Chronic Disease Management Care Research Articles

Integrating Specialist and Primary Care in Chronic Disease Management

Integrating Specialist and Primary Care in Chronic Disease Management

Diverse perspectives on remote collaborative care for chronic disease management

Diverse perspectives on remote collaborative care for chronic disease management

A Causal Network-Based Markov Decision Process Model for Intervention Planning

Patients suffering from chronic diseases often receive interventions after they are discharged from hospitals for their health management. The intervention decisions can be made sequentially during the course of disease progression and treatment process, and timely and proper interventions can lead to better health condition and quality of life and reduce the rate of re-hospitalization. Moreover, to determine effective intervention plans, personalized care should be considered. However, in many cases, intervention plans are not tailored to patients’ health conditions or dynamically adjusted based on their status changes due to the lack of adequate analytical methods. To address this issue, we introduce a causal Bayesian network-based Markov decision process (CNMDP) model to dynamically evaluate the health status and effectiveness of interventions for each patient and update the corresponding intervention strategy. In such a model, a causal Bayesian network is integrated in order to predict the effect of interventions in each patient’s health status. The resulting risk at each decision point is considered in a Markov decision process model by examining diverse factors of a patient to make a personalized optimal decision on intervention planning to minimize the risk of health deterioration or readmission. To illustrate the applicability of the model and develop a specific formulation, an intervention decision model for chronic obstructive pulmonary disease (COPD) patients is presented using the proposed method. Such a model can be applied to other diseases as well to design personalized, prompt, and effective intervention plans. <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">Note to Practitioners</i> —Substantial efforts have been devoted to treatment and care management of chronic diseases. Particularly, there has been an initiative to design appropriate follow-up plans and interventions for postdischarge care to reduce hospital readmissions. However, many intervention plans are not patient specific and do not change with patient conditions. To mitigate such an limitation, based on identified risk factors and causal relationships, a causal Bayesian network model is introduced to predict readmission risk and evaluate intervention effectiveness. The results are then embedded into a Markov decision process to derive optimal intervention plan to minimize readmission risk. Such a process is repeated dynamically to evaluate health status and update intervention strategies. Using chronic obstructive pulmonary disease (COPD) as an example of chronic disease, a case study at a community hospital is presented to illustrate the applicability of the model.

A Framework to Support the Progressive Implementation of Integrated Team-Based Care for the Management of COPD: A Collective Case Study

Background: In Canada, there is consensus about the need for integrated, team-based care in primary care settings to help manage chronic conditions such as chronic obstructive pulmonary disease (COPD). Currently, there is limited understanding on how to support the continued growth and spread of such models; this is coupled with the fact that there is limited empirical evidence to support this process within chronic disease management. There is a need to understand how to support the implementation and spread of integrated, team-based chronic disease management programs in primary care settings, a process that we call progressive implementation.&#x0D; Methods: We studied the supporting and mitigating factors required to successfully implement and spread an integrated, team-based program for COPD management in primary care. We conducted a collective case study using an integrated knowledge translation approach involving key informants and our patient partner throughout the entire research process. Data collection included interviews, living documents, and a focus group. Our study explored an integrated, team-based model of care for COPD known as Best Care COPD (BCC). The BCC program has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants in our research included healthcare providers involved in the delivery of the BCC program.&#x0D; Results: We identified mechanisms influencing the spread of BCC and categorized them as foundational (evidence-based program, readiness to implement and a peer-led implementation team), transformative (adaptive process, provider empowerment and embedded evaluation), and enabling mechanisms (provider training, administrative support, role clarity, and patient outcomes) across three different implementation phases. We developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management within primary care settings.&#x0D; Conclusions: This study explores the implementation and spread of an integrated team-based COPD management program in primary care settings. Despite using COPD management program in Ontario, Canada as an exemplar, we believe the findings can be applied in other chronic disease contexts in primary care settings around the world. We provide a framework to support progressive implementation of integrated team-based care for chronic diseases with the potential to support patients and providers by understanding how to facilitate the continued growth of appropriate models of care. &#x0D; Next Steps: The rapidly increasing prevalence of chronic diseases emphasizes the need to understand how to spread and sustain appropriate models of care to better support patients and providers. The next phase of this study will seek to understand how to support the sustainability of integrated, team-based chronic disease management programs in a primary care setting.&#x0D; Information on Financial Support: This study has received financial support from the Asthma Research Group Inc. and Canadian Institutes of Health Research.

