Care Coordination Challenges Research Articles

Experiences of family of individuals in a locked in, minimally conscious state, or vegetative state with the health care system

ABSTRACT Primary Objective: To understand the experiences of family members of individuals in a locked-in state (LIS), minimally conscious state (MCS), or vegetative state (VS) with the health-care system when caring for their family member. Research Design: The study adopted a qualitative descriptive approach drawing on central tenets of constructivist grounded theory described by Charmaz. Our analysis drew on emphasizing connections between theory, concepts, and empirical data using a constant comparative method. Methods and Procedures: Semi-structured interviews were conducted with family members of individuals in a LIS, MCS, or VS. Participants were recruited between June 2014 and December 2016. Main Outcomes and Results: 22 interviews were conducted, which comprised interviews with 12 family members. The following themes were identified: care coordination challenges, lack of flexibility in health-care policies, and inappropriate care settings. Conclusions: Family members of individuals in a LIS, MCS, or VS described playing a significant role in the lives of their family member. Based on the results of this study, flexibility in health-care policies and/or programming should be adopted in the face of the challenges identified. Implementation of interventions to support caregivers and transitions is increasingly important.

Information tools for care coordination in patient handover: Is an electronic medical record enough to support nurses?

Effectiveness of end-of-shift patient handover between nurses may be impacted by poor communication. This can be improved with the use of information tools, either electronic or paper-based. Few studies have investigated the activities that support patient handover, and fewer have explored how several of these tools used together affects the handover process. The aim of this study was to understand coordination challenges in end-of-shift patient handover between nurses and the influence of multiple information tools used in that context. A qualitative methodology to investigate phenomena in an acute care hospital in the United States was used in this study. Semistructured interviews were used to elicit insights from 16 nurses. Data were analyzed by coding three types of task dependencies (prerequisite, simultaneous, and shared) and three information tools (electronic medical records [EMRs], Kardex, and printouts of EMR data). In preparation for a handover, nurses were burdened by ensuring that information in the EMR was correct and complete. A one-sheet Kardex was the tool nurses in the study preferred, because the essential information was at hand and it provided structure to the communication. Printouts of EMR data were often physically cumbersome and not useful in their current form, although they may be useful for communicating anomalous data. This study provides insights regarding the challenges of care coordination in end-of-shift patient handover between nurses and the usages of a variety of information tools in preparation for handover, as well as the actual handover process. Multiple interrelated information tools may be used to support patient handover. Health leaders should focus efforts on further advancing protocols for end-of-shift nurse handovers. Health system designers should design information tools to align them with their defined purpose in the handover process. Future work should consider both the information needs of nurses and the goal of improving nurse workflows.

Veteran Perspectives on Care Coordination Between Veterans Affairs and Community Providers: A Qualitative Analysis.

To investigate veteran perspectives on challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers in rural areas. We completed qualitative interviews with a geographically diverse sample of 51 veterans who had used both VA and community health care services. Interviews were audio-recorded and transcribed verbatim. We used directed content analysis (informed by previous work with VA and community staff) to elucidate findings, while remaining attentive to emergent themes. We report results in 5 key domains related to interorganizational care coordination: organizational mechanisms, organizational culture, relational practices, contextual factors, and the role of the Third-Party Administrators responsible for scheduling and payment for community services. Veterans described successes and challenges in interorganizational coordination across these domains, while also reporting a variety of workarounds and mitigation strategies. Veterans living in rural areas face myriad challenges when using health care services both within and outside of VA. In the absence of strong mechanisms for ensuring coordination and communication between health care providers at different institutions, veterans themselves may carry the primary burden for coordinating their care. Our results suggest the utility of both structural and relational approaches to enhancing interorganizational care coordination in these settings.

Care coordination challenges between a high-volume center and rural physicians treating patients with pancreatic cancer.

