Care Coordination Team Research Articles

Adapting Group Prenatal Care for Telehealth: A COVID-Era Innovation to Address Barriers to Care for Latinx Clients.

The use of telehealth prenatal care increased exponentially during the coronavirus disease 2019 (COVID-19) pandemic, but there is no literature describing its use for group prenatal care during this time. The COVID-19 pandemic also exacerbated structural barriers to care that disproportionately affect Black and Latinx people. Telehealth enabled pregnant people to access health care and minimize infectious risks. Telehealth group prenatal care (T-GPNC) incorporated the essential elements of CenteringPregnancy with telehealth is an innovative care delivery method borne out of necessity during the COVID-19 pandemic that has potential to mitigate structural barriers to care. Mary's Center is a federally qualified health center (FQHC) in Washington, DC, and Maryland that rapidly pivoted to individual telehealth prenatal care early in the pandemic. Mary's Center used our experience with group care and guidance from the Centering Healthcare Institute on virtual Centering to launch T-GPNC. This new model included home self-monitoring equipment and video classrooms, mixed with in-person individual care visits. We used a team-based approach with nurses, midwives, and community health workers to provide holistic care to pregnant people. Our robust care coordination team also connected them to home visiting, mental health services, and nutrition counseling. The purpose of this article is to describe how Mary's Center modified the CenteringPregnancy model of group prenatal care for telehealth, following the hallmarks of CenteringPregnancy, and met the needs of Spanish-speaking clients, henceforth Latinx clients. A secondary purpose is to demonstrate how telehealth can expand access to health care and remove structural barriers that may prevent pregnant people from attending in-person appointments. We also discuss the structural inequities in digital access and literacy in the context of program implementation.

26 Culturally informed developmental paediatric care: A qualitative study

Abstract Background Paediatricians provide developmental care through developmental surveillance, identification and management of specific developmental disorders, and health advocacy. Despite being one of the most common reasons to visit a paediatrician, the provision of care in this field is challenging as it intersects with medical, mental health, and educational systems. Additionally, the rise of international migration, inequities in health systems, and unique culturally based concepts of child development require paediatricians to have unique skills for culturally informed care provision in this area. Objectives A qualitative study was conducted to describe the perceptions of paediatricians on providing culturally informed developmental paediatric care to diverse populations. Design/Methods Semi-structured interviews were completed with paediatricians who primarily provide developmental care to understand the challenges, opportunities, and potential educational enhancements to improve culturally informed care for developmental paediatrics. Thematic analysis was used to analyze the transcribed interviews using inductive and deductive approaches. Results Three major themes emerged from 18 individual semi-structured interviews. The first theme, “cultural translation,” described language differences, interpretation, and trust-building between discordant physician/family dyads. The second theme, “inequity,” described systemic barriers that diverse populations experience, power distance in healthcare relationships, and pandemic-related amplifications of inequity. The third theme, “educational opportunities,” highlighted reflective practice opportunities, immersive experiences in diverse settings, and building a community of practice for paediatricians to build their knowledge base. Paediatricians practicing developmental paediatric care highlighted unique elements to the practice which may benefit from practice changes and curricular reform. Integration of meaningful training in the use of interpretation services, multicultural health brokers, and care coordination teams is a recommended intervention which is transferable to many disciplines. Peer-mentorship from colleagues of differing cultural backgrounds may help reduce race-based stereotypes and enhance perspective taking. Conclusion Paediatricians had a variety of perspectives on the provision of developmental paediatric care to diverse populations within Canada. There were a range of perceived opportunities for improvements in care noted on individual and systems levels. The development of infrastructure to build capacity in culturally informed developmental paediatric care to reduce culturally based health gaps is a needed future direction for developmental paediatrics.

