providing, and receiving tSCI care (1) identified existing guidelines, pathways, and care models; (2) created the tSCI Care Pathway with key elements or building blocks ("the what"), not specific recommendations ("the how") for each care stage (Acute, Rehabilitation, and Community), with elements highlighting the role of primary care and equity considerations on the pathway; (3) identified regional gaps in the tSCI Pathway and prioritized them for implementation; and (4) developed quality indicators.

Outcomes

The tSCI Pathway was drafted in overarching and detailed formats. For Acute Care, building blocks focused on appropriate assessment, initial management, and transition planning; for Rehabilitation, building blocks focused on access to specialized rehabilitation and assessment and planning of community needs; for Community, building blocks focused on follow-up, mechanisms for re-access, and holistic support for persons and families; and for equity considerations, building blocks focused on those at-risk or requiring complex supports. Team-based primary care and navigation supports were seen as crucial to reduce inequities.

Conclusion

This is the first comprehensive care pathway for tSCI. The Pathway is grounded in person-centred care, integrated care and services, and up-to-date clinical practice guidelines. The tSCI Care Pathway is flexible to regional realities and individual needs to ensure equitable care for all.

Healthcare Professionals' Perspectives of Nonsurgical Care of Older Inpatients with Class II or III Obesity and Comorbidities: A Qualitative Study

Background

Older people with Class II or III obesity and comorbidities experience complex care needs with frequent hospital admissions. In 2019/20 the National Health Service in England reported a 17% increase in hospital admissions of patients with obesity compared to 2018/19. Gaps in care for this population have been identified.

Purpose

The purpose of this study was to understand the experiences and perspectives of healthcare professionals delivering non-surgical care to older people with Classes II or III obesity admitted to a tertiary care hospital.

Methods

Healthcare professionals delivering non-surgical care to older people admitted with Class II or III obesity with comorbidities were recruited from an Australian tertiary referral hospital. Qualitative semi-structured interviews were conducted with 24 healthcare professionals from seven disciplines between August and December 2019. The interviews were audio-recorded, transcribed, and reviewed by participants for accuracy. Thematic inductive data analysis was deductively mapped to the Theoretical Domains Framework (TDF).

Results

Four major themes of Barriers, Facilitators, Current Practice, and Recommendations and 11 subthemes were identified and mapped to nine domains in the TDF. The Barriers subtheme identified perceived patient related factors, health system issues, and provider issues, while the Facilitators subtheme included a patient centred approach, knowledge, and resources in the subacute setting. The major Current Practice theme explored factors influencing clinical management, and the Recommendations subthemes included engaging patients, access to quality care, education and support, and obesity as a chronic disease.

Conclusion

This novel application of the TDF provided broad insights related to the barriers and facilitators in delivering non-surgical care to this hospital population, from the perspective of healthcare professionals. Understanding how these barriers interact can provide strategies to influence behaviour change and assist in the development of a holistic multidisciplinary model of care.

Testing a Model of Care for Patients on Immune Checkpoint Inhibitors Based on Electronic Patient-Reported Outcomes: Protocol for a Randomized Phase II Controlled Trial

BACKGROUND

Management of severe symptomatic immune-related adverse events (IrAEs) related to immune checkpoint inhibitors (ICIs) can be facilitated by timely detection. As patients face a heterogeneous set of symptoms outside the clinical setting, remotely monitoring and assessing symptoms by using patient-reported outcomes (PROs) may result in shorter delays between symptom onset and clinician detection.

OBJECTIVE

We assess the effect of a model of care for remote patient monitoring and symptom management based on PRO data on the time to detection of symptomatic IrAEs from symptom onset. The secondary objectives are to assess its effects on the time between symptomatic IrAE detection and intervention, IrAE grade (severity), health-related quality of life, self-efficacy, and overall survival at 6 months.

METHODS

For this study, 198 patients with cancer receiving systemic treatment comprising ICIs exclusively will be recruited from 2 Swiss university hospitals. Patients are randomized (1:1) to a digital model of care (intervention) or usual care (control group). Patients are enrolled for 6 months, and they use an electronic app to complete weekly Functional Assessment of Cancer Therapy-General questionnaire and PROMIS (PROs Measurement Information System) Self-Efficacy to Manage Symptoms questionnaires. The intervention patient group completes a standard set of 37 items in a weekly PROs version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) questionnaire, and active symptoms are reassessed daily for the first 3 months by using a modified 24-hour recall period. Patients can add items from the full PRO-CTCAE item library to their questionnaire. Nurses call patients in the event of new or worsening symptoms and manage them by using a standardized triage algorithm based on the United Kingdom Oncology Nursing Society 24-hour triage tool. This algorithm provides guidance on deciding if patients should receive in-person care, if monitoring should be increased, or if self-management education should be reinforced.

RESULTS

The Institut Suisse de Recherche Expérimentale sur le Cancer Foundation and Kaiku Health Ltd funded this study. Active recruitment began since November 2021 and is projected to conclude in November 2023. Trial results are expected to be published in the first quarter of 2024 and will be disseminated through publications submitted at international scientific conferences.

CONCLUSIONS

This trial is among the first trials to use PRO data to directly influence routine care of patients treated with ICIs and addresses some limitations in previous studies. This trial collects a wider spectrum of self-reported symptom data daily. There are some methodological limitations brought by changes in evolving treatment standards for patients with cancer. This trial's results could entail further academic discussions on the challenges of diagnosing and managing symptoms associated with treatment remotely by providing further insights into the burden symptoms represent to patients and highlight the complexity of care procedures involved in managing symptomatic IrAEs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05530187; https://www.clinicaltrials.gov/study/NCT05530187.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48386.

