Transform Care Delivery Research Articles

Market Consolidation and Innovation in US Dialysis

While patients with end-stage kidney disease have benefited from innovations in clinical therapeutics and care delivery, these changes have been primarily incremental and have not fundamentally transformed care delivery. Dialysis markets are highly concentrated, which may impede innovation. Unique features of the dialysis industry that have contributed to consolidation can help to explain links between consolidation and innovation. We discuss these unique features and then provide a framework for considering the effects of consolidation on innovation in dialysis that focuses on the following economic considerations: (1) industry characteristics, composition, and stage of consolidation, (2) innovation characteristics and relative profitability, (3) the role of government regulation, and (4) innovation from smaller providers and new entrants. We present examples of how these considerations have influenced the adoption of alternative dialysis technologies such as peritoneal dialysis and erythropoietin-stimulating agents, and we discuss how consolidated markets can both help and hinder recent policy initiatives to transform dialysis care delivery. Only by considering these important drivers of consolidation, future efforts can be successful in transforming end-stage kidney disease care.

Advancing primary care with Artificial Intelligence and Machine Learning

Primary care is the largest healthcare delivery platform in the US. Facing the Artificial Intelligence and Machine Learning technology (AI/ML) revolution, the primary care community would benefit from a roadmap revealing priority areas and opportunities for developing and integrating AI/ML-driven clinical tools. This article presents a framework that identifies five domains for AI/ML integration in primary care to support care delivery transformation and achieve the Quintuple Aims of the healthcare system. We concluded that primary care plays a critical role in developing, introducing, implementing, and monitoring AI/ML tools in healthcare and must not be overlooked as AI/ML transforms healthcare.

The Evolution of Telehealth From Pre-COVID-19 Pandemic Through A Hybrid Virtual Care Delivery Model: A Pediatric Hospital's Journey.

The COVID-19 pandemic transformed care delivery and influenced telehealth adoption by rehabilitation professionals and their patients. The purpose of this paper is to describe a pediatric health system's telehealth services pre-pandemic and how those services were scaled during the pandemic. A secondary aim is to provide a roadmap for the operational delivery of telehealth and rehabilitation services, including transition to a hybrid care delivery model. Findings suggested that telehealth can be rapidly scaled to address patient healthcare needs for an early intervention population during a pandemic. Telehealth use during the pandemic helped ensure continuity of care and likely reduced the risk of exposure to patients and staff to the virus. Benefits included enhanced access to care, and savings in time and money for families. Interestingly, as the pandemic declined, the use of telehealth services declined due to patient preference, with many families opting to request a return to in-person care.

Forecasting the Future of Healthcare Democratization

Abstract Health longevity, cost reduction, prevention-based healthcare, personalized medicine, predictive diagnostic, transformed care delivery, de-aging, healthy lifestyle trends, and implementation of intelligent technologies should lead to a more democratized (availability for everyone on this planet) healthcare provision. Forecasting the future of healthcare and health policy certainly is imperfect but nevertheless a precious scientific approach that can lead to novel innovative approaches. In the last decade, the healthcare system faced several challenges, including the significant increase of care costs, demographic changes towards the older population, inability to prevent and overcome pandemics, increased chronic and non-communicable diseases, or resistance to adopting emerging technologies. The need to shift the focus from sickness to health becomes a critical mission. We developed a lecture titled "Healthtech Innovation Design" for graduate students from medicine, biomedical engineering, neuroscience and software engineering. The lecture's goal is to teach innovation methodologies, exponential technologies and methods to achieve healthcare democratization. A critical component is to promote initiatives with global teams focused on the future of health. The educational and initiative programs were impactful in growing interest toward innovation, focusing on disruption and healthcare democratization. Participants awareness towards the main issues and challenges was raised. Interdisciplinary participation was qualitatively processed to generate a holistic vision toward innovation. Through embracing digitalization to a patient-centric approach, affordable care services, and the expansion of precision medicine, the entire healthcare organization and management will likely undergo a worldwide change. Notably, digital technologies, the leverage of artificial intelligence and empathy would satisfy unmet clinical needs. With a future-oriented statement, the forecast of healthcare becomes more imaginable, in which democratization will allow the affordability of services in different countries and economic status.