Abstract P155: Identifying Inpatient and Outpatient Factors That Reduce Heart Failure Exacerbation Readmissions

Acute heart failure 30-day readmissions are associated with increased patient morbidity and mortality. Our aim is to identify systemic factors that can reduce heart failure readmissions, including the implementation of a heart failure care coordination team. We assessed the hypothesis that individualized post-discharge education and summary from the heart failure care coordination team will reduce 30-day heart failure readmissions.This retrospective study included 213 patients, 18 years and older admitted with NYHA Class II-IV and ACC/AHA Stage B-D heart failure exacerbations from July 2021- March 2022, at a community hospital. Collected variables included demographics, medical comorbidities, labs, echocardiographic findings, inpatient orders, LACE index score, discharge follow-up, receipt of an after-visit summary, length of stay, and 30-day readmission. Descriptive data was summarized as counts and percentages for categorical data, and mean or median for continuous data. Between-group parametric data means were compared by calculating the t-test for independent variables, or medians using the Mann-Whitney U test for data that were nonparametric. Categorical variables were compared by calculating the chi-square test for association or Fisher’s exact test, as appropriate. The primary study objective was tested using Logistic regression modeling. Throughout this study, a p-value ≤0.05 (two-tail) was considered statistically significant. The medical records of all available reduced treatment plan patients were compared to preserved treatment plan patients in approximately equal numbers. Pair-wise t-tests required the greatest number of subjects. Using the conventional power level of 80%, a two-tailed alpha of 0.05, and assuming a medium effect size, it was estimated that this comparison will require at least 114 subjects. In this study, 189 of 213 patients were reached by the heart failure care coordination team. 49/189 were readmitted in 30 days and 140/189 were not. For the readmission group, the percentage of patients who were CKD Stage 3 or 4 (39.4%, 28 of 71) was higher than those who were not (21.1%, 30 of 142) with a p-value of 0.005. The percentage of patients who had discharge BNP checked (39.1%, 18 of 46) was higher than those who were not (24.1%, 40 of 166) with a p-value of 0.043. A higher LACE index score was associated with readmission as compared to a lower score, with a p-value of < 0.001. In conclusion, presence of CKD stage 3 or 4, discharge BNP, and a higher LACE-index score were associated with 30-day heart failure readmission. Counterintuitively, the heart failure care coordination team did not have an impact on this endpoint, contrary to our hypothesis. Future studies with a larger sample size and focus on the outpatient care team efforts may be helpful in elucidating the team's potential in preventing heart failure readmission.

Evaluation of a Clinic-Based, Electronic Social Determinants of Health Screening and Intervention in Primary Care Pediatrics

ObjectiveSocial determinants of health (SDOH) significantly affect individuals' health outcomes, yet universal electronic SDOH screening is not standard in primary care. Our study explores the implementation of an electronic SDOH screening in the electronic health record (EHR) and follow-up intervention among primary care pediatric patients within an academic clinic. MethodsBeginning in August of 2022, patients and their families determined to have at least one SDOH need qualified for an in-clinic referral to a coordinated care team member. We assessed the overall efficacy and feasibility of the implementation. ResultsOver the 4-month pilot, 1473 of 2064 (71.4%) eligible patients were screened, with 472 (32%) patients screening positive on at least one SDOH domain. Of the 472 screened positive, 48 (10.2%) declined a referral. Two hundred and forty-seven of the 424 (58.3%) received a referral to a care coordination team member. ConclusionsThis study demonstrates the feasibility of a universal electronic SDOH screening tool within the EHR within an urban, academic-based clinic.