Evaluating Feasibility of a Secondary Stroke Prevention Program

Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information (referrals, uptake, participant demographics and costs), and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre-post scores on standardized clinical tests (e.g., waist circumference and 6-Minute Walk (6MWT)). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for 'relevance' (100%), 'felt safe to exercise' (96%) and 'intend to continue' (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors (diet, exercise, smoking and alcohol). Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m, p < 0.001) and waist circumference (MD -2.1 cm, 95%CI -3.9 cm to -1.4 cm, p < 0.001). The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention.

Modeling the Health Economic Burden of Hepatitis C Virus Infection in Turkey: Cost-Effectiveness of Targeted Screening

BACKGROUND/AIMS

In 2016, World Health Organization introduced global goals to eliminate hepatitis C virus by 2030. The aim of this study is to analyze the epidemiologic and economic burden of hepatitis C virus in Turkey and compare current practice (regular care) with a hypothetical active screening and treatment approach (active scenario).

MATERIALS AND METHODS

A Markov model was used to analyze and compare regular care with a scenario developed by experts including the screening and treatment of all acute and chronic hepatitis C virus infections between 2020 and 2050. General and targeted populations were focused. The model reflected the natural history of the disease, and the inputs were based on a literature review and expert opinions. Costs were provided by previous studies and national regulations.

RESULTS

The active scenario resulted in higher spending for all groups compared with regular care in the first year. Cumulative costs were equalized in the 8th, 12th, 13th, and 16th year and followed by cost-savings of 49.7 million, 1.1 billion, 288.6 million, and 883.4 million Turkish liras in 20 years for prisoners, refugees, people who inject drugs (PWID), and all population, respectively. In all groups, the mortality was found to be lower with the active scenario. In total, 62.8% and 50.6% of expected deaths with regular care in 5 and 20 years, respectively, were prevented with the active scenario.

CONCLUSIONS

An active screening and treatment approach for hepatitis C virus infection could be cost-effective for PWID, prisoners, and refugees. Almost two-thirds of deaths in regular care could be prevented in 5 years' time with this approach.

Evaluation of RuralkidsGPS; A Novel Integrated Paediatric Care Coordination Model of Care in Rural Australia - a Mixed-Methods Study Protocol

Introduction

The Kids Guided Personalised Service (KidsGPS) is an integrated model of care coordination for children and young people (CYP) living with medical complexity. After successful implementation in an urban setting, the model of care will be rolled-out at scale to four rural regions in New South Wales, Australia to establish RuralKidsGPS. This paper describes the approach and methods for the outcome and implementation evaluation of RuralKidsGPS.

Description

The evaluation aims to assess health, economic and implementation outcomes and processes whilst identifying barriers and enablers to inform future rollouts. Measures of health service utilisation (primary outcome), child health related quality of life and parent/carer experiences will be assessed. The implementation evaluation will occur alongside the outcomes evaluation and is underpinned by the Consolidated Framework for Implementation Research and informed by validated quantitative measures and qualitative interviews with patients, families, healthcare providers and service managers. An economic analysis will determine incremental cost effectiveness ratios for the new model of care using health service utilisation data.

Conclusion

RuralKidsGPS, if effective, has the potential to improve equity of access to integrated care for CYP and their families and this protocol may inform other evaluations of similar models of care delivered at scale.

Integration of Telehealth in Routine Perinatal Care: A Model of Care for Primary Healthcare Clinics in Saudi Arabia

This study aims to introduce a new model of antenatal/postnatal care that integrates virtual clinics with the current model of care, including a discussion on the current model, pre-existing barriers, and prenatal framework, and the need for transition to telehealth beyond the pandemic. In antenatal primary health care centers, such as King Abdulaziz Medical City (KAMC), low-risk antenatal/postnatal care receives clinical care through complete physical attendance in antenatal/postnatal clinics in primary care clinics for pregnancy follow-up and in tertiary hospitals for fetal ultrasound and invasive procedures if needed. Pregnancy is confirmed through a regular family medicine (FM) clinic where risk assessment through history, physical examination, and investigations are carried out. If the pregnant woman is at low risk, she will be started on folic acid, 1 mg or 5 mg based on the risk assessment (if it was not received before). Pregnant women will be given a telehealth appointment for the lab results. Concomitantly, the pregnant women will receive an appointment in the antenatal clinics, which board-certified family physicians run. High-risk patients will be referred to the hospital for further care. Current postnatal care is delivered through regular booking with the FM clinic through physical attendance sometimes, and virtual care is provided upon physican/patient request. Current care meets the past quality care and patient expectations. However, with the current Saudi Vision 2030 and after the experience with virtual care during the COVID-19 pandemic, the current services need to move a step forward to meet the rapidly developing medical care/needs in Saudi Arabia. Various challenges must be addressed, and new models must be included in clinical care for pregnant and postnatal women. Introducing virtual antenatal/postnatal care to the current care could be a new era in maternity primary health care; this model will move the clinical care provided to pregnant/postnatal women a step forward that meets the excellence of high-quality, evidence-based medical care.

Embedding nurse-led supportive care in an outpatient service for patients with Chronic Obstructive Pulmonary Disease

AIM

To describe a small multidisciplinary team's experience of the process of embedding nurse-led supportive care into an existing Chronic Obstructive Pulmonary Disease outpatient service.

DESIGN

Case study methodology METHODS: Data were collected from multiple sources including key documents and semi-structured interviews with healthcare professionals (n = 6) conducted between June and July 2021. A purposive sampling strategy was used. Content analysis was applied to key documents. Interviews were transcribed verbatim and analysed using an inductive approach.

RESULTS

Subcategories under the four-stage process were identified from the data.

ASSESSMENT

evidence of needs of patients with Chronic Obstructive Pulmonary Disease; gaps in care and evidence of other models of supportive care. Planning: setting the supportive care service structure and intention; resources and funding; leadership, specialization and respiratory/palliative care roles.

IMPLEMENTATION

relationships and trust; embedding supportive care and communication.

EVALUATION

benefits and positive outcomes for staff and patients, and, improvements and future considerations for supportive care in the COPD service.