58 Background: Pancreatic cancer (PC) patients treated at high-volume centers (HVCs) benefit from specialty services that may not be accessible to rural patients: complex treatment planning, advanced surgical and chemo-radiation options, and multidisciplinary team-based care. As a result, rural PC patients often seek treatment at multiple locations for different episodes of care (i.e., chemotherapy and surgery). The facilitators and barriers to coordinating care between rural physicians and HVCs for rural PC patients treated by both types of providers are not well-understood. Methods: We conducted semi-structured interviews with PC specialists (medical, surgical, and radiation oncologists, n = 9) at a HVC (The Ohio State University) actively treating and co-managing rural PC patients with rural physicians. Using rigorous qualitative methods, two co-authors independently coded the interview transcripts to develop a thematic account of HVC-rural physician care coordination barriers and facilitators. Results: Initial interactions between PC specialists and rural PC patients often require duplication of diagnostic testing (i.e., imaging) due to inadequate transfer of medical records at the time of consultation. This is partly due to inefficient phone communication between HVCs and rural physicians. Such inefficiencies often discourage two-way communication between HVCs and rural physicians, and this can hinder development of a shared understanding of patients’ treatment plans. Specialists suggested a dual-approach may help to improve care coordination in this context: (a) developing better personal relationships with rural physicians to facilitate information-sharing and “closing-the-loop” on patients’ treatment plans; and (b) implementing data systems that permit physicians to share patients’ records across organizations. Several specialists acknowledged the benefit of having a dedicated care coordinator who could help patients connect with specialists, navigate the different healthcare systems, and relay information between providers. Conclusions: Given the challenges that can complicate the PC treatment process for rural patients, it is important to consider opportunities to address these issues. Taking steps to improve efficiency in communication may help facilitate the development of cohesive treatment plans and promote team-based care. Further studies are needed to examine the effects of care coordination interventions, like the use of care coordinators, on improving care for rural PC patients.

Abstract D079: Oncologists’ approach in managing pre-existing chronic comorbidities during patients’ active cancer treatment

Abstract Background Cancer frequently occurs with other chronic diseases, and this poses serious care coordination challenges during patients’ active cancer treatment (ACT) and contributes to disparities in health outcomes. There is limited research addressing pre-existing chronic comorbidity (PCC) management during ACT. This study aimed to examine oncologists’ approach for PCC management during ACT. Methods Oncologists in the National Cancer Institute’s Community Oncology Research Program (NCORP) were surveyed about their approach in managing PCC. The Likert scale survey was piloted-tested, IRB-approved, and administered to oncologists. In December 2018, NCORP network oncologists were sent an email invitation to complete the online survey. Pearson chi-square test was used to identify differences in oncologists’ management approach of PCC. Results Among the 375 respondents of the ongoing survey, 45.6% practiced primarily as medical oncologists, 37.3% as hematology, surgical, or radiation oncologists, and 17.1% as other oncology specialists. Approximately 70% of oncologists reported that >50% of their patients had ≥ 1 PCC. When asked about the three most challenging PCC to manage, 23.3% cited diabetes, 19.5% cited heart disease, and 57.1% cited another PCC. Medical oncologists were more likely to cite diabetes first (77.5%) and less likely (22.5%) to cite heart disease first compared to other specialists (p=0.004). Co-management with patients’ PCP was the most common management approach for diabetes among medical oncologists (42.2%) compared to those of other specialties (15.0%) while referral to other physicians was the most common approach among those of other specialties (50.0%) compared to medical oncologists (22.5%) (p=0.002). Consultation and referral were the most common management approaches for heart disease across oncology specialties. Conclusion Oncologists face significant challenges to manage patients’ PCC during ACT. These results indicate that the medical oncologist is more likely to co-manage diabetes with patients’ PCP compared to other oncology specialists, but heart disease was seldom co-managed. Greater collaboration between oncology and non-oncology specialists is needed for effective management of PCC during ACT to ensure complete and coordinated care and to reduce disparities in health outcomes for these patients. Citation Format: Dudith Pierre-Victor, Iman K. Martin, Brenda Adjei, Mary Shaw-Ridley, Bruce Rapkin, Marjorie Good, Diane ST. Germain, Bernard Parker, Worta McCaskill-Stevens. Oncologists’ approach in managing pre-existing chronic comorbidities during patients’ active cancer treatment [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D079.

Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis.

To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans. We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses. Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges. Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.

Effects of State-level Medicaid Expansion on Veterans Health Administration Dual Enrollment and Utilization: Potential Implications for Future Coverage Expansions.

The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care. We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants' dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services. Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA's Corporate Data Warehouse and Medicaid Analytic Extract files. For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48-5.25), a 4.63-point decline in VA proportion of admissions (-5.87 to -3.38), and a 11.70-point decrease in the VA proportion of ED visits (-13.06 to -10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion. This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.

2444. Infection Prevention in Home Healthcare: Results from a National Study of Home Health Agencies

BackgroundAs the population of older Americans with chronic conditions continues to grow, the role of home healthcare (HHC) services in improving care transitions between acute care and independent living has become a national priority. This has led to the development of value-based purchasing (VBP) initiatives, changes in the Centers for Medicare and Medicaid Services’ Home Health Conditions of Participation, and the Joint Commission’s national patient safety goals for HHC. We aimed to describe the infection prevention and control (IPC) infrastructure in US home health agencies (HHA).MethodsFrom March to November 2018, we conducted in-depth, phone interviews with 41 staff from 13 HHAs across the United States, including administrators, IPC and quality improvement (QI) personnel, registered nurses and home health aides. In October 2018, we launched a nationwide survey to a random sample of 1,500 HHAs stratified by census region, ownership status and urban/rural location, and achieved a 40% response rate. Transcripts of the qualitative interviews were coded and themes were identified using content analysis. Survey data were analyzed using descriptive statistics.ResultsThemes from the interviews included: 1) Uniqueness of HHC setting, 2) Importance of staff and patient/caregiver education, (3) Care coordination challenges, and, (4) Keys to success and innovation. From the surveys, we found that, at the majority of HHAs, the staff member in charge of IPC had other responsibilities including QI (57%), clinical/administrative/managerial (49%), supervision of clinical services/patient coordination (48%), and education/training (45%). For those staff members in charge of IPC, over a third had received no specific IPC training, and only 5% were certified in IPC. For those staff who received training, the training was provided by external consultants (26%) or a professional society/health department (28%). Respondents cited the most challenging aspect of IPC as collecting/reporting infection data (24%), adherence to/monitoring bag technique (15%) and adequate staff coverage (13%).ConclusionThis work represents a current snapshot of IPC infrastructure and challenges in US HHC agencies and identifies important barriers to IPC in these settings.Disclosures All authors: No reported disclosures.

Physicians' perspectives on medication adherence and health promotion among cancer survivors.

Cancer survivors face an increased risk of cardiovascular events compared with the general population. Adopting a healthy lifestyle may reduce these risks, and guidelines encourage health-promotion counseling for cancer survivors, but the extent of physician adherence is unclear. This mixed-method study surveyed 91 physicians, including 30 primary care physicians (PCPs), 30 oncologists, and 31 specialists (urologists, dermatologists, and gynecologists). Interviews also were conducted with 12 oncologists. Most PCPs (90%) reported recommending health promotion (eg, weight loss, smoking cessation) to at least some cancer survivors, whereas few oncologists (26.7%) and specialists (9.7%) said they ever did so (P<.001). Although most physicians believed that at least 50% of cancer survivors would be adherent to medication regimens to prevent cancer recurrence, they also believed that, if patients were trying to lose weight, they would not remain medication-adherent. In interviews, oncologists expressed fear that providing health-promotion advice would distress or overwhelm patients. Additional health-promotion barriers identified by thematic analysis included: identifying cancer as oncologists' focal concern, time pressure, insufficient behavior change training, and care coordination challenges. Facilitators included perceiving a patient benefit and having health-promotion resources integrated into the cancer care system. Physicians often do not have the time, expertise, or resources to address health promotion with cancer survivors. Research is needed to evaluate whether health-promotion efforts compromise medical regimen adherence, as physicians' responses suggest.