A hospital care coordination team intervention for patients with multimorbidity

Objective: To develop and evaluate a hospital care coordination team intervention for patients with multimorbidity and multiple specialists at the outpatient clinic
 Study setting: A middle-large teaching hospital (542 beds) in the Netherlands
 Study design: Practice-based, participatory pilot study with mixed-methods, using the Framework for Developing and Evaluating Complex Interventions. The intervention consisted of an intake, a comprehensive review by a dedicated care coordination team, a consultation to discuss results and two follow-up appointments.
 Data Collection: We included adult patients who had visited seven or more outpatient specialist clinics in 2018. We excluded patients with less than two scheduled hospital appointments or if the potential participant was already receiving coordinated care. We collected quantitative and qualitative data on patient characteristics, number and type of recommendations from the comprehensive review, experiences and short-term outcomes.
 Principal Findings: 250 patients were assessed for eligibility. We excluded 119 patients, 54 of these patients (21,6%) were deceased at the time of assessment and 28 patients (11,2%) had less than two scheduled appointments. Out of 131 invited patients, 28 participants underwent the intake and comprehensive review. The review produced recommendations for at least two out of three categories (medication, involved medical specialists, other) for 21 participants. Patients’ experienced effects of the intervention ranged from very large to no effect. Identified key uncertainties of the intervention were finding the best suited patient population and the minimum of required data that can be collected with feasible effort during regular clinical care.
 Conclusions: The developed hospital care coordination team intervention resulted in mixed outputs and short-term outcomes. We learned that recruitment and selection should be refined to include patients with multimorbidity who might benefit most. Outcomes of research and clinical care should align as much as possible and focus on evaluating the result of care coordination first.

CASE STUDIES OF A SENOR-ENHANCED CARE COORDINATION MODEL TO ADDRESS OLDER ADULT HEALTH

Abstract Smart technologies hold enormous potential in the early detection of activity change that may indicate illness or functional decline among older adults. However, little research currently exists on the application of such technologies to community-dwelling older adults. Our program, Age-friendly Sustainable Smart and Equitable Technologies for Aging in Place (ASSETs for AIP) uses open-source smart home technologies and consumer-grade wearable devices to monitor community-dwelling older adults recently discharged from the Show-Me Home program. We employ a novel approach; pairing technology with a care coordination team, comprised of a registered nurse, occupational therapist, and a licensed social worker. This presentation will highlight the function of this team, and how they leverage sensor-generated health information to provide care coordination. Using a clinical interface that displays the sensor-generated health data, this team provides ongoing monitoring of daily activity to identify early changes in routine that may indicate the development of a health problem. As significant changes in health data present, our clinical team works with clients to understand the change and formulate a plan of action. For example, an unexplained spike in heart rate may lead the clinician to discuss recent activity, exertion, and potential modifications in routine for a client. An increase in middle-of-the night bathroom trips may indicate a health change, for the which the client will be coached in what to communicate to their provider. Case studies from our program will be discussed in this presentation, to highlight this model of sensor-enhanced care coordination.

A hospital care coordination team intervention for patients with multimorbidity: A practice-based, participatory pilot study.

This study aims to develop and pilot a hospital care coordination team intervention for patients with multimorbidity and identify key uncertainties. Practice-based, participatory pilot study with mixed methods in a middle-large teaching hospital. We included adult patients who had visited seven or more outpatient specialist clinics in 2018. The intervention consisted of an intake, a comprehensive review by a dedicated care coordination team, a consultation to discuss results and two follow-up appointments. We collected both quantitative and qualitative data. Out of 131 invited patients, 28 participants received the intake and comprehensive review. The intervention resulted in mixed outputs and short-term outcomes. Among the 28 participants, 21 received recommendations for at least two out of three categories (medication, involved medical specialists, other). Patients' experienced effects ranged from no to very large effects. Key uncertainties were how to identify patients with a need for care coordination and the minimum of required data that can be collected during regular clinical care with feasible effort. Recruitment and selection for hospital care coordination should be refined to include patients with multimorbidity who might benefit most. Outcomes of research and clinical care should align and first focus on evaluating the results of care coordination before evaluating health-related outcomes.

Care coordination in primary care: mapping the territory.