Home healthcare patient, caregiver and provider perspectives on use of unscheduled acute care and the usability and acceptability of on-demand telehealth solutions

Background/Objectives: Home health care (HHC) agencies provide an important role in helping to transition patients from acute care to independent residential living. Telehealth has the potential to transform care delivery in HHC, however the majority of studies in HHC have focused on the use of telemonitoring for patients with specific chronic conditions. The objective of this study was to examine reasons HHC patients use acute care services and assess the acceptability of on-demand telehealth services among HHC patients, caregivers and personnel to help alleviate the need for seeking in-person acute care.Design/Setting/Participants/Measures: This study was a secondary analysis of qualitative data from in-depth interviews of 30 HHC personnel, patients and caregivers from a Medicare-certified HHC agency affiliated with a large healthcare system from January through May 2020. A conventional content analysis approach was used to identify themes.Results: Themes associated with reasons for seeking acute care included: sense of urgency, behavioral and psychosocial factors, and access to care. Participants described their perceptions of the benefits, usability and acceptability and barriers to using telehealth. Patients and HHC personnel agreed that on-demand telehealth should not replace in-person visits but all identified roles that on-demand telehealth services could play in improving communication and access to care. The biggest barriers to use of telehealth identified by HHC personnel were cost, access and ability to use technology by HHC patients.Conclusion: This study identified reasons HHC patients seek unscheduled acute care and the usability and acceptability of on-demand telehealth services to increase access to care among HHC patients. These findings underscore the need to improve communication and coordination between patients, HHC personnel, and primary care providers and the role that on-demand telehealth services can have in transforming HHC.

Learn Intestinal Failure Tele-ECHO Project: An innovative online telementoring and case-based learning clinic.

Intestinal failure (IF) is a rare chronic disease requiring intravenous (IV) fluids or parenteral nutrition (PN) dependency for optimal patient health and sustenance. The complex care is best managed by specialized multidisciplinary teams. Patients who have limited access to intestinal rehabilitation centers often receive IV/PN care from clinicians lacking specialty expertise. An innovative videoconferencing project was launched in May 2019 to provide online telementoring and case-based learning in IF. The Extension for Community Healthcare Outcomes (ECHO) model was adopted to provide education and virtual support via the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) project. Online clinics include patient case presentations, moderated discussion, best-practice recommendations, and didactic continuing education lectures on IF- and PN-related topics. Participation is interprofessional and international. Via knowledge dissemination and specialty mentorship, LIFT-ECHO is expected to improve healthcare for patients with IF and transform care delivery by overcoming the limitations in access to expertise.

The Design of Voxe: An Electronic Patient-Reported Outcome Measure Platform to Capture Pediatric Transplant Patients’ Voices and Transform Care

Purpose Patient-reported outcome measures (PROMs) are vital to engage patients meaningfully and capture their varied experience. The objective of this research program is to transform care delivery and improve health outcomes for pediatric transplant patients by implementing PROMs into clinical practice. Informed by the results of previous research - Phases 1 (Systematic Review), 2 (Key Stakeholder Interviews), and 3 (Consensus Workshop) - the aim of this study (Phase 4) is to create an electronic PROM (ePROM) platform - Voxe - that will capture and integrate PROM data into clinical care. Methods The ‘user-centric’ approach, in which end-users (i.e., patients and healthcare providers) are central to the design process, has guided the development of Voxe. Study participants include 12 heart, kidney, liver, or lung transplant recipients between 10 - 17 years of age and 16 members of their interdisciplinary healthcare teams. A rapid and iterative testing methodology has been implemented to ‘test, learn and improve’ Voxe prior to coding and launch. The International Organization for Standardization (ISO) model is also being utilized. Results To ensure success, ISO performance indicators are being benchmarked and tracked. During each iteration objective and subjective standards with metrics of (1) effectiveness - accuracy and completeness with which users achieve specific goals; (2) efficiency - resources used in relation to results achieved; and (3) satisfaction - extent to which the users’ physical, cognitive, and emotional responses that result from the use of Voxe meet the users’ needs and expectations are being collected. Using a Desirability Index, patient participants described Voxe as “clear”, “friendly”, “helpful” and “creative” and healthcare providers noted the ease of use of Voxe and its ability to enable “a more patient-centered model of care”. Conclusion The ‘test, learn, and improve’ model enables objective and subjective metrics from patients and healthcare providers to directly influence how Voxe looks and operates to drive adoption and success. Future phases will include usability testing and an implementation effectiveness evaluation of the platform. Ultimately, Voxe leverages eHealth technology as an innovative approach to capture and integrate patients’ voices into their care experience.