Perceptions of the Implementation of Pediatric Behavioral Health Integration in 3 Community Health Centers.

Pediatric behavioral health integration (BHI) represents a promising approach to address unmet child mental health need but little research exists to guide BHI implementation. Through in-depth interviews with 38 professionals involved in a comprehensive pediatric BHI initiative at 3 community health centers, we explored perceptions of the impact of BHI on clinical practice, and facilitators and barriers to BHI implementation. Professionals identified 2 overarching themes about the impact of BHI on clinical practice (greater interdisciplinary collaboration/communication and enhanced provider wellness); 5 themes about facilitators of BHI (staff buy-in for BHI, leadership support, staff belonging to the same team culturally and/or structurally, co-location with close physical proximity, and data-driven quality improvement); and 5 themes about barriers to BHI (inadequate clinician staffing, insufficient space, limited provider time, billing/reimbursement issues, and care coordination challenges). Future pediatric BHI efforts may consider these findings to develop strategies to promote facilitators and reduce barriers during implementation.

FACTORS IMPACTING LOSS-TO-FOLLOW-UP FROM A MEMORY CARE CENTER: A STUDY OF POTENTIAL PALLIATIVE CARE NEEDS

Dementia is a progressive and ultimately terminal illness requiring palliative care for people with dementia (PWD) and their caregivers. With cognitive and functional decline, caregivers experience increasing challenges in navigating the healthcare system and utilizing traditional ambulatory care services. We aimed to address a gap in our understanding of palliative care needs among PWD and their caregivers, who were lost to follow-up after being seen at a memory care unit within a large quaternary US academic medical center. We conducted a chart review of the characteristics and needs of 61 people with a diagnosed dementia syndrome, who were lost to follow-up for at least a year prior to death, after being seen at least once between 2012–2017 at the UCSF Memory and Aging Center. Among PWD who died, 50% were lost to follow-up a year or more before death. Of those whose charts we reviewed, 48% were female, 66% were white, with median education of 16 years. The most common diagnoses were Alzheimer's disease (47%), vascular dementia (24%), and dementia with Lewy body disease (13%). Commonly documented reasons for PWD and their caregivers not returning for care in the memory and aging center included switching care to another provider (33%), patient mobility changes (25%), and an overwhelmed caregiver (22%). Notes of conversations with caregivers provided additional insights related to care coordination challenges and a sense that there was no one to meet their needs: “L and her sister feel no one is coordinating [their] mom's care or has the ‘big picture’”; “Mr. X is overwhelmed with the challenges and stresses of managing his wife's care and their own household situation.” Understanding the end of life needs of PWD will be foundational for the subsequent design and implementation of clinical palliative care interventions that are person and caregiver centered. Attention to care coordination, PWD mobility limitations and caregiver stress will be key components of care for future dementia palliative care interventions.

Oncologists’ perceived confidence in managing pre-existing chronic comorbidities during patients’ active cancer treatment.

e18036 Background: Cancer frequently occurs with other chronic diseases, and this poses serious care coordination challenges during patients’ active cancer treatment (ACT). There is limited research addressing chronic comorbidity (CC) management during ACT. This study aimed to examine practicing oncologists’ perceived confidence in independently managing CC during ACT. Methods: Oncologists in the National Cancer Institute’s Community Oncology Research Program (NCORP) were surveyed about their perceived confidence in managing CC. The Likert scale survey was piloted-tested, IRB-approved, and administered to oncologists. In December 2018, NCORP network oncologists were sent an email invitation to complete the online survey. Pearson chi-square test was used to identify oncologists’ differences in perceived confidence in managing CC. Results: Among the 201 respondents of the ongoing survey, 48% were medical oncologists, 21.2% radiation or surgical oncologists, and 30.8% were of other specialties. Overall, 69% agreed (agree or strongly agree), 17.3% were neutral, and 13.4% disagreed (strongly disagree or disagree) that they were confident in managing all CC independently. While 69% of oncologists were confident when managing any CC, only 49% and 19.8% remained confident when managing CC previously managed by a primary care physician (PCP) and by a non-oncology subspecialist, respectively. Across oncologic subspecialties, 47.6%, 77.9% and 72.1% of radiation/surgical oncologists, medical oncologists, and those of other specialties, respectively, agreed that they were confident in independently managing CC (p = 0.003). Conclusions: Most oncologists are confident in managing all CC during patients’ ACT. However, they were less confident with CC previously managed by PCPs, and even less confident for CC previously managed by non-oncology subspecialists. These results indicate opportunities for greater collaboration between oncology and non-oncology specialists to ensure complete and coordinated care for cancer patients with comorbidities.

