Innovative Care Delivery Research Articles

Psychological distress, structural barriers, and health services utilization among U.S. adults: National Health interview survey, 2011–2017

Undertreatment of mental illness is associated with greater acute care and costs and worse mental and physical outcomes. Structural barriers may contribute to worse care. National Health Interview Survey data for 2011–2017 were used to examine associations of psychological distress and nine structural barriers with four health services, guided by the Andersen Behavioral Model of Health Services Utilization. Per the Kessler-6 Scale, United States adults 18–64 years of age (sample size = 172,209, estimated annual population = 189.4 million) were categorized as: no or low psychological distress (NLPD: 79.2%), moderate (MPD: 17.1%), and serious (SPD: 3.7%). Those with MPD and SPD had higher likelihoods of any mental health visit (Adjusted Odds Ratio: 3.53; 8.36, respectively), hospitalization (AOR: 1.16; 1.55), emergency room/department visit (AOR: 1.62; 2.23), and lower likelihood of office visits (AOR: 0.42; 0.64) in the past 12 months compared to NLPD (all p < 0.001). Psychological distress was the largest contributor of explained variation for mental health visits (67%), hospitalization (37%), and ER/ED usage (47%). Adults with SPD and MPD faced structural barriers at higher proportions. For example, reports of “had trouble finding general doctor” were: NLPD (2.2%), MPD (6.0%), and SPD (11.8%). Eight structural barriers were positively associated with ER/ED use and five barriers negatively associated with office visits. Barriers significantly associated with all four outcomes were: “Told health care coverage not accepted” and “Delayed care, couldn’t get appointment soon.” Innovative policy solutions coupled with comparable innovations in care delivery for complex patient populations could ensure equitable access to health services for individuals with psychological distress.

A Road Map for Health Care Consolidation

Summary This issue of NEJM Catalyst Innovations in Care Delivery contains articles, case studies, and research reports on mergers and acquisitions, behavioral health care in nursing homes, advanced practice providers, telemedicine, fertility care, and maternal health.

Virtual Group Therapy Within a Shared Medical Appointment: Innovative Care Delivery in Behavioral Oncology.

Diagnosing and treating behavioral concerns should be prioritized throughout cancer survivorship. Behavioral health is included in national guidelines for survivorship care, but meeting those needs for a growing population of.

Drive-Through Medicine: A Novel Health Care Delivery Mechanism for the COVID-19 Pandemic

BackgroundCoronavirus disease 2019 (COVID-19) placed additional strain on an already struggling health care system. In response, novel solutions such as telehealth have been explored, however, there is significant room for innovation in health care delivery. ObjectivesThe aim of our study was to evaluate the effectiveness of a drive-through medical treatment system for evaluating patients with COVID-like symptoms. MethodsWe designed a prototype drive-through medical treatment facility (DMF) to triage large volumes of patients quickly and efficiently, while fully evaluating, treating, and discharging low-risk patients. A retrospective chart review was performed to extract clinical and logistical metrics. ResultsA total of 2164 patients were evaluated between May 1 and July 1, 2020. Overall accuracy for patient classification was 92.4% (95% confidence interval [CI] 91.2–93.5%). Screening criteria resulted in a return with need for workup or admission rate of 0.25%, yielding a sensitivity of 83.3% (95% CI 65.3–94.4%). Of those presenting to the DMF, 179 patients (8.3%) were diverted to the main emergency department (ED) for further evaluation, of which 14% received diagnostic workups and 5% subsequent admission to an inpatient service, yielding a specificity of 92.8% (95% CI 91.7– 93.9%). Length of stays for those seen in the DMF vs. the main ED (M = 38 min vs 149 min) yielded a mean difference of 111 min per encounter and a total time savings of 3762 h. ConclusionDrive-through medical systems can accurately triage patients presenting with potential COVID-19 and effectively treat lower-risk patients, thereby reducing ED utilization.