CONCLUSION

A collaboration between respiratory and palliative care services resulted in successfully embedding nurse-led supportive care in a small outpatient service for patients with Chronic Obstructive Pulmonary Disease. Nurses are well placed to lead new models of care that aim to address unmet biopsychosocial-spiritual needs of patients. More research is needed to evaluate nurse-led supportive care in Chronic Obstructive Pulmonary Disease and other chronic illness settings; the effectiveness of nurse-led supportive care from the perspective of patients and caregivers and the impact of nurse-led supportive care on health service usage.

PATIENT OR PUBLIC CONTRIBUTION

The development of the model of care is informed by ongoing discussions with patients with COPD and their caregivers. Data availability statement: Research data are not shared (due to ethical restrictions).

IMPACT

Embedding nurse-led supportive care in an existing Chronic Obstructive Pulmonary Disease outpatient service is achievable. Nurses with clinical expertise can lead innovative models of care that address the unmet biopsychosocial-spiritual needs of patients with conditions such as Chronic Obstructive Pulmonary Disease. Nurse-led supportive care may have utility and relevance in other chronic disease contexts.

Integrated Care for Type 1 Diabetes: The West Bengal Model

Introduction

A structured dedicated health programme for Type 1 diabetes mellitus (T1DM) has been initiated in the state of West Bengal, India.

Aim

The aim is to provide comprehensive healthcare to all children, adolescents and young adults living with T1DM, along with the provision of free supply of insulin, glucose measuring devices, blood glucose test strips, and other logistics. The strategic framework for programme implementation is to utilise the infrastructure and manpower of the already existing non-communicable disease (NCD) clinic under National Health Mission.

Methodology

Establishing dedicated T1DM clinics in each district hospital by utilising existing healthcare delivery systems, intensive training and hand-holding of named human resources; providing comprehensive healthcare service and structured diabetes education to all T1DM patients; and building an electronic registry of patients are important components of the programme. T1DM clinics run once a week on the same day throughout the state. All T1DM patients are treated with the correct dose of insulin, both human regular insulin and glargine insulin. Patients are routinely monitored monthly to ensure good glycaemic control and prevent complications of the disease. Routine anthropometric examination and required laboratory investigations are conducted in the set-up of the already existing NCD clinic. Ongoing monitoring and evaluation of the T1DM programme are being conducted in terms of glycated haemoglobin (HbA1c) values, growth and development, complication rates, psychological well-being, quality of life, and direct and indirect expenditure incurred by families. Through this programme, any bottlenecks or gaps in service delivery will be identified and corrective measures will be adopted to ensure better health outcomes for those living with T1DM.

Evidence-based models of rural palliative care: A systematic review

BACKGROUND

Forty-five percent of the world's population lives in rural areas, yet their access to palliative care is quite limited. Identifying the care elements rural populations with palliative care needs require is critical to improving care outcomes.

AIM

To identify the key care elements that optimise palliative care for people in rural communities.

DESIGN AND DATA SOURCES

A systematic review of articles studying the impact of novel rural model of care interventions was undertaken in May 2022. This study is reported using the PRISMA Statement and was registered with Prospero (CRD42020154273). Three databases were searched, and the data analysed according to Popay's narrative synthesis, and elements classified using the WHO Innovative Care for Chronic Conditions (ICCC) Framework.

RESULTS

Of the 9508 identified papers, 15 met the inclusion criteria, reporting on 14 studies involving 1820 rural patients. Care received spanned 12/18 of the WHO ICCC Framework elements, with wide variability in how these elements were operationalised. The five elements that signal improved outcomes were: (1) Promote continuity and coordination; (2) Prepared, informed and motivated health care teams; (3) Prepared, informed and motivated patients and families; (4) Organise and equip health care teams and (5) Promote consistent financing.

CONCLUSIONS

A well-coordinated multidisciplinary team approach, led by clinicians with specialist palliative care expertise, integrated across local health care settings, using information systems and care planning, is critical to optimising rural palliative care patient outcomes. Rural patients and their families require timely input from specialist palliative care clinicians and information to address their needs.Prospero registration ID: CRD42020154273 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=154273.

Current status of and future perspectives on care for cancer survivors in China

Cancer is currently a major public health issue faced by countries around the world. With the progress of medical science and technology, the survival rate of cancer patients has increased significantly and the survival time has been effectively prolonged. How to provide quality and efficient care for the increasingly large group of cancer survivors with limited medical resources will be a key concern in the field of global public health in the future. Compared to developed countries, China's theoretical research and practical experience in care for cancer survivors are relatively limited and cannot meet the multi-faceted and diverse care needs of cancer patients. Based on the existing models of care worldwide, the current work reviews care for cancer survivors in China, it proposes considerations and suggestions for the creation of models of cancer care with Chinese characteristics in terms of optimizing top-level system design, enhancing institutional mechanisms, accelerating human resource development, and enhancing self-management and social support for patients.

Socioeconomic status and diabetes technology use in youth with type 1 diabetes: a comparison of two funding models

Background

Technology use, including continuous glucose monitoring (CGM) and insulin pump therapy, is associated with improved outcomes in youth with type 1 diabetes (T1D). In 2017 CGM was universally funded for youth with T1D in Australia. In contrast, pump access is primarily accessed through private health insurance, self-funding or philanthropy. The study aim was to investigate the use of diabetes technology across different socioeconomic groups in Australian youth with T1D, in the setting of two contrasting funding models.

Methods

A cross-sectional evaluation of 4957 youth with T1D aged <18 years in the national registry was performed to determine technology use. The Index of Relative Socio-Economic Disadvantage (IRSD) derived from Australian census data is an area-based measure of socioeconomic status (SES). Lower quintiles represent greater disadvantage. IRSD based on most recent postcode of residence was used as a marker of SES. A multivariable generalised linear model adjusting for age, diabetes duration, sex, remoteness classification, and location within Australia was used to determine the association between SES and device use.