To document the current approaches to care coordination among different types of care systems in Minnesota. Observational survey of leaders of most of the care systems in Minnesota that have implemented care coordination. Survey questions about organizational structure, size, and approach to care coordination were sent to the leaders of 42 care systems with a total of 327 primary care clinics. Surveys were completed by leaders at every care system participating in this study (100% response rate); 16 small care systems (each with 1-2 clinics) had a total of 26 primary care clinics, 15 medium care systems (3-9 clinics) had 57 clinics, and 11 large care systems (> 9 clinics) had 244 clinics. The large care systems had larger clinics (clinicians per clinic, 8.6 in large vs 4.3 in small and 5.2 in medium; P = .03) and more clinicians per care coordinator (5.7 vs 3.3 and 4.0; P = .04). They also more frequently included a social worker in their care coordination team: 82% vs 25% of small and 40% of medium care systems (P = .01). However, the services provided and complexity tools used were similar. Nearly all reported addressing both medical and social needs for their complex patients with multiple chronic conditions. Although there are large differences in resources and capabilities between large and small care systems, they were not associated with much difference in the approach taken to care coordination. This map of the care coordination territory in Minnesota has the potential to be valuable to researchers and care system leaders for understanding current implementation trends and directing further evaluations.

Using Community Paramedicine to Treat Hepatitis C Virus in Upstate South Carolina.

Hepatitis C virus (HCV) is an infection of the liver that can lead to significant liver damage and hepatocellular carcinoma. Individuals born between 1945 and 1965 and individuals with intravenous drug use represent the largest HCV demographics and often experience barriers to treatment. In this case series, we discuss a novel partnership between community paramedics (CPs), HCV care coordinators, and an infectious disease physician to provide HCV treatment to individuals with barriers accessing care. Three patients tested positive for HCV within a large hospital system in the upstate region of South Carolina. All of the patients were contacted to discuss their results and scheduled for treatment by the hospital's HCV care coordination team. Patients who expressed barriers to attending in-person appointments or were lost to follow-up were offered a telehealth appointment facilitated by CPs performing a home visit with the added ability to draw blood and perform a physical assessment guided by the infectious disease physician. All of the patients were eligible for and prescribed treatment. The CPs assisted with follow-up visits, blood draws, and other patient needs. Two of the three patients connected to care had an undetectable HCV viral load following 4 weeks of treatment, whereas the third was undetectable after 8 weeks. Only one patient reported a mild headache that was potentially linked to the medication, whereas the others did not report any adverse effects. This case series highlights the barriers experienced by some HCV-positive patients and a distinctive plan to address impediments to access for HCV treatment.

Creating a proactive interdisciplinary approach to care: Embedding oncology care coordination within an oncology patient and family support program.

51 Background: The benefits of providing psycho-oncology services have been well documented in producing better effective team collaboration, patient outcomes, and reduced healthcare utilization. Cedars-Sinai Cancer spans five locations and serves over 11,000 patients a year. Their robust Patient and Family Support program (PFSP) includes psychiatry, palliative medicine, social work, nutrition, cancer rehabilitation, survivorship, and chaplaincy to envelop patients in multiple dimensions of support. A new oncology care coordination (CC) model embedded a social work (SW) and nurse (RN) CC within PFSP to identify and meet diverse unmet needs of patients through close interdisciplinary collaboration. Methods: Oncology CC was established within PFSP, containing an oncology SW CC and an oncology RN CC. Patients with higher acuity needs were identified through multiple avenues such as: health plan reporting and dashboards in the electronic medical record (EMR) providing alerts for patients with unmet needs. Preliminary data was captured on interdisciplinary collaboration and care coordination from a daily log kept by coordinators, as well as from the EMR. Results: Over 6 months (9/2021 to 2/2022), the PFSP CC team served 688 patients providing 1280 interventions. Of the 1280 interventions, 22% were coordination with other PFSP services; of which 54% was with SCM, 36% with Clinical SW, and 18% represented new referrals. 13% focused on outside services including medical devices, home health, and community resources. 6% comprised of post-discharge calls by the RN CC and 16% represented direct SW CC outreach. Care coordination such as appointment scheduling, assistance with prescriptions and communication with medical teams represented 9%, 1% and 11% of the interventions respectively. Conclusions: Results demonstrated for this subset of patients that the highest needs of oncology PFSP CC were SW and SCM, to address needs such as pain and symptom management, goals of care conversations and community resource linkage. Anecdotally, communication with primary oncology and other medical teams proved to be an essential role of the CC team, particularly to address inpatient to outpatient transitions of care. Discussion: CC team involvement is time-limited and appears to rely on the long-term relationship patients have with PFSP interdisciplinary team members for interventions to be long-lasting and effective. The CC team leveraged existing relationships that PFSP providers had established with primary oncology teams, allowing for timely care coordination. Future goals include: 1) developing an algorithm to better identify patients with higher acuity and unmet needs; 2) measuring impacts of CC services on care outcomes, health care utilization and reduced symptom burden; 3) expanding the CC team to serve more of the patient population.