Patterns and predictors of oral anticancer agent utilization in diverse metastatic renal cell carcinoma patients.

279 Background: Availability of targeted oral anti-cancer agents (OAA) has transformed care delivery for metastatic renal cell carcinoma (RCC) patients. Our objective was to identify patterns and predictors of OAA use within the 12 months after metastatic RCC was detected to understand the extent of real-world adoption of these treatment advances. Methods: We used a novel, North Carolina, registry-linked multi-payer claims data resource to examine patterns of use of sorafenib, sunitinib, pazopanib, everolimus, axitinib, cabozantinib, and levantinib in a cohort of metastatic RCC patients diagnosed over 10 years (2006-2015, with claims through 2016). Patients were required to have 12 months of pre- and post-metastatic-index-date continuous enrollment. Log-Poisson models estimated unadjusted and adjusted risk ratios (RRs) and 95% confidence limits (CLs) for associations between patient characteristics and OAA use. In sensitivity analyses, we used a competing risk framework to estimate adjusted risk differences (RD) in OAA use. Results: Our population-based study of 713 patients demonstrated relatively low (37%) OAA use at any time during the 12 months post-metastatic-index date among publicly and privately insured patients, with shifting patterns of use consistent with regulatory approvals over time. Lower OAA use was observed among patients who were older, frailer, and with greater comorbidity burden. Other patient-level characteristics, such as sex, race, rurality and type of insurance were not significant predictors of OAA use. Conclusions: These data underscore the importance of distinguishing clinically appropriate from potentially poor-quality care and warrant additional studies to understand in more depth the system, provider and patient level drivers of these patterns.

Launching a Statewide COVID-19 Primary Care Hotline and Telemedicine Service.

Oregon Health & Science University's primary care team envisioned and implemented the COVID-19 Connected Care Center, a statewide telephone "hotline" service. The hotline has taken more than 5825 calls from patients in 33 of Oregon's 36 counties in less than 3 months. In preliminary survey data, 86% of patients said their questions were answered during the call, 90% would recommend this service, and 70% reported a reduction in stress levels about coronavirus. In qualitative interviews, patients reported their questions answered, short wait times, nurses spent time as needed, and appropriate follow-up was arranged. Academic health centers may have the capacity to leverage their extensive resources to rapidly launch a multiphased pandemic response that meets peoples' need for information and access to primary care, while minimizing risk of infection and emergency department use and rapidly supporting primary care teams to make the necessary operational changes to do the same in their communities. Such efforts require external funding in a fee-for-service payment model.

A Midwestern Academic HIV Clinic Operation during the COVID-19 Pandemic: Implementation Strategy and Preliminary Outcomes.

During the COVID-19 pandemic, HIV clinics had to transform care delivery for people with HIV (PWH). We developed a multifaceted telehealth implementation strategy and monitored number of out of care patients (OOC), medical visit frequency (MVF), gap in care (GiC) and viral suppression (VS), and compared measures to baseline data. Between April and October 2020, 1559 visits were scheduled; 328 (21%) were missed, and 63 (4%) were new to care. Of the remaining 1168 follow-up visits, 412 (35%) were telehealth visits. As of October 2020, there were 53 patients OOC, MVF was 55% and GiC was 24% compared to 34, 69% and 14% at baseline, respectively. Overall VS rate remained high at 93% (97% for telehealth and 91% for in-person visits, p = 0.0001). Our implementation strategy facilitated quick provision of telehealth to a third of PWH receiving care in our clinic. While MVF decreased and GiC increased, VS rates remained high.

