Alternative Delivery Models Research Articles

Deliverology in Community Economic Development: Enhancing Results Frameworks and Performance Measurement

<p> </p><p><span> </span>This paper will assess the viability of implementing an alternative delivery model and performance measurement framework – commonly known as ‘deliverology’ – at the level of community economic development. First, a review of relevant literature on traditional economic development delivery models and performance metrics is conducted to determine strengths and weaknesses. Next, a deliverology approach is defined and analyzed to determine whether such a model can address the weaknesses of more traditional approaches. The results indicate that a deliverology approach has many potential advantages for economic development service delivery and addresses many of the weaknesses of current models and frameworks. Since deliverology remains rather new compared to more traditional approaches, further research in terms of a case study in a large urban municipality is recommended as a way to test the applicability of deliverology to community economic development. </p><p><strong>Keywords: </strong>deliverology, performance measurement, results and delivery framework, community economic development, service delivery model</p>

Efficacy of a blended low-intensity internet-delivered psychological programme in patients with multimorbidity in primary care: study protocol for\xa0a randomized controlled trial

BackgroundThe World Health Organization (WHO) has included comorbidity between depression and a chronic disease among the 10 leading global health priorities. Although there is a high prevalence of multimorbidity, health care systems are mainly designed for the management of individual diseases. Given the difficulty in delivering face-to-face psychological treatments, alternative models of treatment delivery have been proposed, emphasizing the role of technologies such as the Internet. The aim of this study is to assess the efficacy in Primary Care (PC) of a blended low-intensity psychological intervention applied using information and communication technologies (ICTs) for the treatment of multimorbidity in PC (depression and type 2 diabetes/low back pain) by means of a randomized controlled trial (RCT). Our main hypothesis is that improved usual care combined with psychological therapy applied using ICTs will be more efficacious for improvement in the symptomatology of multimorbidity, compared to a group with only improved treatment as usual six months after the end of treatment.MethodsA protocol has been designed combining a face-to-face intervention with a supporting online programme that will be tested by an RCT conducted in three different regions (Andalusia, Aragon and the Balearic Islands). The RCT will evaluate three hundred participants diagnosed with depression and type 2 diabetes/low back pain. Four highly experienced research groups specializing in clinical psychology are involved in this trial, and there will be ample possibilities for translation and transfer to usual clinical practice.DiscussionThis clinical trial will lead to improvement in financial sustainability, maximizing the use of resources and responding to principles of efficiency and effectiveness. Furthermore, based on the evaluation of the feasibility of implementing this intervention in primary care facilities, we expect to be able to suggest the intervention for incorporation into public policy. In conclusion, positive results of this study could have a significant impact on one of the most important health-related problems, multimorbidity.Trial registrationClinicalTrials.gov, NCT03426709. Registered retrospectively on 08 February 2018.

Transdermal buprenorphine patch: Potential for role in management of opioid dependence.

Despite proven clinical utility, use of sublinugual buprenorphine is fraught with issues of potential diversion among patients with opioid dependence. Transdermal buprenorphine patches provide an alternative delivery model that can be utilized to reduce such diversion. This narrative review discusses the transdermal buprenorphine formulations, and its pharmacology, drug interaction and tolerability profile. The studies utilizing buprenorphine transdermal patches in the treatment of opioid dependence are examined, while the potential of using such patches for maintenance treatment of opioid dependence is examined.

Debate: Alternative delivery models and corporatization in local government

"Debate: Alternative delivery models and corporatization in local government." Public Money & Management, 39(1), pp. 4–5

Effectiveness of Planned Teaching Programme on Knowledge Regarding cardiac Rehabilitation among patients Undergone Coronary artery bypass Grafting Surgery

Cardiac rehabilitation involves delivery of structured exercise, education and risk reduction, in a cost-effective manner. Robust evidence demonstrates it reduces mortality up to 25%, improves functional capacity, as well as decreases re-hospitalization. Despite its benefits, and clinical practice guideline recommendations to refer cardiac patients, cardiac rehabilitation programs are grossly under-used. Worldwide, there is low availability of cardiac rehabilitation; only 38.8% of countries globally have cardiac rehabilitation programs. Specifically, 68.0% of high-income and 23% of lower middle income class have cardiac rehabilitation. Cardiac rehabilitation density estimates ranged from 1 program per 0.1–6.4 million inhabitants. Cardiac rehabilitation availability is much lower than that of other evidence-based secondary prevention therapies, such as revascularization and pharmacological therapies. Multi-level strategies to augment cardiac rehabilitation capacity and availability at national and international levels such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.

