Fragmented Care Research Articles

Qualitative acceptability testing of a paper-based care planner in patients with metastatic non-small cell lung cancer (mNSCLC).

259 Background: Patients with cancer and their caregivers often describe the fragmented, multi-modal and multi-provider cancer care experience as undertaking a difficult expedition without a map. Based on her experience in 2020 and using self and family management theories (doi: 10.1016/j.outlook.2008.10.004.), Daswani developed a pan-cancer patient planner, which helps patients and families prepare for appointments, track symptoms, and manage their care. It has been available since 2021 through hospitals, advocacy organizations and online retail channels. We adapted and customized the pan-cancer planner for patients with mNSCLC. We tested acceptability through a series of structured patient interviews, and a brief, in-person survey tool. Methods: A lung cancer survivor recruited members of the lung cancer community to participate in a 30-minute structured virtual interview. After reviewing the planner, interviewees were asked: 1) about their diagnosis and treatment experience and 2) to provide semi-structured feedback. We conducted interviews until thematic saturation was reached. We modified the planner based on interview results, distributed planners to patients and care-partners at a major lung cancer patient summit and immediately collected a brief survey to assess patient knowledge of their diagnosis and motivation for planner access. Results: The table shows high level thematic groups of interview responses. Interviewed patients concluded that the planner would have improved their experience because they would have: Stayed organized, facilitated note-taking during appointments, better tracked and managed symptoms & meds, been more confident in decision-making and been able to journal, stay grounded and more mindful. Of 94 planners distributed at the summit, 49 patients knew their diagnosis, 31 knew their stage, 28 knew their cancer mutation status. Of the four domains of self-management, positive responses were: 1. Increase confidence 44 (47%) 2. Gain peace of mind 40 (43%) 3. Stay organized 58 (62%) 4. Manage meds & symptoms 42 (45%). Conclusions: A paper based mNSCLC specific planner is acceptable to patients and they anticipate it would help with all four domains of self management (confidence, peace of mind, organization, med and symptom management) and enhance a difficult experience. We plan further usability testing as we did with the breast cancer planner (JCO Oncol Pract 19, 2023 (suppl 11; abstr 552)). Interviews of 8 (7 female, 1 male) patients (3 with English as a second language) were held in December 2023. Diagnosis Biomarker Testing Treatment Living with lung cancer Medical terms difficult to understand “Mutation” term caused anxiety Understanding options important Need for community Diagnosis often delayed Loss of agency Gratitude for care team Digital tools desired Cumulative trauma Additional languages Young adult survivorship desired

An ICT-enabled community oriented primary care intervention in mining communities during COVID-19 (2019–2022): perceived changes in the role and place of community health workers

BackgroundThis is a study of service provider perceptions of the place, role and practices of CHWs in a four-year, large-scale private sector funded, public service ICT-enabled COPC intervention with rural and remote mining communities. Like all South African communities, apart from large mining house employees and some contractors, most people use available public healthcare services and private traditional as well as limited allopathic private sector providers. In addition to the limitations of facility centred primary healthcare and a fragmented health care system, the many negative health effects of mining on the communities, go unattended.MethodsThis is a rapid, qualitative pragmatic study. Using site and participation convenience sampling, 37 semi-structured individual or group interviews were conducted with 57 stakeholders from 38 of the 135 intervention PHC facilities. Using a data driven, inductive approach, the results were analysed thematically in terms of perceived changes in the role and place of CHWs.ResultsCHWs registered 42 490 households and captured the demographic and social profiles as well as the health status of over 154 910 individuals using AitaHealth™. These data provided healthcare professionals and managers with knowledge about community demographics, at-risk groups and vulnerable individuals. The intervention changed the locational focus of CHW practice and expanded their scope of work and competencies in household comprehensive health education, advice and care. It led to a growth in community and professional confidence in CHWs as trusted members of mining community PHC teams and to more focused and efficient clinic work.ConclusionThis ICT-enabled COPC intervention adopted a comprehensive approach to healthcare delivery that started by including CHWs in PHC teams and locating them in communities. Inclusive and systematic continuous learning, clinically-led CHW service support and ICT-enabled information technology engendered trust in CHWs as competent PHC members, and grew community confidence in them and the PHC system as a whole. Although health, care and other professionals and workers valued the changes the intervention brought to their work as well as people’s lives in underserved and vulnerable mining communities, its sustainability is contingent on the vagaries of political will and financial commitment.