112. A Quality Management Project of a Midwestern Academic HIV Clinic Operation During COVID-19: Implementation Strategy and Preliminary Outcomes

BackgroundDuring the COVID-19 pandemic, HIV clinics had to transform care delivery in order to ensure retention in care (RIC) for people with HIV (PWH). The objective of this quality management project is to maintain high rates of RIC and viral load suppression (VLS) during the pandemic for PWH receiving services at an academic HIV clinic in the Midwest.MethodsWe developed a multifaceted implementation strategy for clinic operation using a combination of telehealth and in-person visits. The strategy included: 1) assess for readiness and identify barriers and facilitators, 2) identify and prepare champions, 3) organize clinician implementation meetings, and 4) staff training. As a result, we developed an implementation blue print with criteria for telehealth vs. office visits, criteria for rescheduling patients, conducted staff training on telehealth and personal protective equipment, and changed the clinic structure to accommodate in-person visits for patients who did not meet telehealth criteria and walk-ins. We monitored VLS (defined as HIV RNA < 200 copies per mL) and RIC as measured by medical visit frequency (MVF, defined as percentage of patients who had one visit in each 6 months of the preceding 24 months with at least 60 days between visits); and gap in care (GiC, defined as no visit in the preceding 6 months).ResultsAs of June 14, 2020, there were 1140 active PWH receiving care at the clinic. By February 29, 2020 there were 34 patients lost to care as (defined as no visit within the preceding 12 months). Between March 1 and June 14, 2020 we conducted a total 943 visits, out of which 642 (68%) were in person and 301 (32%) were telephone visits. By end of May 2020, there were 47 patients lost to care. MVF decreased to 40% compared to 69% for FY2020, and GiC increased to 25% compared to 14% for FY2020. VLS rate remained unchanged at 91%.ConclusionThe COVID-19 pandemic resulted in a decrease in MVF and an increase in GiC for PWH. However, VLS remained high at 91%. Our implementation strategy facilitated quick adoption of telemedicine, which helped us provide clinical care to a third of PWH during the pandemic. Telemedicine provided a great tool for ensuring patients remain VLS. Evaluation of implementation outcomes including fidelity and reach remains ongoing.Disclosures All Authors: No reported disclosures

Treatment of opioid use disorder during COVID-19: Experiences of clinicians transitioning to telemedicine

ObjectiveThe COVID-19 pandemic has transformed care delivery for patients with opioid use disorder (OUD); however, little is known about the experiences of front-line clinicians in the transition to telemedicine. This study described how, in the context of the early stages of the pandemic, clinicians used telemedicine for OUD in conjunction with in-person care, barriers encountered, and implications for quality of care. MethodsIn April 2020, we conducted semistructured interviews with clinicians waivered to prescribe buprenorphine. We used maximum variation sampling. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches, to identify and characterize themes. ResultsEighteen clinicians representing 10 states participated. Nearly all interview participants were doing some telemedicine, and more than half were only doing telemedicine visits. Most participants reported changing their typical clinical care patterns to help patients remain at home and minimize exposure to COVID-19. Changes included waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits. Although several participants were serving new patients via telemedicine during the early weeks of the pandemic, others were not. Some clinicians identified positive impacts of telemedicine on the quality of their patient interactions, including increased access for patients. Others noted negative impacts including less structure and accountability, less information to inform clinical decision-making, challenges in establishing a connection, technological challenges, and shorter visits. ConclusionsIn the context of the pandemic, buprenorphine prescribers quickly transitioned to providing telemedicine visits in high volume; nonetheless, there are still many unknowns, including the quality and safety of widespread use of telemedicine for OUD treatment.

COVID-19 and Cancer Care: Ensuring Safety While Transforming Care Delivery.

COVID-19 and Cancer Care: Ensuring Safety While Transforming Care Delivery.