Results

CGM use was lower in IRSD quintile 1 in comparison to quintiles 2 to 5 (p<0.001) where uptake across the quintiles was similar. A higher percentage of pump use was observed in the least disadvantaged IRSD quintiles. Compared to the most disadvantaged quintile 1, pump use progressively increased by 16% (95% CI: 4% to 31%) in quintile 2, 19% (6% to 33%) in quintile 3, 35% (21% to 50%) in quintile 4 and 51% (36% to 67%) in the least disadvantaged quintile 5.

Conclusion

In this large national dataset, use of diabetes technologies was found to differ across socioeconomic groups. For nationally subsidised CGM, use was similar across socioeconomic groups with the exception of the most disadvantaged quintile, an important finding requiring further investigation into barriers to CGM use within a nationally subsidised model. User pays funding models for pump therapy result in lower use with socioeconomic disadvantage, highlighting inequities in this funding approach. For the full benefits of diabetes technology to be realised, equitable access to pump therapy needs to be a health policy priority.

Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis

BACKGROUND

Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery.

OBJECTIVE

Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture.

METHODS

Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis.

RESULTS

Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements.

CONCLUSIONS

Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

A Novel and Integrated Digitally Supported System of Care for Depression and Anxiety: Findings From an Open Trial

BACKGROUND

The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely.

OBJECTIVE

This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students.

METHODS

US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness.

RESULTS

Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated.

CONCLUSIONS

STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described.

A systematic review of models of care for polycystic ovary syndrome highlights the gap in the literature, especially in developing countries

Introduction

The aim of the study was to identify available polycystic ovary syndrome (PCOS) models of care (MoCs) and describe their characteristics and alignment with the international PCOS guideline.

Methods

Ovid MEDLINE, All EBM, PsycINFO, Embase, and CINAHL were searched from inception until 11 July 2022. Any study with a description of a PCOS MoC was included. Non-evidence-based guidelines, abstracts, study protocols, and clinical trial registrations were excluded. We also excluded MoCs delivered in research settings to minimize care bias. Meta-analysis was not performed due to heterogeneity across MoCs. We describe and evaluate each MoC based on the recommendations made by the international evidence-based guideline for assessing and managing PCOS.

Results

Of 3,671 articles, six articles describing five MoCs were included in our systematic review. All MoCs described a multidisciplinary approach, including an endocrinologist, dietitian, gynecologist, psychologist, dermatologist, etc. Three MoCs described all aspects of PCOS care aligned with the international guideline recommendations. These include providing education on long-term risks, lifestyle interventions, screening and management of emotional well-being, cardiometabolic diseases, and the dermatological and reproductive elements of PCOS. Three MoCs evaluated patients' and healthcare professionals' satisfaction, with generally positive findings. Only one MoC explored the impact of their service on patients' health outcomes and showed improvement in BMI.

Conclusion

There is limited literature describing PCOS MoCs in routine practice. Future research should explore developing cost-effective co-created multidisciplinary PCOS MoCs globally. This may be facilitated by the exchange of best practices between institutions with an established MoC and those who are interested in setting one up.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346539, identifier CRD42022346539.

Feasibility of a prospective physiotherapy model of care during the intense treatment phase of childhood cancer (FITChild): A mixed methods design

BACKGROUND

Children diagnosed with cancer often develop significant physical treatment-related side effects. This study evaluated the feasibility of a targeted, proactive, individualised physiotherapy intervention programme for children with a recent cancer diagnosis.

PROCEDURE

This feasibility study was a single-group mixed methods study, consisting of pre- and post-intervention assessment, followed by a survey and interviews of parents. Participants were children and adolescents with a new cancer diagnosis. The physiotherapy model of care consisted of education, surveillance, standardised assessment, individually tailored exercise and a fitness tracker.

RESULTS

All participants (n = 14) completed over 75% of the supervised exercise sessions. No safety or adverse events occurred. Over the 8-week intervention period, an average of 7.5 supervised sessions were completed per participant. The overall experience provided by the physiotherapist service was rated as excellent by 86% (n = 12) and very good by 14% (n = 2) of parents. All parents surveyed (n = 14) rated the level of support provided by the physiotherapy service as excellent, and all participants completed the standardised assessments pre- and post-exercise intervention. There was a significant improvement in 6MWD from 240 m (SD 193 m) compared to 355 m (SD 115 m) (p = .015), as well as improvements in the Physical Function domain (p = .013) and combined Psychosocial and Physical Function domains (p = .030).

CONCLUSIONS

A prospective structured and targeted physiotherapy model of care appears feasible for use with children and families in the acute phase of cancer treatment. The regular screening was acceptable and may have helped build a strong rapport between the physiotherapist and the families.

Towards a Dignified Death: A New Approach to Care for People Using Substances Who Are at, or Near, the End of Their Lives

There are no effective intervention studies for people using substances who are at, or near, the end of their lives. The needs of this group of people have been consistently overlooked even within the literature that identifies marginalised groups of people in need of greater recognition in palliative and end-of-life care. The aims of the project were to: (i) determine what a new, co-produced, model of care should look like for people using substances needing palliative and end-of-life care, and (ii) establish whether the new model had the potential to improve people's access to, and experience of, end-of-life care. This paper presents the development of the new approach to care. It was developed using participatory action research principles over a course of online workshops during the COVID-19 pandemic lockdown period in the UK. A theory of change that aims to inform future policy and practice development is presented. While the ambition of the research was stunted by the pandemic, the process of its development and dissemination of the model and its resources has continued. Response from participants highlighted the importance of this work, however, in this new field of policy and practice, preparatory work that engages a wide range of stakeholders is crucial to its success. This relationship building and topic engagement are major parts of implementation before more substantial and sustainable development goals can be met.