The Disproportionate Burden Of Alzheimer's On Latino Communities.

Latino patients with dementia face a complex web of challenges, from serious comorbidities to delayed diagnoses to fragmented care.

Experiences And Preferences Of People With Stroke And Caregivers, Around Supports Provided At The Transition from Hospital to Home

Abstract Background Transitioning home from organised stroke services poses many challenges for people with stroke (PWS) and their caregivers (CGs), requiring them to navigate through complex uncertainties. There are gaps in our understanding of appropriate support interventions for managing the transition home. In this qualitative study, we explored the perspectives of PWS and their CGs regarding their support experiences and preferences during this period. Methods Between November 2022 and March 2023, and within six months of hospital discharge, audio-recorded, semi-structured interviews were conducted with PWS and their CGs. All interviews were transcribed, imported into NVivo software, and analysed using reflexive thematic analysis. Results Sixteen interviews were conducted, nine with PWS and seven with CGs. Four themes relevant to their collective experiences and preferences were identified: (i) Need for tailored information-sharing, at the right time, and in the right setting; (ii) The importance of emotional support; (iii) Left in limbo, (iv) Inequity of access. Experiences depict issues such as insufficient information-sharing, communication gaps, and fragmented and inequitable care; while a multi-faceted approach is desired to ease anxiety and uncertainty, minimise delays, and optimise recovery and participation during transition. Conclusion Our findings highlight that regardless of the discharge route, and even with formal support systems in place, PWS and families encounter challenges during the transition period. There is a need for more personalised and timely information-sharing to support individuals and caregivers effectively. A multi-faceted approach is recommended to alleviate anxiety, reduce delays, and provide equitable care for all involved.

Integrated Care in Action: A Case Study of Collaborative Multidisciplinary Approach for Older Adults in Ireland

Abstract Background In Ireland, the healthcare landscape is evolving with frameworks which emphasize community-based care, such as Enhanced Community Care and the National Integrated Care Programme for Older Persons. Our Integrated Care Team for Older Persons (ICPOP) service exemplifies this shift by providing intensive, immediate multidisciplinary care to frail adults, aiming to maintain their independence in their homes and communities. Methods In the case study we describe service users journey with ICPOP. The case study illustrates the transition from fragmented care to a collaborative, patient-centred approach. ICPOP employs a structured process involving comprehensive assessment, goal setting, weekly multidisciplinary team meetings, stakeholder liaison, and detailed discharge reports. This approach focuses on early supported discharge and close coordination with local MDT teams, fostering effective communication and shared decision-making. Results This case study demonstrates the effectiveness of ICPOP's multidisciplinary model. Key factors contributing to this success include physical co-location, shared goals and vision, mutual trust, and established relationships among professionals. Furthermore, the integration of Allied Health Professionals (AHPs) within community teams enriches the care continuum and enhances outcomes for older adults. Conclusion To further enhance integrated care delivery, digital solutions are crucial. Implementing shared electronic health records and facilitating access to medical findings can streamline communication and improve care coordination. Additionally, prioritizing written discharge summaries for clients can ensure continuity of care and empower patients and their families in the post-discharge phase. This patient journey underscores the importance of collaborative, patient-centred care models in achieving the objectives of Sláintecare leading to better outcomes for older adults in Ireland.

Redesigning Community Dwelling Geriatric Integrated Care Program for Better Care Co-Ordination and Health Outcomes

Abstract Background Existing health services and care models need to adapt to the increasing ageing population, multimorbidity, and frailty. Thus, diverse healthcare providers and caregivers are demanded to continue living at home. An Integrated Care Program, involving a multidisciplinary team with a patient-centred focus, is being promoted as an alternative model of care. However, uncoordinated existing services put them at risk of fragmented care, leading to adverse outcomes. This study aimed to fill gaps in previous ICP research by introducing a change roadmap into the implementation phase of the program. In addition, the study proposed evaluating the effectiveness and implementation of the pilot project together with the process evaluation. Methods The study conducted a systematised literature review to examine the outcomes and different structures of the ICP. Implementation Science was utilised to define, design, and deliver the model of change. Results A systematised literature review showed that most ICPs were led by an Advanced Nurse Practitioner with positive outcomes. SWOT analysis, stakeholders’ involvement, existing community service providers, and a population survey provide an in-depth perspective of the target population and set up contextually adapted implementation strategies. An ANP-led MDT was proposed to co-ordinate the ICP. A process evaluation to assess the care model together with health outcomes was outlined. Conclusion The study showed that ANP-led MDT, person-centred, co-ordinated care provides the best ICP implementation strategy. The study will further understand the ICP implementation process among frail older people in the community.