Underrepresented minority clinical trial participation: Perspectives of the research care team and patients.

93 Background: Clinical trials (CT) are important treatment options for patients with cancer, yet enrollment rates among underrepresented minority (URM) patients remain suboptimal. Oncology care teams need to assess barriers and facilitators of CT participation and identify practices and resources to better support patients. As part of a larger mixed-methods project, we elicited perspectives on improving URM CT enrollment from oncology research care teams and patients. Methods: We conducted four 60-minute focus groups with 12 oncology physicians, 12 research nurses, and nine clinical research coordinators, and semi-structured interviews with nine URM CT patients at a large academic medical center between January and December 2021. Results: Thematic analysis of the focus groups and interviews identified multiple barriers and potential resources and supports at the patient, healthcare team, institutional, and trial design levels. Barriers included difficulty ensuring patient understanding and informed consent, especially among patients with low health literacy and limited-English proficiency, complex logistical and financial demands of CT participation for patients, and the lack of multidisciplinary oncology care team collaboration. Collectively, these barriers undermined communication, trust, and the quality of patients’ relationships with the care team, all affecting CT participation. Suggested resources and practices included proactive needs assessments for all patients with early engagement of social workers, providing a liaison or navigator for each patient, services and support to reduce patient out of pocket costs, expansion of non-English materials availability and increased used of interpreters, increased training and diversity for all care team roles, and simplifying CT requirements by streamlining informed consent documents, eliminating unnecessary CT-related appointments, and broadening eligibility criteria. Conclusions: Findings suggest that changes in clinical trial design, care team coordination, and early assessment and monitoring of patients’ needs and experiences may help reduce access barriers and increase enrollment of URM patients into cancer CTs.

Influence of interaction between community health workers and adults with chronic diseases on risk mitigation through care coordination

Introduction Addressing health disparities and barriers to care requires a comprehensive approach that involves participation of health care providers, multiple organizations, and service providers in the communities affected. Given the importance of using community health workers to help address the complex and overlapping medical, social, and behavioral needs of high-risk individuals, it is of utmost importance to understand their impact on health outcomes. This study examines how in-person interaction between community health workers and their clients influence the client's level of risk mitigation achieved through care coordination using the Pathways Community HUB model. Methods The study utilized two years of data extracted from the Care Coordination Systems database for 391 adults who participated in the Northwest Ohio Pathways Community HUB program. Using multinomial logistic regression analysis, we assessed how the interaction between community health workers and adults with chronic diseases who participated in the Northwest Ohio Pathways Community HUB program influenced the successful mitigation of their social, behavioral, and other medical risks over a 2-year period. Results Our findings show that as the number of in-person contacts between the community health worker and the client increased, the likelihood of completing all Pathways increased by 27% when compared to completing less than 50% of the assigned Pathways, after adjusting for potential confounders (odds ratio: 1.27, 95% confidence interval: 1.07−1.52). Discussion Using community health workers as part of care coordination teams may be effective in connecting communities to systems of care, helping individuals manage their health conditions and connecting individuals to needed social services. Their direct in-person interaction with at-risk individuals may increase the extent to which these individuals successfully address risks to their health and well-being.