Models of care for people with dementia approaching end of life: A rapid review

BACKGROUND

People with dementia have different care and support needs at their end of life compared to people with other life-limiting illnesses, and general palliative care models may not meet the needs of people with dementia and their carers and families. Some dementia-specific end-of-life care models have been implemented, and a summary of existing models was undertaken to inform development of a local model.

AIM

To identify best-practice models of care for people in the advanced and end stages of dementia, and their families and carers.

DESIGN

A rapid review with narrative summary of peer-reviewed articles and grey literature was conducted.

DATA SOURCES

Ten databases were searched for articles published between January 2000 and April 2022. Inclusion criteria were: all care settings; AND the model focuses on people with end-stage or advanced dementia; AND contained multiple components.

RESULTS

Nineteen articles or reports, describing twelve dementia-specific models of end-of-life care in a range of care settings were identified for inclusion in the review. There is strong evidence that the principles of best practice palliative care for people with advanced dementia are well known, but limited examples of translation of this knowledge into integrated models of care. The key issues that emerged from the findings were: referral and admission to care, integration of care, sustainability and evaluation.

CONCLUSIONS

Findings can be used to inform development of improved end-of-life care pathways for people with dementia, but well-designed research studies are needed to evaluate the effectiveness of integrated models of care for this vulnerable population.

Articulating an ontologically situated, intergenerational model of care

OBJECTIVE

To articulate how Aboriginal community-controlled art centres support the role of Elders and older people within an ontologically situated, intergenerational model of care.

METHODS

In this paper, we draw on stories (data) generated through interviews involving 75 people associated with three Aboriginal community-controlled art centres and field notes taken during a Participatory Action Research (PAR) study. The study was undertaken in collaboration with three community-controlled art centres and two aged care providers over almost 4 years, in diverse Indigenous sovereignties, all located in geographically remote Australian locations.

RESULTS

Engaging with decolonising and Indigenous theoretical frameworks, our analysis identified three interwoven meta-themes. These include connection to law and culture; purpose; and healing. Each theme had important subthemes, and all were central to upholding the well-being of older people and their families, as well as the art centre workforce, Country, and their broader communities.

CONCLUSIONS

Our analysis articulates an ontologically situated model of care within Aboriginal community-controlled art centres. The model sees that older people receive care from art centres and provide care to each other, to younger generations, to art centre staff, to Country, and to their broader communities. In this model, those in receipt of care, many of whom are older people, art centre directors, and important artists, govern how care is conceptualised and delivered.

Stemming the tide of mental health problems in young people: Challenges and potential solutions

One in five people experience clinically relevant mental health problems before the age of 25 years. Furthermore, in Australia, one in seven children are reported to experience a mental health disorder. Consequently, there has been a steady increase in demand for mental health services for children and young people, and this has been compounded by the COVID-19 pandemic. Unfortunately, currently many children and young people with mental health difficulties are not accessing appropriate and/or timely care, with individuals and families finding it increasingly difficult to access and navigate suitable services. In part, this is related to the fragmented and isolated manner in which child mental health services are operating. To address the current issues in access to appropriate child and adolescent mental health care in Australia, a novel Integrated Continuum of Connect and Care model is proposed to integrate relevant services along a tiered care pathway. The aim of this model is to facilitate timely access to mental health services that meet the specific needs of each child/young person and their family. This model will function within co-located service hubs that integrate health care through a comprehensive assessment followed by a link up to relevant services. The Integrated Continuum of Connect and Care has the potential to pave the way for unifying the fragmented child and youth mental health system in Australia.

Rheumatic heart disease in pregnancy: Maternal and neonatal outcomes in the Top End of Australia

BACKGROUND

Women with rheumatic heart disease (RHD) can have a lower cardiac reserve to cope with pregnancy and labour, leading to increased obstetric and cardiac risks. The Northern Territory has been repeatedly reported to have the highest prevalence of RHD in Australia, yet evidence specific to pregnancy is scarce in the literature.

AIMS

The primary aim of this paper is to describe the baseline characteristics and maternal outcomes of pregnant women with RHD presenting to the largest obstetrics referral hospital in the Northern Territory. The secondary aim is to evaluate the current model of care in relation to their cardiac status.

METHODS

A retrospective observational study was conducted over a 9.5-year period. Demographics, cardiac, obstetrics and anaesthetics data were collected for analysis.

RESULTS

One hundred and twenty-nine pregnancies were included for analysis. All women were identified as Aboriginal or Torres Strait Islander, and 85% were of a RHD priority of 2 or 3. Of all 28 patients who had an emergency caesarean section, only one patient was indicated for cardiac reasons. There was no maternal or neonatal death reported. Three preterm births were induced secondary to maternal concerns related to RHD cardiac decompensation. There were no major adverse neonatal outcomes, including neonatal death, intraventricular haemorrhage or respiratory distress syndrome. Multidisciplinary care was also evaluated.

CONCLUSION

We observed a low rate of maternal and fetal morbidity and no mortality in a cohort of women with mild to severe RHD. These favourable outcomes have occurred in a multidisciplinary centre with significant experience in managing the medical and cultural complexities of this group.

A descriptive study of the clinical impacts on COVID-19 survivors using telemonitoring (The TeleCOVID Study)

Background

There is increasing evidence that COVID-19 survivors are at increased risk of experiencing a wide range of cardiovascular complications post infection; however, there are no validated models or clear guidelines for remotely monitoring the cardiac health of COVID-19 survivors.

Objective

This study aims to test a virtual, in-home healthcare monitoring model of care for detection of clinical symptoms and impacts on COVID-19 survivors. It also aims to demonstrate system usability and feasibility.