Design of a Dyadic Digital Health Module for Chronic Disease Shared Care: Development Study.

The COVID-19 pandemic forced the spread of digital health tools to address limited clinical resources for chronic health management. It also illuminated a population of older patients requiring an informal caregiver (IC) to access this care due to accessibility, technological literacy, or English proficiency concerns. For patients with heart failure (HF), this rapid transition exacerbated the demand on ICs and pushed Canadians toward a dyadic care model where patients and ICs comanage care. Our previous work identified an opportunity to improve this dyadic HF experience through a shared model of dyadic digital health. We call this alternative model of care "Caretown for Medly," which empowers ICs to concurrently expand patients' self-care abilities while acknowledging ICs' eagerness to provide greater support. We present the systematic design and development of the Caretown for Medly dyadic management module. While HF is the outlined use case, we outline our design methodology and report on 6 core disease-invariant features applied to dyadic shared care for HF management. This work lays the foundation for future usability assessments of Caretown for Medly. We conducted a qualitative, human-centered design study based on 25 semistructured interviews with self-identified ICs of loved ones living with HF. Interviews underwent thematic content analysis by 2 coders independently for themes derived deductively (eg, based on the interview guide) and inductively refined. To build the Caretown for Medly model, we (1) leveraged the Knowledge to Action (KTA) framework to translate knowledge into action and (2) borrowed Google Sprint's ability to quickly "solve big problems and test new ideas," which has been effective in the medical and digital health spaces. Specifically, we blended these 2 concepts into a new framework called the "KTA Sprint." We identified 6 core disease-invariant features to support ICs in care dyads to provide more effective care while capitalizing on dyadic care's synergistic benefits. Features were designed for customizability to suit the patient's condition, informed by stakeholder analysis, corroborated with literature, and vetted through user needs assessments. These features include (1) live reports to enhance data sharing and facilitate appropriate IC support, (2) care cards to enhance guidance on the caregiving role, (3) direct messaging to dissolve the disconnect across the circle of care, (4) medication wallet to improve guidance on managing complex medication regimens, (5) medical events timeline to improve and consolidate management and organization, and (6) caregiver resources to provide disease-specific education and support their self-care. These disease-invariant features were designed to address ICs' needs in supporting their care partner. We anticipate that the implementation of these features will empower a shared model of care for chronic disease management through digital health and will improve outcomes for care dyads.

Acceptance and Commitment Therapy Among Informal Caregivers of People With Chronic Health Conditions

Although there is substantial evidence to suggest the health benefits of acceptance and commitment therapy (ACT) among informal caregivers of people with chronic health conditions, the great variation in intervention designs among published studies limits its application. To identify intervention characteristics of ACT that are associated with improved psychological health and to assess the acceptability of ACT among informal caregivers. Seven English- and 3 Chinese-language databases without limits on publication dates, the reference lists of previous reviews, and gray literature were searched up to February 2023. Randomized clinical trials comparing the effect of ACT vs control groups on improving psychological health among informal caregivers. Two reviewers independently screened searched records and extracted data from eligible studies. Random-effects meta-analysis and mixed-effects metaregression were performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. Psychological health outcomes (eg, depressive symptoms) measured by valid measurements and the acceptability of ACT based on identified parameters. A total of 29 studies with 2010 participants, published between 2015 and 2023, were identified. ACT showed moderate to large effect sizes for improving psychological health at postintervention assessments (Hedges g range, -0.55 [95% CI, -0.98 to -0.12] to -1.14 [95% CI, -1.83 to -0.45]) and at 1-to-3-month and 4-to-6-month follow-ups (Hedges g range, -0.47 [95% CI, -0.69 to -0.25] to -1.29 [95% CI, -2.33 to -0.24]). Multivariable metaregression analysis regarding intervention characteristics found that ACT delivered in a mixed individual- and group-based format, face-to-face, or through more intervention sessions was associated with greater improvements for experiential avoidance (face-to-face: β = -1.170 [95% CI, -2.020 to -0.319]; number of sessions: β = -0.242 [95% CI, -0.353 to -0.130]), depressive symptoms (mixed delivery format: β = -2.583 [95% CI, -4.845 to -0.321]; face-to-face: β = -1.555 [95% CI, -3.002 to -0.108]), or anxiety symptoms (face-to-face: β = -1.241 [95% CI, -2.337 to -0.146]). In general, ACT had low attrition rates (11%), and participants' adherence (51%-80%) and satisfactory ratings (72%-95%) lend support to its acceptability. This systematic review and meta-analysis found that ACT was consistently associated with improvements in psychological health, supporting its application to improve informal care for chronic disease management. This review provides specific details on the design parameters of ACT for achieving greater efficacy.