An intervention package for supporting the mental well-being of community health workers in low, and middle-income countries during the COVID-19 pandemic

BackgroundAs the COVID-19 pandemic continues, there is an increasing reliance on community health workers (CHWs) to achieve its control especially in low, and middle-income countries (LMICs). An increase in the demand for their services and the challenges they already face make them prone to mental health illness. Therefore, there is a need to further support the mental health and well-being of CHWs during the COVID-19 pandemic. MethodsWe organised a workshop on Zoom to deliberate on relevant components of an intervention package for supporting the mental health of CHWs in LMICs during the COVID-19 pandemic. We used a thematic analysis approach to summarise deliberations from this workshop. OutcomesParticipants identified the need for a hub for coordinating CHW activities, a care coordination team to manage their health, training programs aimed at improving their work performance and taking control of their health, a communication system that keeps them in touch with colleagues, family, and the communities they serve. They cautioned against confidentiality breaches while handling personal health information and favoured tailoring interventions to the unique needs of CHWs. Participants also advised on the need to ensure job security for CHWs and draw on available resources in the community. To measure the impact of such an intervention package, participants encouraged the use of mixed methods and a co-designed approach. InterpretationAs CHWs contribute to the pandemic response in LMICs, their mental health and well-being need to be protected. Such protection can be provided by using an intervention package that harnesses inputs from members of the broader health system, their families, and communities.

Considerations for Optimal Administration of Chimeric Antigen Receptor (CAR) T-Cell Therapy Programs: A Multi-Stakeholder Qualitative Analysis

CAR-T therapies represent a novel advance in oncology, albeit at list prices that exceed $373,000 (and that does not capture their total cost to the healthcare system). Since initial product approval in 2017, stakeholders and observers have attempted to investigate clinical and financial impacts of CAR-T therapies, and potential approaches to optimizing access and use by eligible patients. Most existing research is from a single stakeholder perspective - patients, providers, or payers - limiting the ability to draw broader conclusions on trends and offer prospective recommendations. To address this knowledge gap, we sought to identify and describe critical success factors for optimal delivery of CAR-T therapies. We undertook a qualitative study based on interviews with multiple US-based stakeholders including clinicians, financial and operations staff, and payer-insurers.Interviewees–which included oncologists (n=6), facility financial and operational personnel (n=4), and coverage and reimbursement decision-makers from US health plans (n=3)–completed structured, live, hour-long, interviews covering clinical, administrative, and general topics on patient access to CAR-T therapies. All clinicians had experience with ≥1 FDA-approved CAR-T therapies in both registered clinical trials and clinical practice; financial and operational personnel were affiliated with the same facilities as the clinicians, and also had real-world experience with these therapies; payer representatives were directors from a large national commercial plan, regional integrated delivery network, and a Medicare administrative contractor, respectively.Consensus facility feedback (i.e., clinicians, operational personnel) was that CAR-T is effective, and that their administrative processes had been optimized through care team coordination and experience-based efficiencies; in contrast, 2 of 3 payer interviewees expressed that, while CAR-T therapies have shown efficacy, their real-world benefits and applicability are less well-defined. Facility interviewees noted that: (1) reimbursement from commercial insurers is higher than from Medicare, with the latter associated with per-patient net-neutral or negative margins; (2) when possible, differential reimbursement between inpatient and outpatient settings may drive patient management towards outpatient care; and (3) negative-margin cases are currently deemed acceptable due to nonclinical factors (i.e., competitive pressure within a geographic region, anticipated branding/marketing value) and relatively small treated populations. From payer interviewees, CAR-T cost and perceived cost-to-value have made health plans more receptive to considering outcomes-based contracting, capitated provider payments, or other mitigation methods. Left unoptimized, these factors may adversely impact patient access to, and long-term provider attractiveness of, CAR-T therapies.All interviewees agreed that as the CAR-T marketplace grows, a strong preference exists for manufacturers to develop and communicate for their therapies durable outcomes data, clear and comprehensive reimbursement information, and competitive pricing. With the potential for many approved products in a single indication, and/or a single approval for indications with relatively large eligible patient populations, interviewees also conveyed interest in compelling health economic data. Facility interviewees also acknowledged that if it remains an overall net-negative margin service, new providers will be less able to start CAR-T programs and smaller programs may encounter sustainability issues, collectively jeopardizing patient access to these life-changing therapies.Overall, findings from this study suggest that during the continued maturation of the landscape, stakeholders will need to be proactive to ensure that CAR T-cell therapies can be maintained amidst financial and operational pressures. Several CAR-T therapy options for multiple myeloma are on the immediate horizon, likely increasing demand among eligible patients. Accordingly, the need to link real-world evidence of the clinical value and institutional investment burden of these therapies to reimbursement is imperative, both to insulate payers and enable clinicians to provide innovative therapies. [Display omitted] DisclosuresFaber: Amgen: Honoraria; Adaptive: Honoraria; Cardinal Health: Honoraria; Celgene: Honoraria; Astra Zeneca: Honoraria; GlaxoSmith Kline: Honoraria; Janssen: Honoraria; Juno: Honoraria; Karyopharm: Honoraria; Kite: Honoraria; Takeda: Honoraria; Sanofi Genzyme: Honoraria. Hunter: BMS: Consultancy, Honoraria; Kite: Consultancy, Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria. Deol: Kite, a Gilead Company: Consultancy. Crivera: Johnson & Johnson: Current Employment, Current equity holder in publicly-traded company. Riccobono: Legend Biotech: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company. Garrett: Legend Biotech USA: Current Employment. Jackson: Memorial Sloan Kettering Cancer Center: Consultancy; Janssen: Current Employment. Fowler: Amgen: Ended employment in the past 24 months; Janssen: Current Employment. Berger: Janssen Scientific Affairs: Consultancy, Research Funding. Lorden: Janssen Scientific Affairs: Consultancy, Research Funding. Stewart: Janssen Scientific Affairs: Consultancy, Research Funding.