Methods

This open label, prospective, descriptive study was conducted in South Western Sydney. Included in the study were patients admitted to the hospital with the diagnosis of COVID-19 between June 2021 and November 2021. Eligible participants after consent were provided with a pulse oximeter to measure oxygen saturation and a S-Patch EX to monitor their electrocardiogram (ECG) for a duration of 3 months. Data was transmitted in real-time to a mobile phone via Bluetooth technology and results were sent to the study team via a cloud-based platform. All the data was reviewed in a timely manner by the investigator team, for post COVID-19 related symptoms, such as reduction in oxygen saturation and arrhythmia.

Outcome measure

This study was designed for feasibility in real clinical setting implementation, enabling the study team to develop and utilise a virtual, in-home healthcare monitoring model of care to detect post COVID-19 clinical symptoms and impacts on COVID-19 survivors.

Results

During the study period, 23 patients provided consent for participation. Out of which 19 patients commenced monitoring. Sixteen patients with 81 (73.6%) valid tests were included in the analysis and amongst them seven patients were detected by artificial intelligence to have cardiac arrhythmias but not clinically symptomatic. The patients with arrhythmias had a higher occurrence of supraventricular ectopy, and most of them took at least 2 tests before detection. Notably, patients with arrhythmia had significantly more tests than those without [t-test, t (13) = 2.29, p < 0.05].

Conclusions

Preliminary observations have identified cardiac arrhythmias on prolonged cardiac monitoring in 7 out of the first 16 participants who completed their 3 months follow-up. This has allowed early escalation to their treating doctors for further investigations and early interventions.

Cardiovascular Nursing Workforce Challenges: Transforming the Model of Care for the Future

The complexities of acute and critical care cardiovascular management demand specialty trained and experienced nurses to ensure quality patient outcomes. An ongoing nurse labor shortage threatens to destabilize the healthcare system and presents a twofold challenge: a decreasing supply of registered nurses and increasing demand for nursing services. This article describes the numerous forces driving the current nursing shortage as well as the impact of the coronavirus-19 pandemic on nurse job satisfaction and turnover. We present a reinvented model of nursing care as a framework for healthcare organizations to address nurse staffing challenges.

The challenge of dealing with non-AIDS comorbidities for people living with HIV: Perspectives and experiences of patients and healthcare providers

As the cohort of People Living with HIV (PLHIV) ages, so does the spectrum and burden of non-AIDS define HIV-associated conditions (NARC). PLHIV are likely to need different and increased healthcare services. It requires health systems to adapt to this disease trend and conform to a chronic care model, which respects the distinct needs of the ageing population. In this article, we explore the lived experiences of PLHIV and their healthcare providers in managing the challenges of dealing with NARC in Arba Minch, Southern Ethiopia. This study utilises interpretative substantive methods, encompassing qualitative interviews and Focus Group Discussions. The Normalisation Practice Theory (NPT) guided the semi-structured questions concerning routine screenings and current models of HIV care for ageing individuals. The main structural challenges in providing adequate geriatric care included: (i) the lack of awareness of the risk of NARCs; (ii) the absence of blended care; (iii) an HIV-centred approach exclusive of multidisciplinary care; and (iv) financial constraints. In an era with increasing NARCs, traditional HIV care models must adapt to the emerging challenges of a 'greying' and growing population.

Identifying Primary Care Models of Dementia Care that Improve Quality of Life for People Living with Dementia and their Care Partners: An Environmental Scan

Dementia is a growing concern in Canada, affecting peoples' health and raising the cost of care. Between June and October 2019, we conducted an environmental scan to identify primary care models, strategies, and resources for dementia care from 11 pre-selected countries and assess their impact on quality-of-life measures. Search strategies included a rapid scoping review, grey literature search, and discussions with stakeholders. Eighteen primary care-based models of dementia care were identified. Common factors include team-based care, centralized care/case coordination, individual treatment plans, a stepped-care approach, and support for care partners. Five provinces had released a dementia strategy. Evidence of positive outcomes supported primary care-based models for dementia care, although only one model demonstrated evidence of impact on quality of life. Although these findings are encouraging, further research is needed to identify primary care-based models of dementia care that demonstrably improve quality of life for people living with dementia and their care partners.

Effecting change and improving practice in a regional Emergency Department: A Mental Health Nurse Practitioner's perspective

Providing appropriate, timely intervention and care to people who present with mental health issues to an Emergency Department presents unique ongoing challenges, often affecting patient experiences and outcomes. To address such concerns, a Mental Health Liaison Nurse role, led by a Mental Health Nurse Practitioner, was introduced to a regional Emergency Department. This role provided integrated emergency-based mental health clinical practice, with positive findings reported in a recently published multi-site translational research project. With sound quantitative and qualitative evidence detailing the benefits of this role, the experiential perspective from a clinician working in this frontline space further confirms the importance of having access to such a position in leading cultural and systemic change. This discussion article identifies key processes that align current research with the clinical perspective. Such processes recognize the challenges of implementing a new role and moving forward from these to embed consistent clinical practices. The need to build sound internal and external stakeholder partnerships, effect change implementation, and assign recommendations to ensure sustainability of improved practice and processes are highlighted in this paper. This article is, therefore, designed to assist other advanced practice nurses, who may be embarking on a similar journey and want to influence organizational policy and practice.

Optimizing Access to the COVID-19 Vaccination for People Experiencing Homelessness

The success of the Australian COVID-19 vaccination strategy rested on access to primary healthcare. People experiencing or at risk of homelessness are less likely to access primary healthcare services. Therefore, leaders in homeless health service delivery in Sydney identified the need to develop a vaccine hub specifically for this vulnerable population. The aim of this study was to develop an evidenced based model of care to underpin the Vaccine Hub and optimize access to vaccination for people experiencing or at risk of homelessness. A mixed methods study was conducted that included interviews with key stakeholders involved in establishing and delivering the Inner City COVID-19 Vaccine Hub, and a survey with people receiving COVID-19 vaccination. Over the 6-month period of this study, 4305 COVID-19 vaccinations were administered. Participants receiving vaccination reported feeling safe in the Vaccine Hub and would recommend it to others. Stakeholders paid tribute to the collective teamwork of the Vaccine Hub, the collaboration between services, the 'no wrong door' approach to increasing access and the joy of being able to support such a vulnerable population in challenging times. The study findings have been populated into a Vaccination Hub Blueprint document that can be used as a template for others to improve access to vaccinations for vulnerable populations.