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care.

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference.

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

Asthma care coordination in schools by school nurses: An integrative literature review.

The purpose of this integrative literature review is to document and synthesize the available evidence on school nurse asthma care coordination challenges and explain the components of asthma care coordination/case management at schools. The Whittemore and Knafl guidelines were followed for this integrative literature review. Twelve diverse primary sources-one qualitative study, eight quantitative studies, and three mixed-method studies-were used for the review. Data were analyzed using the matrix method. A total of 12 papers met the inclusion criteria. The initial group categorization was based on variables, patterns, and conceptual classification. Results were divided into two categorizations of asthma care coordination program components and asthma care coordination challenges at schools; subthemes were identified under the categorizations. The results showed that care coordination was key for students with chronic diseases including asthma. Asthma care coordination has many challenges, but school nurses can drive effective asthma care by including the essential components of care coordination. Successful asthma care coordination may prevent health care fragmentation, emergency room visits, hospitalization, and school absenteeism, and can increase asthma knowledge and the quality of life for students and parents.

Care Coordination and Population Health Management Strategies and Challenges in a Behavioral Health Home Model.

Behavioral health home (BHH) models have been developed to integrate physical and mental health care and address medical comorbidities for individuals with serious mental illnesses. Previous studies identified population health management capacity and coordination with primary care providers as key barriers to BHH implementation. This study examines the BHH leaders' perceptions of and organizational capacity to conduct these functions within the community mental health programs implementing BHHs in Maryland. Interviews and surveys were conducted with 72 implementation leaders and 627 front-line staff from 46 of 48 Maryland BHH programs. In-depth coding of the population health management and primary care coordination themes identified subthemes related to these topics. BHH staff described cultures supportive of evidence-based practices, but limited ability to effectively perform population health management or primary care coordination. Tension between population health management and direct, clinical care, lack of experience, and state regulations for service delivery were identified as key challenges for population health management. Engaging primary care providers was the primary barrier to care coordination. Health information technology and staffing were barriers to both functions. BHHs face a number of barriers to effective implementation of core program elements. To improve programs' ability to conduct effective population health management and care coordination and meaningfully impact health outcomes for individuals with serious mental illness, multiple strategies are needed, including formalized protocols, training for staff, changes to financing mechanisms, and health information technology improvements.

EConsult Mental Health: Electronic Referral and Consultation to Integrate Primary Care and Mental Health.

We describe the implementation of a novel electronic platform for specialty referral and consultation, eConsult Mental Health. This innovation aims to address mental health care access and coordination challenges in the nation's second largest public health system in Los Angeles. eConsult Mental Health is one of the largest documented electronic platforms to facilitate the integration of behavioral health services in primary care. Although implementation has been met with barriers unique to mental health care, eConsult Mental Health appears to be a promising tool to expand the spectrum of care for Los Angeles County safety net primary care providers in patient-centered medical homes.