Abstract 1122‐000033: Automated Detection of Intracerebral Hemorrhage Using Artificial Intelligence: Pilot Deployment of Viz ICH

Introduction : Stroke is a major cause of morbidity and mortality. Hemorrhagic strokes are often more severe and associated with higher mortality when compared to ischemic stroke and account for approximately 13% of all strokes. Initial care for patients with intracerebral hemorrhage (ICH) is in part guided by neuroimaging findings. Non‐contrast computed tomography (NCCT) is often the first imaging obtained in the work up of the acute stroke patient given its diagnostic accuracy for hemorrhage, ubiquity, low cost, and short scan time. Immediate evaluation of imaging by stroke experts, such as neurologists, neurosurgeons, and radiologists, is essential. Artificial intelligence tools can help to expedite image assessment and careteam coordination thereby accelerating time to treatment. In this study, we report on the use of Viz ICH, an AI‐enhanced ICH detection platform, to identify ICH on initial CT and coordinate emergent care in an urban health system with an ICH Center. Methods : All consecutive stroke codes presenting with ICH from May 2019 to August 2019 were eligible for analysis. Non‐contrast CT (NCCT) was conducted for each patient and submitted to the Viz ICH in a prospective fashion. An automated volumetric analysis of these NCCTs was conducted by Viz ICH and assessment was conducted for potential ICH. If suspected ICH was detected, Viz ICH sent an automated prompt to the stroke care team for review. CT impressions provided by radiologists served as the clinical reference standard test and Viz ICH output served as the index test. Diagnostic accuracy tests were then performed. Results : A total of 682 patients were analyzed for ICH, out of which 28 patients were positive for intracerebral hemorrhage (ICH) (4%) and 654 were negative for hemorrhage (96%) based on radiology impressions. Viz ICH was able to correctly identify hemorrhages in 25/28 patients and non‐hemorrhages in 650/654 patients. Overall, the software had high diagnostic accuracy with 89.3% sensitivity, 99.4% specificity, and an overall accuracy of 99.0%. The software also had a positive predictive value of 86.2%, a negative predictive value of 99.5%, a positive likelihood ratio of 145.98, and a negative likelihood ratio of 0.108. Conclusions : Viz ICH is an AI‐enhanced platform that may help in the diagnosis and detection of ICH, with a sensitivity of 89.3 and a specificity of 99.4% in this preliminary study. Though future validation studies with a larger cohort of patients positive for each type of hemorrhage must be conducted for true diagnostic accuracy data, Viz ICH has the potential to be an adjunct tool to streamline ICH triage, reduce treatment delays, and improve outcomes of patients presenting with ICH.