Exploring Impact of Multidisciplinary Care on Patient Activation in Saudi Rheumatoid Arthritis Patients: A Cross-Sectional Survey-Extended Results from the COPARA National Project.

Multidisciplinary setting in healthcare provide positive patient outcomes. To evaluate the impact of specialized rheumatology clinics (multidisciplinary settings) on the activation and engagement of rheumatoid arthritis (RA) patients. This cross-sectional survey assessed patient activation using the patient activation measure-13. Participants attending Specialized Rheumatology Clinics (SRC multidisciplinary clinics) were compared with age- and sex-matched patients attending Standard of Care (SOC). The study was observational in nature, assessing several demographic and therapeutic options and their relation to the clinical setting and patient activation. This study included 117 SRC matched RA patients with 117 SOC. The majority of the included patients were female (n=211, 90.2%), >40 years of age (n=177, 75.6%), and had intermediate-to-high education (n=147, 62.8%). Patients in the SRC were also more likely to have activation levels 3 and 4 with an odds ratio of 3.194 (95% confidence interval [CI] 1.835-5.562, p<0.001). In addition, SRC participants were more likely to be in levels 3 and 4 activation, even after adjustment for confounding variables, with an adjusted odds ratio of 2.401 (95% CI 1.121-4.758, p=0.012) and 2.175 (95% CI 1.127-4.196, p=0.020), respectively. Establishing SRC for RA patients seems to have a positive impact on patient activation and engagement and adds to the previously explored benefits of multidisciplinary care in chronic disease management.

Clinical Integration of Digital Patient-Reported Outcome Measures in Primary Health Care for Chronic Disease Management: Protocol for a Systematic Review.

Health measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation. We will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs' implementation strategies. We will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis. This study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022. Results from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies. PROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513. DERR1-10.2196/48155.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews.

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI). Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021. Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models. Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use). Narrative synthesis, including proportion of reviews documenting outcome benefits. More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease. Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Nurse-led virtual interventions in managing chronic diseases: a protocol for a systematic review of randomised controlled trials

IntroductionTechnological advances are changing nursing practice; however, nurse-led virtual care for chronic disease management has not yet been adequately explored and described. This study will review and analyse the effects...

A step in the right direction: the potential role of smartwatches in supporting chronic disease prevention in health care.

A step in the right direction: the potential role of smartwatches in supporting chronic disease prevention in health care.

A Review on Community Care for Chronic Disease Management Based on Digital Health Care: For Elderly Living Alone

In the face of aging, it can be difficult for the elderly to accept and cope with changes. During the coronavirus disease 2019 (COVID-19) pandemic, changes in the medical service market for health care such as non-face-to-face treatment implementation, education and counseling, seminars, and camps have accelerated. Changes in medical use through mobile phones, tablet PCs, wearable devices, etc. were inevitable. It is important to study how the current early elderly population maintains change in daily life and the extent to which elderly people living alone can participate in such change. This review aims to answer the question, “What should we consider when treating and consulting patients regarding use of the vastly changing medical environment?” In particular, the study focuses on digital healthcare and community care and related health and welfare policies with consideration of aging and increasing chronic diseases.