Alternative service models for delivery of healthcare services in high-income countries: a scoping review of systematic reviews

IntroductionCosts associated with the delivery of healthcare services are growing at an unsustainable rate. There is a need for health systems and healthcare providers to consider the economic impacts of...

Systematic Review of School Telehealth Evaluations

School telehealth is an alternative delivery model to increase student health-care access with minimal evaluation to aid decision makers in the adoption or expansion of programs. This systematic review assesses school-based telehealth programs using a dissemination and implementation (D&I) framework to inform practitioners and decision makers of the value of school telehealth. We assessed findings from 20 studies on telehealth published between January 2006 and June 2018 and summarized program evaluation on a range of D&I constructs. The sample population included children in school- or center-based early childhood education under age 22 and included parents, providers, and school personnel across urban and suburban locations. There is some evidence that school telehealth can reduce emergency department visits and improve health status for children with chronic and acute illnesses. Future research should report on barriers and facilitators of implementation of programs, including costs related to application of telehealth services and utilization rates.

Computer-Aided Telephone Support for Primary Care Patients with Common Mental Health Conditions: Randomized Controlled Trial.

BackgroundDepression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitating the development and validation of alternative models of care delivery. Existing evidence supports the acceptability and effectiveness of providing mental health care by telephone.ObjectiveThis analysis assesses patient’s acceptability of computer-aided telephone support delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking.MethodsThe Primary care Assessment and Research of a Telephone intervention for Neuropsychiatric conditions with Education and Resources study is a randomized controlled trial comparing a computer-aided telephone-based intervention to usual care enhanced by periodic assessments in adult primary care patients referred for the treatment of depression, anxiety, or at-risk drinking; no part of the study involves in-person contact. For this analysis, the following data were obtained: reasons provided for declining consent; reasons provided for withdrawing from the study; study retention rate; and a thematic analysis of a satisfaction survey upon study completion.ResultsDuring the consent process, 17.1% (114/667) patients referred to the study declined to participate and 57.0% of them (65/114) attributed their refusal to research-related factors (ie, randomization and time commitment); a further 16.7% (19/114) declined owing to the telephone delivery of the intervention. Among the 377 participants who were randomized to the 1-year intervention, the overall retention rate was 82.8% (312/377). Almost no participants who withdrew from the study identified the telephone components of the study as their reason for withdrawal. Analysis of a qualitative satisfaction survey revealed that 97% (38/39) of comments related to the telephone components were positive with key reported positive attributes being accessibility, convenience, and privacy.ConclusionsOur results suggest that a computer-aided telephone support is highly acceptable to primary care patients with depression, anxiety, or at-risk drinking. In particular, these patients appreciate its accessibility, flexibility, and privacy.Trial RegistrationClinicalTrials.gov NCT02345122; https://clinicaltrials.gov/ct2/show/NCT02345122 (Archived by WebCite at http://www.webcitation.org/73R9Q2cle)

Editorial and News

Editorial and News

Hierarchies in interprofessional training

ABSTRACT Adverse patient outcomes are often the result of conflict or poor communication among healthcare professionals. Use of interprofessional care teams can improve healthcare and delivery of services. Healthcare systems have been historically hierarchical in nature with physicians regularly taking a leadership position. The presence of hierarchy can be a source of conflict in interprofessional healthcare teams. This article analyzes qualitative data from a four-day interprofessional training for family medicine residents, pharmacy students, nurse practitioner students, and counseling psychology students. Data was collected through journals, participant observation, and focus groups. Findings from this study demonstrate three key themes related to hierarchy: (1) tension regarding the idea that the physician is the team leader or “quarterback,” (2) experiences of marginalization by team members while working in interprofessional teams, and (3) the tendency for issues regarding hierarchy to go unresolved. Additionally, authors briefly address structures within healthcare that contribute to hierarchy as well as a discussion of alternative models of teamwork and healthcare delivery.