Home-Based Primary Care: Adaptability Criteria for the Bedroom Layout and the Furnitures/Technological Equipments.

Within the past decade, advances in medical technology, the desires and complex care needs of an ageing population, and innovative care delivery models have initiated a shift from providing care in hospitals to outpatient settings. And more recently, the acceleration and amplification of these factors is pushing healthcare options even further from the traditional inpatient and outpatient settings towards acute and subacute care in the home. This has led the medical community to look toward providing more tools and methods of care that patients can access safely right from home and the designers to think as the homes of the future will be flexible to support both an array of devices to provide a healthcare delivery and the humanization and personalization of the domestic space. The paper identifies criteria for the flexible design of the physical environment (including the home, equipment, furniture, etc.) that support and facilitate safety, comfort, and healing, in relation to the various patient populations, at their own physical and psychosocial needs, at the range of equipment/technology (from chronic to acute care), at the caregiving and daily living activities.

Transforming Health Care, One Article at a Time

Summary This issue of NEJM Catalyst Innovations in Care Delivery contains articles, case studies, and research reports on accountable care, patient experience, quality improvement, abortion and reproductive health, teledermatology, and rural health.

Correction to: Translating Clinical Guidelines into Care Delivery Innovation: The Importance of Rigorous Methods for Generating Evidence.

Correction to: Translating Clinical Guidelines into Care Delivery Innovation: The Importance of Rigorous Methods for Generating Evidence.

Engaging nurses in patient recruitment to research trials in the emergency department.

Research is essential for the implementation of evidence-based practice and can lead to improvements and innovations in care delivery. Although ultimately beneficial for patients and staff, the data collection involved in research often presents challenges, particularly in the emergency department (ED) setting. This article describes the challenges of undertaking a feasibility trial in a city centre ED. The target research population were adult patients who presented to the ED with an issue related to opioid misuse, for example opioid overdose, injection site wounds and/or abscess, or injury sustained during opioid intoxication. Challenges experienced during this trial included a demanding work environment, ED attendees not being suitable for recruitment into research, and suspension of the trial during the coronavirus disease 2019 (COVID-19) pandemic. The author details the strategies introduced to ensure effective patient recruitment to the trial, including nurse secondment onto the research team, offering incentives, raising awareness of the trial among ED staff and implementing flexible training. These strategies continued to be effective after a period of suspension due to the COVID-19 pandemic.

Promoting the Pipeline of Diverse Individuals Within Gastroenterology: Reflections From AGA FORWARD Program Scholars

Promoting the Pipeline of Diverse Individuals Within Gastroenterology: Reflections From AGA FORWARD Program Scholars

From Health Care to Whole Health

Summary This issue of NEJM Catalyst Innovations in Care Delivery contains articles, case studies, and research reports on social determinants of health (SDOH), psychosocial care in the ICU, AI for health care–associated infections, workforce resilience, and Covid-19 vaccination.

Framework for integrating electronic patient-reported data in routine cancer care: an Oncology Intake Questionnaire.

ObjectiveAs part of ongoing implementation of electronic patient-reported outcome tools at the Dana-Farber Cancer Institute, here we describe the development of the electronic New Patient Intake Questionnaire.Materials and MethodsThe original New Patient Intake Questionnaire includes a review of symptoms, oncology history, family history, health behaviors, health and social status, health literacy and numeracy, which was modified for integration into the EHR using content determination, build and configuration, implementation, analytics, and interventions. The engagement of key stakeholders, including patients, clinical staff, and providers, throughout the development and deployment of the electronic Questionnaire was crucial to producing a successful tool. Continual modifications based on input of stakeholders (such as mode of tool deployment) were made to ensure the utility and usability of the tool for both patients and providers.ResultsImplementation of the EHR-integrated electronic New Patient Intake Questionnaire improved collection of the PRD by increasing questionnaire accessibility for patients, while also providing all available data to clinicians and researchers. Careful consideration of the content and configuration of the questionnaire allowed for a successful, institute-wide implementation of the tool.DiscussionThis effort demonstrates the feasibility of implementation of a system-wide electronic questionnaire, emphasizing the importance of iterative refinement to create a tool that is both patient-centric and usable for clinicians.ConclusionsThe electronic New Patient Intake Questionnaire allows for systematic collection of the PRD, which should benefit cancer care outcomes through innovative care delivery and healthcare interventions.