Understanding Unmet Care Needs of Rural Older Adults with Chronic Health Conditions: A Qualitative Study

Rural populations experience poorer access to the necessary health services for chronic health conditions. Although studies of rural healthcare access continue to expand, most are based on quantitative data, yet normative views and lived experiences of rural adults might offer a better understanding of healthcare access and their specific unmet needs. This qualitative study sought the views of both rural-centric older people and healthcare professionals to understand health needs, barriers, and enablers of accessing health services, with a focus on chronic health condition(s). Between April and July 2022, separate in-depth interviews were conducted with 20 older people (≥60 years) in a rural South Australian community. Additionally, focus group interviews were conducted with 15 healthcare professionals involved in providing health services to older adults. Transcripts were coded using the NVivo software and data were thematically analysed. Participants described a range of unmet care needs including chronic disease management, specialist care, psychological distress, and the need for formal care services. Four barriers to meeting care needs were identified: Workforce shortages, a lack of continuity of care, self-transportation, and long waiting times for appointments. Self-efficacy, social support, and positive provider attitudes emerged as crucial enabling factors of service use among rural ageing populations. Older adults confront four broad ranges of unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. There are potential facilitators, such as self-efficacy, provider positive attitudes, and social support, that could be leveraged to improve healthcare services access for older adults.

8.H. Workshop: Health equity and Chronic diseases: Public health and Primary care roles

Abstract Publicly funded health systems are based on the principle of universal access to care. However, significant gaps still exist between services needed and services received (i.e. unmet need for healthcare), especially in chronic disease management and prevention, particularly affecting marginalized groups in the society. Public Health and Primary Care should be working in integrated systems, as they are crucial in addressing health needs in the community and population at large. Several international organizations and leading scholars in the field have been advocating for the integration or primary care and public health to improve population health as well as to tackle complex issues such as multimorbidity. However, these two sectors are still working in silos across several countries, with a significant negative impact in terms of efficiency of the services provided and health care costs. The aim of this workshop will be to provide a global perspective on the issue of health equity in chronic disease management and prevention, with focus on marginalized population subgroups, such as elderly, immigrants and people from low socioeconomic status. We will discuss as well the determinants of unmet health needs for access to primary care in middle-aged and older adults, and examine the reasons for unmet need. We will further discuss about the need and strategies for enhanced integration between public health and primary care in chronic disease management and prevention. Key messages • Public health systems are based on the principle of universal access to care. However, significant gaps still exist between services needed and services received (i.e. unmet need for healthcare). • Public Health and Primary Care should be working in integrated systems to tackle complex issues such as multimorbidity.

Introduction of medical assistants in France: an innovative approach to healthcare access?

Abstract Epidemic transition, sustained costs and health workforce shortage challenges have led numerous countries to strengthen primary care (PC) and implement new models of care. Faced with declining numbers of general practitioners (GPs), France has introduced medical assistants (MAs) in 2019 to guarantee access to care and maintain workforces in deprived areas. Trained to perform administrative and clinical tasks delegated by a physician, MAs are expected to optimize medical time and improve working conditions in practices. How does French model of MAs impact quality and productivity in GPs’ practices and articulate with other policies? We conducted a qualitative case study in 6 pilot practices to explore the effects of MAs’ work (interviews with 12 GPs, 6 MAs, collection of tasks performed by 6 MAs), complemented with views from public policy makers and health professional unions (9 interviews). MA was defined as a function centered on physicians’ needs, accessible both to administrative staff and nursing professions. MAs with a clinical profile performed a wider range of tasks, were more prone to perform clinical tasks and build developed interactions with patients, and seemed better fitted for chronic disease care management. Recruitment of MAs by physicians is supported with grants that decrease yearly while practice productivity is expected to rise. In general, a gain of efficiency in daily workload enabled GPs to slightly increase their productivity. However, for most GPs, it primarily helped them to maintain high workload without burning out. Although MAs with clinical background seem better suited for patients’ needs, recent figures have shown that more than half of MAs employed are former secretaries. If in-person secretaries could be endorsed with further administrative duties, MAs could hold a more clinical role in PC teams including physicians and allied health professionals. Other aspects than productivity must be taken into account in a support policy. Key messages • Regardless of productivity objectives to attain, hiring MAs can relieve physicians’ workload and stress, preventing them from burning out and guarantee access to care in deprived areas. • MA’s clinical profile could have a stronger impact on public health issues such as chronic disease care management.