Silver diamine fluoride versus therapeutic sealants for the arrest and prevention of dental caries in low-income minority children: study protocol for a cluster randomized controlled trial

BackgroundDental caries is the most prominent childhood disease in the world. In the United States, more than 50% of children have experienced caries. Untreated caries can have negative impacts on quality of life, academic performance, and school attendance. To reduce oral health disparities, multiple organizations recommend school-based caries prevention.Methods/designA longitudinal, cluster randomized, non-inferiority trial will be conducted in low-income children from primarily Hispanic/Latino backgrounds currently enrolled in public elementary schools in New York City, New York, United States, from 2018 to 2023. The primary objective is to compare the non-inferiority of silver diamine fluoride and fluoride varnish versus glass ionomer therapeutic sealants and fluoride varnish in the arrest and prevention of dental caries. Secondary objectives are to evaluate differences in effectiveness when care is provided by nurses versus dental hygienists and assess the impact of prevention on oral health-related quality of life and educational outcomes. Caries arrest will be evaluated after 2 years, and caries prevention and secondary outcomes will be assessed at the completion of the study. Data analysis will follow intent-to-treat, and statistical analyses will be conducted using a two-sided significance level of 0.05.DiscussionThe comparative effectiveness of alternative caries prevention delivery models is considered to be one of the highest research priorities in the United States. Many treatments are currently available to prevent and arrest dental caries. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children.Trial registrationU.S. National Library of Medicine, www.clinicaltrials.gov, ID: NCT03442309. Registered on 22 February 2018.

Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trial.

ObjectiveCompare the effects and costs of remotely monitored exercise-based cardiac telerehabilitation (REMOTE-CR) with centre-based programmes (CBexCR) in adults with coronary heart disease (CHD).MethodsParticipants were randomised to receive 12 weeks of telerehabilitation or centre-based rehabilitation. REMOTE-CR provided individualised exercise prescription, real-time exercise monitoring/coaching and theory-based behavioural strategies via a bespoke telerehabilitation platform; CBexCR provided individualised exercise prescription and coaching via established rehabilitation clinics. Outcomes assessed at baseline, 12 and/or 24 weeks included maximal oxygen uptake (V̇O2max, primary) modifiable cardiovascular risk factors, exercise adherence, motivation, health-related quality of life and programme delivery, hospital service utilisation and medication costs. The primary hypothesis was a non-inferior between-group difference in V̇O2max at 12 weeks (inferiority margin=−1.25 mL/kg/min); inferiority margins were not set for secondary outcomes.Results162 participants (mean 61±12.7 years, 86% men) were randomised. V̇O2 max was comparable in both groups at 12 weeks and REMOTE-CR was non-inferior to CBexCR (REMOTE-CR-CBexCR adjusted mean difference (AMD)=0.51 (95% CI −0.97 to 1.98) mL/kg/min, p=0.48). REMOTE-CR participants were less sedentary at 24 weeks (AMD=−61.5 (95% CI −117.8 to −5.3) min/day, p=0.03), while CBexCR participants had smaller waist (AMD=1.71 (95% CI 0.09 to 3.34) cm, p=0.04) and hip circumferences (AMD=1.16 (95% CI 0.06 to 2.27) cm, p=0.04) at 12 weeks. No other between-group differences were detected. Per capita programme delivery (NZD1130/GBP573 vs NZD3466/GBP1758) and medication costs (NZD331/GBP168 vs NZD605/GBP307, p=0.02) were lower for REMOTE-CR. Hospital service utilisation costs were not statistically significantly different (NZD3459/GBP1754 vs NZD5464/GBP2771, p=0.20).ConclusionREMOTE-CR is an effective, cost-efficient alternative delivery model that could—as a complement to existing services—improve overall utilisation rates by increasing reach and satisfying unique participant preferences.

No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform.

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

End Users Want Alternative Intervention Delivery Models: Usability and Acceptability of the REMOTE-CR Exercise-Based Cardiac Telerehabilitation Program

ObjectiveEvaluate user experiences of an exercise-based cardiac telerehabilitation intervention (REMOTE-CR) that provided near universal access to real-time remote coaching and behavioral support from exercise specialists. DesignSecondary analysis (12-week follow-up) of a parallel group, single blind, randomized controlled noninferiority trial (ACTRN12614000843651). SettingCommunity-based cardiac rehabilitation. ParticipantsAdults (N=162) with coronary heart disease who were eligible for outpatient cardiac rehabilitation. Eighty-two of 162 trial participants were randomized to receive REMOTE-CR; 67 completed usability and acceptability assessment at 12-week follow-up. InterventionREMOTE-CR comprised 12 weeks of individualized exercise prescription, real-time physiological monitoring, coaching, and behavioral support, delivered via a bespoke telerehabilitation platform. OutcomesEase of use, satisfaction with the technology platform and intervention content, and demand for real-world implementation as an alternative to traditional center-based programs were assessed at 12-week follow-up. ResultsComponents of usability and acceptability were positively evaluated by most participants (44-66 of 67, 66%-99%). Fifty-eight of 67 (87%) would choose REMOTE-CR if it was available as a usual care service, primarily because it provides convenient and flexible access to real-time individualized support from exercise specialists. Technology challenges were rare and had little effect on user experiences or demand for REMOTE-CR. ConclusionsREMOTE-CR can extend the reach and impact of existing cardiac rehabilitation services by overcoming traditional participation barriers while preserving expert oversight. Adoption of emerging technologies should be accelerated to support dynamic, engaging, individualized intervention delivery models, but optimizing overall cardiac rehabilitation participation rates will require multiple delivery models that are tailored to satisfy diverse participant preferences.