Challenges in care co-ordination: missed care in community nursing

Primary healthcare is a major focus of health policy in Ireland and elsewhere. Many disciplines work with communities to potentialise health and well being. Community nurses are one of these health professionals whose philosophy is based on health promotion, early detection of health issues, rehabilitation and addressing inequality and inequity through a lens of the social determinants of health. In Ireland, within the Community Healthcare Organsiations, there are public health nurses and community registered general nurses who manage 'cradle to the grave' geographical caseloads. However, despite structural, population changes and increased complexity of healthcare, reform in community nursing has been absent. This paper describes a study which used the concept of missed care to examine the work of community nurses in Ireland. Missed care may be defined ‘any aspect of required client care that is omitted either in part or in whole or delayed’ Kalisch et al. 2009a: 1510 and has been linked to due to challenges in client safety, client health outcomes, staffing and the underuse of health services. Following full ethical approval from UNiversity College Dublin, community nurses were recruited through the Irish Nurses and Midwives Organsiation. Three methods of data collection are used: a community based missed care survey developed for this study to look at community nurses experience of missed care within a week timeframe; four semi-structured interviews to explore the concept of contemporary missed care in Ireland; and a focus group to develop the impact of missed care through a health economy lens. Within the community based survey all 64 domain questions demonstrated some level of missed care. The data from the interviews and the focus groups supported the findings within the survey. Reasons for missed care were similar to Kalisch et al’s 2009a,b findings for acute care settings: inadequate staffing levels, unanticipated rise in client volume and/acuity/complexity and a lack of administrative support. In particular, missed care was associated with having to provide long term cover when colleagues were sick, on leave or had retired. Role boundaries were seen as fluid and community staff did not appear to have control over what consituted legitimate caseloads under their generalist role. The lack of comprehensive leadership in community nurisng and career clinical development for communty nurses was also identified. The findings are significant in the context of both the job desciptions and health policies in Ireland which emphasise a health promotion and vertical equity approach to care. The experiences of the community nurses demonstrate that they are prioritising clincal work and legislation obligations and although missed care was identified at lower rates in these domains, this was at the expense of health promotion and disease prevention. However, in applying case scenarios based on cost benefit analysis of addressing health promotion areas in a comprehensive way, clear potential economic saving can be made. Consequentally, urgent reform is required to facilitate the community nursing healthforce to adequately contribute to contemporary health demands at primary, secondary and tertiary care levels for individuals, families and communities.

Weight management and physical activity throughout the cancer care continuum.

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

Assessing need for pharmacist involvement to improve care coordination for patients on LAI antipsychotics transitioning from hospital to home: A work system approach.

The use of Long-Acting Injectable (LAI) antipsychotic medications has increased for patients with Serious Mental Illness (SMI). Care coordination for this population is complex, and pharmacist involvement may improve and support long-term medication adherence and patient outcomes. (1) Examine pharmacists' role in addressing care coordination and adherence challenges for patients taking Long-Acting Injectable (LAI) antipsychotics; and (2) explore patients' medication use experiences with LAI antipsychotics and educational needs. This project utilized a holistic work systems approach to assess the usefulness of implementing a pharmacist-led intervention to improve care coordination for patients taking LAI antipsychotics. Data collection and analyses were guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model. Data were collected using interviews with healthcare team members and patients taking LAI antipsychotics and retrospective chart reviews at a psychiatric hospital in Southwestern Pennsylvania. Data collection elicited information about LAI care coordination, the pharmacist's role, and patients' experiences. Content and thematic analyses were conducted to identify opportunities to improve quality of care and patient outcomes. Sixteen healthcare team members and six patients were interviewed. Twenty patient charts were reviewed to examine the care coordination process. Four themes of the workflow process emerged: pharmacist consultation, in-hospital LAI administration, discharge planning, and outpatient treatment. Key challenges identified included inadequate communication, limited knowledge, and the need for standardized roles. Most patients did not know the name of their LAI antipsychotic and did not recall receiving medication counseling, but were interested in discussing medication concerns with pharmacists. There is a need for improved communication during LAI care coordination, targeted education for healthcare team members, and standardization of roles. Many patients did not have adequate LAI antipsychotic knowledge or receive appropriate medication counseling. Increased pharmacist involvement in the care coordination process may promote adherence and optimal management of SMI.