Foodservice systems and mealtime models in rehabilitation: Scoping review

AIMS

To describe current foodservice systems and mealtime care utilized in the rehabilitation setting. A secondary aim was to identify commonly used outcome measures in foodservice research in the rehabilitation setting.

DESIGN

A scoping review.

DATA SOURCES

PubMed, CINAHL, Scopus, Embase, PsycINFO and Cochrane were searched until January 2022.

REVIEW METHODS

The review was conducted according to Joanna Briggs Institute's methodology for scoping reviews. Included studies were conducted in the inpatient rehabilitation setting, adult population ≥18 years old and provided a description of at least one element of the foodservice system, food and menu, waste and/or eating environment.

RESULTS

Of 5882 articles screened, 37 articles were included, reporting 31 unique studies. Most rehabilitation units had cook-fresh production methods (50%), used decentralized bulk delivery methods (67%) had a communal dining room (67%) and had a 3-week menu cycle (71%). Mealtime care was predominantly provided by nursing staff, however few studies reported on specific activities. Nutritional intake was a key outcome measure across included studies (43%), with only six papers reporting on rehabilitation outcomes. Of the intervention studies (n = 9), all were aimed at improving nutritional intake through menu or mealtime care modifications; few (n = 3) studied changes in rehabilitation outcomes.

CONCLUSION

This scoping review identified a considerable lack of reporting of foodservice and mealtime care systems used in rehabilitation settings in the available literature. Further investigation is required to understand what models of mealtime care are provided to patients and to understand the impact of changes to foodservice and mealtime systems on patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was necessary for this review.

Why are women deciding against birth in alongside midwifery units? A prospective single-center study from Germany

OBJECTIVES

For healthy women entering labor after an uneventful pregnancy, advantages of birth in midwife-led models of care have been demonstrated. We aimed to study the level of awareness regarding care in alongside midwifery units (AMU), factors involved in the decision for birth in obstetrician-led units (OLU), and wishes for care and concerns about birth in women registering for birth in OLU who would have been eligible for care in AMU.

METHODS

Healthy women with a term singleton cephalic fetus after an uneventful pregnancy course booking for birth in OLU were prospectively recruited. Data were collected by questionnaire.

RESULTS

In total, 324 questionnaires were analyzed. One quarter (23.1%) of participants never had heard of care in AMU. Two thirds (64.2%) of women had made their choice regarding model of care before entering late pregnancy; only 16.4% indicated that health professionals had the biggest impact on their decision. One-to-one care and the availability of a pediatrician were most commonly quoted wishes (30.8 and 34.0%, respectively), and the occurrence of an adverse maternal or perinatal event the greatest concern (69.5%).

CONCLUSIONS

Although the majority of respondents had some knowledge about care in AMU, expressed wishes for birth matching core features of AMU and concerns matching those of OLU, a decision for birth in OLU was taken. This finding may be a result of lack of knowledge about details of care in AMU; additionally, wishes and concerns may be put aside in favor of other criteria.

A comparative cohort study of gastrointestinal oncology patients: Impact of a shift to telehealth on delivery of interprofessional cancer care

Early studies of oncology visits performed via telehealth demonstrate patient and provider satisfaction; however, understanding of the impact of telehealth on clinic workflows is limited. The incorporation of telehealth visits into an interprofessional model of oncology care was evaluated to assess for changes in care delivery and patient engagement. New patients with a gastrointestinal cancer diagnosis who were actively undergoing treatment and followed for at least three months were divided into two cohorts based on telehealth utilization. Individual patient charts were reviewed by touchpoint, consisting of in-person visits, telehealth visits, phone calls, and patient portal messages. A total of 28 patient charts were analyzed, 11 pre-telehealth conventional care patients, and 17 telehealth patients. Telehealth cohort patients demonstrated an increased average number of total touchpoints when compared to the pre-telehealth cohort (p-value = 0.008) and had an increased number of patient portal and phone call touchpoints (p-value = 0.00 and  0.002). Telehealth provided more interactions between patients and providers demonstrating increased connectivity between a patient and their care team throughout their complex cancer journey. Clinic workflows may need to adjust to account for the increased demand of unscheduled patient interactions.

Childhood Cancer Survivors' Adherence to Healthcare Recommendations Made Through a Distance-Delivered Survivorship Program

Purpose

Ongoing survivorship care allows childhood cancer survivors the opportunity to address treatment-related health problems and improve their quality of life. However, many survivors do not adhere to their healthcare professionals’ recommendations and the factors supporting their adherence remain unclear.

Patients and Methods

Long-term childhood cancer survivors completed the “Re-engage” program, which assessed survivors’ heath needs and provided individualised recommendations for health interventions and surveillance developed by an expert multi-disciplinary team (MDT). We measured survivors’ recall of, and adherence to, their individualised healthcare recommendations at one and six months post-intervention. We conducted a series of univariate negative binomial regressions to investigate factors associated with the total number of recommendations that were correctly recalled and adhered to.

Results

We analysed the data of 25 childhood cancer survivors who participated in Re-engage (mean age = 31.9 years). On average, survivors were provided with 6.6 recommendations (range = 1–11). Survivors accurately recalled receiving 3.0 recommendations at one month post-intervention and 1.9 at six months. Survivors had adhered to an average of 1.3 recommendations by six-month follow-up. In total, 56% of participants reported that they did not adhere to any recommendations. By six-month follow-up, greater adherence to MDT recommendations was associated with having a history of a second cancer (B = 1.391; 95% confidence interval [CI], 0.686 to 2.097; p < 0.001) and reporting a greater level of worry about late effects (B = 1.381; 95% CI, 0.494 to 2.269; p = 0.002).