Integrated care for children with medical complexity living in rural Australia – an evaluation of family experiences using the Paediatric Integrated Care Survey

1. Introduction: The number of children with medical complexity (CMC) residing in regional/rural Australia is growing, challenging the health system to provide equitable and accessible care. Families of CMC experience problems in accessing appropriate care locally; they have high out-of-pocket costs and family disruptions because of long travel distances to access care in metropolitan paediatric hospitals. 2. The Practice Change: The Murrumbidgee Local Health District (MLHD) in New South Wales (NSW), Australia, in collaboration with the Sydney Children’s Hospitals Network (SCHN) partnered with families and local services to co-design a Model of Care (MoC) to better meet the needs of CMC, their families and local services3. Aim and theory of change: To demonstrate changes in parent-reported experiences, we used the Paediatric Integrated Care Survey (PICS) in a longitudinal cohort design at baseline, and 6 months after enrolment in the MoC.4. Targeted population and stakeholders: To qualify for enrolment in the new MoC children had a diagnosed condition involving more than one organ system, were medically fragile or reliant on medical technology, or had used health services frequently in the last 12 months e.g. >6 emergency department presentations, >4 hospital admissions and >10 outpatient clinic visits. Stakeholders included families of CMC, healthcare providers and managers working in the MLHD and and at the SCHN.5. Timeline: The new MoC was implemented in 2018 and CMC have been systematically identified, and enrolled in the MoC. The PICS was administered at baseline and at 6 months.6. Highlights – innovation, impact and outcome: 41 CMC have been enrolled and 18 of the families completed the PICS at both time points. Difficulties navigating healthcare systems, fragmented care, poor communication, and limited care planning and goal setting were apparent at baseline. After accessing the MoC for at least 6 months (6-14 months) there was a 33% increase in written short term care goals (p=0.045). Care teams were 11% more likely to discuss healthcare decisions that impact the whole family (p=0.005) and intra-team communication improved for 5.5% of families (p=0.003). Interestingly, 22% of families were less comfortable letting team members know about concerns about their child’s healthcare (p=0.001). The care coordination team in the MoC reported valuing the PICS results as an assessment of need for integrated care.7. Comments on sustainability and 8. Transferability: The Moc has been embedded into the system in the MLHD, a rural area of NSW, Australia. The clinical teams working with families of CMC felt that the the PICS results informed their practice. The MoC, including assessments using the PICS has been adapted to another rural area - the Southern NSW LHD.9. Conclusions, 10. Discussion, and 11. Lessons learned: Using the PICS periodically during implementation of the new MoC provides feedback loops to inform future model adjustments. The PICS has highlighted the need for shared care plans and recognition of the impacts of caring for a CMC on family functioning. Qualitative research is needed to better provide context to the longitudinal PICS data.

Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team.

Objectives: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions—FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population.Methods: We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population.Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 – 1.75) and hospital days per year (16.83, CI 1.76 – 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization.Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.

Lessons Learned, Best Practices: Care Coordination for Children with Medical Complexity.

Although care coordination has long been established in the health care system in the United States, too often it may compete or work at cross purposes with care teams serving patients and families. Care coordination is a team sport that requires strong clinician-family partnerships as well as adequate time and resources to be done effectively. We incorporate the latest literature to offer clarity for identifying, coordinating, and funding care for children with medical complexity (CMC), the most medically fragile, high-cost subpopulation of children and youth with special health care needs. Algorithms for identifying CMC exist. Calculation of the cost of care for CMC is confounded by cost shifting to families and the variable course of illness and aging in this heterogeneous population. Multiple studies of different sizes have reported similar care coordination team structure, staffing ratios, and cost ranges. We describe models for funding this work and how they can be tailored to individual practice environments. [Pediatr Ann. 2020;49(11):e457-e466.].

The pharmacist’s role in implementation of the ABCDEF bundle into clinical practice

To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.

STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit.

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.