Access to Care: Using eHealth to Limit Location-Based Barriers for Patients With Cancer

Rural and urban communities may encounter barriers to care, which can lead to delays in timely screening, diagnosis, and treatment. eHealth interventions, such as televisits and remote patient monitoring, are being used increasingly to improve patient access to quality clinical cancer care and to support patient-provider communication. This article describes how eHealth can bridge gaps in patient access to cancer care and provides insight into successful eHealth program implementation. Articles that evaluate access to care and eHealth program implementation were summarized. Two case studies illustrate eHealth as a strategy to improve care delivery and access. Integrating eHealth into clinical practice can help to transform care delivery and improve patient access to quality cancer care by limiting barriers.

Jerry A. Mansfield Interview

Leadership is a journey, particularly for individuals who influence patient care delivery in hospitals and health care systems throughout the globe. For the nurse leader, it is a daily focus on a myriad of fronts including staff engagement, patient experience, quality and safety and financial performance. Dr. Mansfield made the decision to become a Registered Nurse because of the difference one RN made during his hospitalization as a teenager. This leadership profile offers one leaders’ perception of current challenges and opportunities in the industry; a time of unprecedented and transformative change in health care.

Gregory A. Adams, MHA

Gregory A. Adams is executive vice president and group president for Kaiser Permanente, reporting to the chairman and CEO. He has direct responsibility for all 8 Kaiser Permanente Regions, serving more than 12.3 million members and operating 39 hospitals and 701 medical office facilities. In addition to his group president responsibilities, he serves on the organization's national executive team and executive committee. Adams started his career with Kaiser Permanente in 1999 and has held a number of executive leadership positions within the organization, including president of the Northern California Region. Prior to joining Kaiser Permanente, Adams held several executive roles in the health care industry, providing strategic and operational leadership for hospitals, health systems, and medical groups throughout the country.

Phenomenology as a political position within maternity care.

In this article, the authors use the context of childbirth to consider the power that is endemic in certain forms of evidence within maternity care research. First, there is consideration of how the current evidence hierarchy and experimental-based studies are the gold standard to determine and direct women's maternity experiences, although this can be at the detriment of care and irrespective of women's needs. This is followed by a critique of how the predominant means to assess women's experiences via satisfaction surveys is of limited utility, offering impartial and restricted insights to assess the quality of care provision. A counter position of hermeneutic phenomenology as research method is then described. This approach offers an alternative perspective by penetrating the taken-for-granted ordinariness of an event (such as childbirth) to elicit rich emic meanings. Whilst all approaches to understanding maternity care have a place, depending on the question(s) being asked, the contribution of phenomenology is how it can uncover a depth of contextual understanding into what matters to women and to inform and transform care delivery.

A Large-Scale Advanced Illness Intervention Informs Medicare's New Serious Illness Payment Model.

Patients with advanced illness receive fragmented, hospital-based care that is unaligned with their preferences near the end of life. We describe a team-based intervention that provides home-based, coordinated care to more than 2,000 seriously ill patients daily in nineteen urban, suburban, or rural counties in California. In the last month of life, compared to matched Medicare beneficiaries in similar counties, this program reduced hospital days by 1,361 per 1,000 beneficiaries, hospital deaths by 8.2percent, inpatient payments by $6,127, and the total cost of care by $5,657 per beneficiary. The Centers for Medicare and Medicaid Services (CMS) has announced a new Medicare payment model for serious illness care, based in part on this program. To inform model development and implementation, we describe lessons learned about changing the focus of care for advanced illness from hospital to home, broadening care coordination to achieve system integration, and developing methods for payment and quality accountability that transform care delivery.

Technology combined with expert, relationship-based care.

In his Systems, Not Structures report, minister for health in Northern Ireland (NI) Raphael Bengoa notes: 'Advances in telecare, telemonitoring and electronic assistive technologies are making a significant difference to the way services are delivered. Used effectively, they can make a valuable contribution to the quality of services by improving coordination of services, overcome geographical distances between patients and providers, enable patients to live independent lives for longer and engage patients in their own health and well-being.' After setting out the UK and NI contexts for electronic assistive technologies, this article reflects on the role of triage nurses as 'e-nurses' in the former NI remote telemonitoring service model. It aims to provide nurses involved in service transformation and workforce planning opportunities to consider how e-nurses and 'virtual care' could transform care delivery, while empowering patients.

Transforming care delivery with the ultimate core laboratory

Transforming care delivery with the ultimate core laboratory