Conclusion

Survivors reported sub-optimal levels of adherence and demonstrated limited recall of their healthcare recommendations. Effective communication of recommendations and clear discussion of barriers limiting adherence, coupled with late effects education, may be critical to ensure that survivors engage with their recommendations, to improve their quality of life and health outcomes.

Trial Registration Number

ACTRN12618000194268.

Uncovering the Model and Philosophy of Care of a Psychiatric Inpatient Mother-Baby Unit in a Qualitative Study with Staff

The postnatal period is high-risk time for the first onset and recurrence of maternal mental health disorders. Untreated maternal mental illness can have significant adverse impacts on a woman, her baby, and the wider family unit. For women with mental illnesses that cannot be managed in the community, psychiatric inpatient mother-baby units are the gold standard treatment whereby mothers are co-admitted with their infant for specialist perinatal and infant mental health assessment and treatment. The study explores the model of care and examines the philosophies of care that are used within a psychiatric mother-baby unit. Purposive sampling was used to conduct semi-structured focus group and individual interviews with multidisciplinary staff members at a single mother-baby unit. Themes derived from these interviews were coded into two primary themes and a range of sub-themes. The first primary theme focused on the Model of Care consisting of the following sub-themes: mental health care, physical health care, babies' care, building mother-baby relationship, fostering relationships with supports, and facilitating community support. The second primary theme centered around the Philosophy of Care comprising of: person-centered care, trauma-informed care, compassion-centered care, recovery-oriented care, attachment-informed care, non-judgmental care, strengths-based care and interdisciplinary care. The model can be used to provide consistency across mother-baby units and to support core capabilities of staff in providing an optimal level of care.

A Novel Multidisciplinary Model of Care for Transgender and Gender Diverse Adults: Program Description and Patient Perspectives

Transgender and gender diverse (TGD) adults face significant health care disparities stemming from systematic discrimination and stigma in health care. We created the UCHealth Integrated Transgender Program to provide culturally responsive and clinically competent care to TGD adults in Colorado. This article outlines the clinic model and summarizes results from a qualitative patient survey to assess patients' impressions and recommendations for improvement. A multidisciplinary integrated clinic is a feasible and desired step toward improving health care for the TGD population.

Exploring Models of Care and the Perceived Impact in an Offender Rehabilitation Program

Offender rehabilitation programs incorporating positive psychology interventions such as a strengths-based model can be effective. This study explores the perceived model of service provided by an offender rehabilitation service and the perceived impact that this service has on the lives of its clients. A qualitative methodology was employed in the context of an action research design, using semi-structured interviews with key stakeholders. The data were analyzed using thematic analysis which is an independent and reliable approach to qualitative analysis. The findings suggest that participants perceive the organization to be operating a strengths-based approach and this is perceived as having the potential to have a range of positive effects for clients. Some contrasting views were also identified within the participant groups and these are discussed in this paper. The results of this study complement the existing research and have several implications for future research in this area.

Post-COVID Care Center to Address Rehabilitation Needs in COVID-19 Survivors: A Model of Care

The severe acute respiratory syndrome coronavirus 2019 pandemic surge left a large cohort of patients vulnerable to cardiopulmonary, neurological, and psychiatric complications. This post-COVID Care center was established to identify patients with disease sequalae and deliver early multidisciplinary rehabilitation services. The evaluation included comprehensive history and physicals, screening tests, labs, and imaging to determine appropriate specialist referrals. After a 6-month period, 278 unique referrals were made to address symptoms reported by 114 patients in specialities including pulmonology, cardiology, and psychiatry. This framework allowed for individualized patient treatment and monitoring of disease after the acute phase of infection. This study highlights the substantial physical and psychosocial impact a coronavirus disease 2019 infection has on patients' long-term trajectory and emphasizes the need for early targeted rehabilitation Post-COVID Care centers. As the world transitions into the chronic phase of this pandemic, this model of care will provide a framework to improve the quality of health care delivery.

Exploring patient centredness, communication and shared decision-making under a new model of care: Community rehabilitation in canada

Patient-centred care and patient engagement in healthcare and health research are widely mandated by funders, health systems and institutions. Increasingly, shared decision-making (SDM) is recognised as promoting patient-centred care. We explore this relationship by studying SDM in the context of integrating novel patient-centred policies in community rehabilitation. There is little research on SDM in rehabilitation, and less so in the critical community context. Patient co-investigators led study co-design. We aimed to describe how patients and providers experience SDM at community rehabilitation sites that adopted a novel, patient-centred Rehabilitation Model of Care (RMoC). Guided by focused ethnography, we conducted focus groups and interviews. Patient and professional participants were recruited from 10 RMoC early-adopter community rehabilitation sites. Sites varied in geography, patient population and provider disciplines. Patient and community engagement researchers used a set-collect-reflect method to document patient perspectives. Researchers captured provider perspectives using a semi-structured question guide. We completed 11 focus groups and 18 interviews (n = 45 providers, n = 17 patients). We found that most early-adopter providers spoke in a shared, patient-first language that focused on patient readiness, barriers and active listening. Congruent patient perceptions reflected inclusion in decision-making, goal setting and positive relationships. Many patients queried how care would become and remain accessible before and after community rehabilitation care respectively. Remaining connected while in the community was described as important to patients. Providers identified barriers like time, team dynamics and lack of clarity on the RMoC aims, which challenged the initiative's long-term sustainability. Policy innovations can promote SDM and communication through multiple strategies and training to facilitate candid, encouraging conversations. Sustainability of SDM gains is paramount. Most providers moved beyond tokenistic engagement, but competing responsibilities and team member resistance could thwart continuity. Further research is needed to empirically assess respectful and compassionate communication and SDM in community rehabilitation long term.