Contracting Models Shift Dynamics of Engineering and Construction

Alternative project delivery models can potentially shorten a project's schedule and lower the overall project cost.

The Value of Urgent and Emergent Care in Otolaryngology

The aim of this report is to review the literature regarding the value of care provided for urgent and emergent otolaryngologic conditions and to investigate alternative models of health care delivery. Ear, nose, and throat problems comprise a large portion of chief complaints in emergency departments (EDs). Otolaryngologic conditions are predominantly low acuity and may be handled on an outpatient basis, leading to a potential mismatch between the needs of the patient and the level of resources expended. Alternative models have been investigated both in otolaryngology and in other medical specialties, but the implications for quality of care and cost are uncertain. Urgent and emergent care for ear, nose, and throat conditions is not well studied and is ripe for new models of health care delivery, which may include specialty-specific EDs, clinics, and urgent care centers. Economic analysis of the models will be essential to provide evidence of value and is currently lacking.

Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes.

Direct Primary Care (DPC), where patients pay a fee to a primary care provider to obtain access to services, is a delivery model that has received notable attention and enthusiasm from some providers. Proponents of DPC believe that the model increases accessibility, reduces overhead, and ultimately improves care for patients; however, there is little evidence in the peer-reviewed literature to support these claims. The objective of this analysis was to apply Starfield's adaptation of Donabedian's Structure-Process-Outcome conceptual model to evaluate primary care to formally display the links between potential changes in clinical structure and processes from DPC adoption. Based on existing literature on the constructs in Starfield's model, expectations of DPC's impact at the patient, clinic, and system levels were defined. DPC uses changes to financing and the population eligible to trigger potential gains in continuity and accessibility to subsequently improve care processes. There is evidence to support DPC as a theoretically sound approach to improve attributes of primary care, such as first contact care and longitudinality at the clinic level for participating patients. At the health system level, DPC has low-construct validity that would suggest a positive impact on the potentially eligible population's health due to membership fees that exclude patients who are more likely to be vulnerable and complex than patients who are willing and able to stay in the practice. Descriptive and comparative research of included and excluded patients is needed to inform providers, patients, and policy makers of the DPC's ability to attain the attributes of primary care and ultimately achieve better outcomes over alternative primary care delivery and financing models. Meanwhile, theoretic application informed by years of research on primary care provide insight as to what changes to expect and to monitor as practices consider DPC adoption.

SMARTphone and social media-based Cardiac Rehabilitation and Secondary Prevention (SMART-CR/SP) for patients with coronary heart disease in China: a randomised controlled trial protocol

IntroductionThe burden of cardiovascular disease (CVD) is rapidly increasing in developing countries, however access to cardiac rehabilitation and secondary prevention (CR/SP) in these countries is limited. Alternative delivery models that...

Structural barriers to comprehensive, coordinated HIV care: geographic accessibility in the US South

ABSTRACTStructural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source—publicly-funded health centers serving low-income populations—could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical.

Alternative payment and care-delivery models in oncology: A systematic review.

Rising US health care costs have led to the creation of alternative payment and care-delivery models designed to maximize outcomes and/or minimize costs through changes in reimbursement and care delivery. The impact of these interventions in cancer care is unclear. This review was undertaken to describe the landscape of new alternative payment and care-delivery models in cancer care. In this systematic review, 22 alternative payment and/or care-delivery models in cancer care were identified. These included 6 bundled payments, 4 accountable care organizations, 9 patient-centered medical homes, and 3 other interventions. Only 12 interventions reported outcomes; the majority (n = 7; 58%) improved value, 4 had no impact, and 1 reduced value, but only initially. Heterogeneity of outcomes precluded a meta-analysis. Despite the growth in alternative payment and delivery models in cancer, there is limited evidence to evaluate their efficacy. Cancer 2018. © 2018 American Cancer Society.