Access to pediatric dermatology.

To identify factors that impact accessibility to pediatric dermatology and review healthcare delivery models that improve access and address these barriers. Up to one-third of pediatric primary care visits include a skin-related problem, yet pediatric dermatology subspecialist services are highly inaccessible. Workforce shortages and geographic, sociocultural, and economic barriers perpetuate inaccessibility. Teledermatology expands care, particularly to underserved or geographically remote communities, and reduces healthcare-related costs. Federal legislation to support telehealth services with adequate reimbursement for providers with parity between live, video, and phone visits will dictate the continued feasibility of virtual visits. Innovative care delivery models, such as language-based clinics, multidisciplinary teleconferencing, or embedded dermatology services within primary care are other promising alternatives. Despite efforts to expand access, dermatology still ranks among the most underserved pediatric subspecialties. Improving access requires a multipronged approach. Efforts to expand exposure and mentorship within pediatric dermatology, diversify the workforce and clinical curriculum, recruit and retain clinicians in geographically underserved areas, and collaborate with policymakers to ensure adequate reimbursement for teledermatology services are necessary.

The Health Care Connection to Climate Change

Summary This issue of NEJM Catalyst Innovations in Care Delivery contains articles, case studies, and research reports on extreme heat events and climate change, patient-reported measures, transitional care, Covid-19 treatments, and telemedicine.

Health Care Innovation in Action

Summary This issue of NEJM Catalyst Innovations in Care Delivery contains articles, case studies, and research reports on Covid-19 patients, respiratory therapy via telemedicine, depression treatment standards, mental health support through esports, menopause care, and advanced practice providers.

Care innovations and health disparities: An exploration of COVID-19 outcomes in inpatient and hospital-at-home care settings

Background: Hospital at home (HaH) programs have been a critical resource for providing inpatient care to acutely ill patients throughout the COVID-19 pandemic. Given that this innovative care delivery model relies on technology and environmental concerns, questions have been raised about the effectiveness of HaH for vulnerable groups. However, evidence is extremely limited regarding equity issues in the HaH context. Thus, we explored COVID-19 outcomes within vulnerable groups. Methods: We conducted a matched, retrospective study of 116 acutely ill patients with COVID-19, aged ≥18 years, who presented to an AH emergency department (ED) and were admitted for inpatient care. Treatment patients were admitted to AH HaH between July 15 and September 31, 2020, and control patients were hospitalized between May 8 and June 25, 2020. Patients were matched based on oxygen requirement and DS CRB-65 (DEFINE) score. Race or ethnicity and area deprivation index (ADI) were chosen as predictors of health disparities. The ADI incorporates 17 indicators of poverty, educational attainment, and housing quality at the census tract level. Outcomes included 30-day (from discharge) severe illness or death composite, IP readmission, and ED visit. Results: The frequency of 30-day severe illness or death and ED visits were equivalent between the groups (n = 11; ED n = 5); the proportion of severe illness was higher for White patients in AH-HaH (n = 9 vs n = 5), and for Hispanic patients treated in the hospital (n = 5 vs n = 0; Fig. 1). There were no 30-day inpatient readmissions in the AH-HaH group, but 8 readmissions occurred with inpatients. The distribution of severe illness among the ADI quintiles varied. For traditional inpatients, disease progression was limited to ADI Q3–5 (Q3 = 3, Q4 = 6, Q5 = 2); for AH-HaH patients, disease progression was not influenced by ADI. The effect of ADI on 30-day ED readmission was nonsignificant. Conclusions: Although exploratory in nature, the results suggest that HaH may help combat sources of health disparities that have dominated the pandemic. Although inpatient care resulted in inpatient readmissions, mainly among Black and Hispanic patients, AH-HaH stays were not associated with any inpatient readmissions. The equivalent distribution among ADI quintiles of patients who became severely ill within 30 days of their AH-HaH stay suggests that HaH may be able to leverage innovation to reach vulnerable populations and reduce the impact of factors that contribute to inequity.Funding: NoneDisclosures: None

Innovative virtual care delivery in a Canadian paediatric tertiary-care centre.

Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children's Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

Shared Access to Patient Portals for Older Adults: Implications for Privacy and Digital Health Equity.

Growing reliance on the patient portal as a mainstream modality in health system interactions necessitates prioritizing digital health equity through systems-level strategies that acknowledge and support all persons. Older adults with physical, cognitive, sensory, and socioeconomic vulnerabilities often rely on the involvement of family and friends in managing their health, but the role of these care partners in health information technology is largely undefined and poorly understood. This viewpoint article discusses challenges and opportunities of systematic engagement of care partners through shared access to the patient portal that have been amplified in the context of the COVID-19 outbreak and recent implementation of federal information blocking rules to promote information transparency alongside broader shifts toward care delivery innovation and population aging. We describe implementation considerations and the promise of granular, role-based privacy controls in addressing the nuanced and dynamic nature of individual information sharing preferences and fostering person- and family-centered care delivery.

The Ever-Advancing Cost of Care

Summary This issue of NEJM Catalyst Innovations in Care Delivery contains articles, case studies, and research reports on de-implementation of low-value care, payer-provider alignment, group treatment for hepatitis C, lower-cost drugs for retinal disease, collaborative care for severe and persistent mental illness, and wearable sensors for pediatric patients with type 1 diabetes.

The Affordable Care Act After a Decade: Industrial Organization of the Insurance Exchanges

The regulated insurance exchanges set up in the Affordable Care Act (ACA) were designed to deliver affordable, efficient health coverage through private insurers. It is crucial to study the complex industrial organization (IO) of these exchanges in order to assess their impacts during the first decade of the ACA and to project their effects going forward. We revisit the inherent market failures in health care markets that necessitate key ACA exchange regulations and investigate whether they have succeeded in their goals of expanding coverage, creating robust marketplaces, providing product variety, and generating innovation in health care delivery. We discuss empirical IO research to date and also highlight shortcomings in the existing research that can be addressed moving forward. We conclude with a discussion of IO research-based policy lessons for the ACA exchanges and, more generally, for managed competition of private insurance in health care.

Innovations in Care Delivery for Patients With Serious Mental Illness Among Accountable Care Organizations.

This study examined whether and how organizations participating in accountable care organization (ACO) contracts integrate primary care and treatment for patients with serious mental illness. This study used responses to the 2017–2018 National Survey of ACOs (55% response rate) to measure ACO-reported use of three integrated care strategies: care manager to address physical health treatment coordination or nonmedical needs (e.g., job support and housing), patient registries to track physical health conditions, and primary care clinician colocated in a specialty mental health setting. Logistic regression was used to determine associations between ACO characteristics and strategy use. Of 399 respondents who answered questions on integration, 303 (76%) reported using at least one integrated care strategy in at least one location. Use of care managers (defined by the respondent) was most common (N=281, 70%), followed by use of a patient registry (N=146, 37%) and colocation of a primary care clinician in a specialty mental health setting (N=118, 30%). Respondents reporting that their largest Medicaid contract or largest commercial contract included quality measures specific to serious mental illness (e.g., antipsychotic adherence) were more likely to use each integrated care delivery strategy. Self-reported use of three collaborative care strategies (care management, patient registry, or mental health consulting clinician) for treatment of depression or anxiety was associated with use of integrated primary care and treatment for serious mental illness. In a national survey of ACOs, few respondents reported using either patient registries or primary care colocation to integrate primary care and treatment for serious mental illness.