Evaluation of the Effect Coronavirus Lockdown had on Chronic Disease Management Care in Pediatrics: A Survey of Jordanian Pediatricians.

The outbreak of the COVID-19 pandemic puts a great strain on the healthcare system, as the national and global infection rates increased rapidly. Efforts were devoted to minimizing the effects of the spreading pandemic without overwhelming the already stretched healthcare system. The study objective was to establish how coronavirus lockdown was affecting chronic disease care among pediatric patients admitted to hospitals in developing countries. For that purpose, a cross-sectional survey of registered pediatricians was carried out. Findings showed that the mortality rate from COVID-19 in children seemed to be low. However, children with chronic illnesses were likely to be gravely affected by the disturbance of repetitive healthcare services. About 79% of pediatricians treated a child with a chronic condition during the lockdown. Furthermore, 15% of patients with chronic diseases visiting pediatricians exhibited uncontrolled emerging complications. In addition, 9% of pediatricians reported one to five fatalities among children under their care due to delay or lack of appropriate medical care in the period of the lockdown. Residents (48.9%) reported a significantly (p < 0.001) higher proportion of providing face-to-face services compared with consultants (17.9%) and specialists (13.6%). In conclusion, the care of chronically ill children should be taken into consideration when implementing lockdown and/or social distancing, thus minimizing the negative effects of lockdown and/or social distancing on children with chronic diseases.

Enablers and barriers to non-dispensing pharmacist integration into the primary health care teams of Aboriginal community-controlled health services.

The primary health care management of chronic disease affecting Aboriginal and Torres Strait Islander peoples requires healthcare quality and equity demands to be met, and systems that foster better team-based care. Non-dispensing pharmacists (NDPs) integrated within primary healthcare settings can enhance the quality of patient care, although factors that enable or challenge integration within these settings need to be better understood. To investigate enabling factors and barriers influencing integration of NDPs within Aboriginal community-controlled health services delivering primary health care. This was achieved through qualitative evaluation of the Integrating Pharmacists within Aboriginal Community Controlled Health Services (IPAC) Trial exploring the perceptions of NDPs, community pharmacists, healthcare staff, managers, and Aboriginal and Torres Strait Islander patients of these services. NDPs were employed across twenty urban, rural, and remote services in three Australian states and provided pre-defined medication-related roles to adult Aboriginal and Torres Strait Islander patients. Perceptions were elicited from online surveys, interviews, and focus groups. Transcripts were thematically analyzed using the constant comparison method to identify, compare, and refine emerging themes. One hundred and four participants informed the findings, including 24 NDPs, 13 general practitioners, 12 service managers, 10 community pharmacists, 17 health service staff, and 17 patients. Enablers of integration included: personal (previous experience with Aboriginal and Torres Strait Islander peoples, cultural awareness, skills, individual attributes); health service-related (induction programs, Aboriginal Health Worker support, team-building initiatives); and community-related factors (engaged community elders, leaders, cultural mentors, community pharmacy champions). Barriers to NDP integration included a lack of systems supports for patients and staff to adapt to NDP roles, health service factors, travel requirements, a lack of community linkages, and time and budget constraints. NDP integration within primary health care services has potential to enhance medication-related services to Aboriginal and Torres Strait Islander peoples if enabling factors are supported and health systems and adequate resources facilitate the integration of pharmacists within these settings.

Patient advocates' views of patient roles in interprofessional collaborative practice in primary care: A constructivist grounded theory study.

Interprofessional collaborative practice has been shown to be an appropriate model of care for chronic disease management in primary care. However, how patients play a role in this model is relatively unknown. The aim of this constructivist grounded theory focus group study was to explore the perceptions of patient advocates regarding the role of patients in interprofessional collaborative practice for chronic conditions in primary care. Primary data were collected from patient advocates, from public and private Australian organisations and who represent patients with chronic disease in primary care, through focus groups in July-August 2020. Videoconference focus groups were recorded, transcribed verbatim and inductively, thematically analysed using the five-step approach by Charmaz: (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation and (5) theme and sub-theme development. Three focus groups comprising 17 patient advocates with diverse cultural and professional backgrounds participated. Two themes and five sub-themes relating to interprofessional collaborative practice teams were constructed from the data. In theme 1, patients 'shifted across the spectrum of roles' from 'relinquishing control to the team', 'joining the team' to 'disengaging from the team'. The second theme was the need for 'juggling roles' by 'integrating patient role with life roles', and 'learning about the patient role'. The diversity and variability of patient roles as described by patient advocates highlight the challenges of working with people with chronic conditions. The diverse patient roles described by advocates are an important finding that may better inform communication between patients and health professionals when managing chronic conditions. From the health professional perspective, identification of the role of a patient may be challenging. Therefore, future research should explore the development of a tool to assist both patients and health professionals to identify patient roles as they move across the spectrum, with the support of policy makers. This tool should aim to identify and promote patient engagement in interprofessional collaborative practice in primary care settings.

Study on Health Care Service Standard of Chronic Disease Management Based on Process Reengineering and the Delphi Method.

The Delphi method is also called an expert consultation method, scientifically measuring the objectivity, practicality, and authority of the metric. This study aims to build a standard plan for chronic disease management care services in hospitals and guide the development of chronic disease management care services. This article proposes a chronic disease management nursing experiment, further revises the current hospital chronic disease management nursing service, redesigns the program, compiles the chronic disease management hospital nursing standard list according to the new program, and uses expert suggestions to modify the standard program items. It adopts a preliminary expert inquiry table, submits Delphi expert inquiry, and constructs a chronic patient prevention strategy for clinical nursing practice to learn from the reference for guiding the actual specific situation of nursing, providing evidence basis and practice guidance. More than 40 initial standards were listed, which were reduced to 30 after revision. The importance of the indicators to different experts was 3.56 to 4.85 points. The coordination coefficient is 0.180~0.356. Finally, after discussion by all parties, more than 40 specific indicators including the size of the new standard have been determined, which provides a great theoretical basis for the establishment of a new type of hospital chronic disease management and nursing service standard in my country. Based on process reconstruction and the Delphi method determined by the hospital chronic disease management nursing service standards, clear normative and operability can provide basis for the development of chronic disease management nursing services.

Pay-for-Performance in the Massachusetts Medicaid Delivery System Transformation Initiative.

Pay-for-performance (P4P) is among the alternative payment models (APMs) that are designed to incentivize enhancements to healthcare efficiency and quality. Massachusetts' Office of Medicaid implemented a delivery system transformation initiative (DSTI) through an 1115(a) Demonstration Waiver to support and incentivize seven safety net hospitals to implement clinical care changes and transition to risk-based APMs. Comparative case study design was used to describe achievement of hospital-specific clinical and operational measures. Qualifying hospitals implemented 47 projects across three categories: (1) development of a fully integrated delivery system, (2) health outcomes and quality, and (3) ability to respond to statewide transformation to value-based purchasing and to accept alternatives to fee-for-service payments that promote system sustainability. Projects commonly focused on care transitions improvements, physical and behavioral healthcare integration, and chronic disease care management interventions. Collectively, the hospitals met all or most of 60 population-focused improvement measures and 10 common measures' targets, indicative of the progress. Some hospitals achieved substantial positive gains; however, missed targets suggest substantial organizational and workflow changes over a longer timeframe as well as consistent patient engagement may be necessary. Overall, the P4P structure of DSTI was effective in encouraging organizational change and supporting the transition of these hospitals towards APMs.