The Effectiveness of a Community Specialist Team for Older Persons in Preventing Emergency Department Attendances 30 and 90 Days Post-Intervention

Abstract Background Population ageing is prevalent throughout Ireland and its impact is evident particularly in acute hospitals with long Patient Experience Times (PETs) in the emergency department. A Community Specialist Team for Older Persons (CSTOP) was established in our area in 2018 with expansion under Sláintecare in 2022. The main goal is to improve access in the community to age attuned services, and thus prevent Emergency Department (ED) presentations and admissions and improving health outcomes for older people. The team provides a comprehensive geriatric assessment and resultant interventions required for each patient. The cohort of patients includes (Frail Intervention Team) FIT referrals from the ED, Geriatrician referrals from Outpatient clinics and GP referrals. Many of these patients have either presented to the Emergency Department or are at risk of same. Methods Data for all CSTOP patients is recorded including medical record numbers. All medical records for patient admitted in 2023 were analysed using the integrated patient management system (IPIMS) in our local hospital. ED presentations and admissions were reviewed at 30 and 90 days post intervention. Results 232 referrals were received in 2023. 42 (18%) had an ED presentation 30 days post discharge and 48 (21%) had a presentation 90 days post discharge. 11 RIPs. Conclusion This study shows the effectiveness of the CSTOP team at preventing ED presentations and resultant admissions. The number of bed days is estimated at 2000. One limitation to our study is data could only be analysed from our hospital system, patients could attend other public or private hospitals during the follow up period. Our results are found to be in keeping with reviews by similar services. Our team provide a rapid access interdisciplinary assessment and intervention to people who may otherwise experience fragmented care within primary care services.

Qualitative perspectives of Medicaid-insured patients on ambulatory care at an academic medical center: challenges and opportunities

BackgroundAmbulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery.MethodsThe authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity.ResultsTwenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or “other” race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers.ConclusionsThe missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

The need for a broad perspective when assessing value-for-money for out-of-hours primary care.

Out-of-hours primary care (OOH-PC) has emerged as a promising solution to improve efficiency, accessibility, and quality of care and to reduce the strain on emergency departments. As this modality gains traction in diverse healthcare settings, it is increasingly important to fully assess its societal value-for-money and conduct thorough process evaluations. However, current economic evaluations mostly emphasise direct- and short-term effect measures, thus lacking a broader societal perspective. This study offers a comprehensive overview of current effect measures in OOH-PC evaluations and proposes additional measures from the evaluation of integrated care programmes. First, we systematically identified the effect measures from published cost-effectiveness studies and classified them as process, outcome, and resource use measures. Second, we elaborate on the incorporation of 'productivity gains', 'health promotion and early intervention', and 'continuity of care' as additional effects into economic evaluations of OOH-PC. Seeking care affects personal and employee time, potentially resulting in decreased productivity. Challenges in taking time off work and limited access to convenient care are often cited as barriers to accessing primary care. As such, OOH-PC can potentially reduce opportunity costs for patients. Furthermore, improving access to healthcare is important in determining whether people receive promotional and preventive services. Health promotion involves empowering people to take control of their health and its determinants. Given the unscheduled nature and the fragmented or rotational care in OOH-PC, the degree to which interventions and modalities provide continuity should be monitored, assessed, and included in economic evaluations. Continuity of care in primary care improves patient satisfaction, promotes adherence to medical advice, reduces reliance on hospitals, and reduces mortality. Although it is essential to also address local settings and needs, the integration of broader scope measures into OOH-PC economic evaluations improves the comprehensive evaluation that aligns with welfare gains.

Hospital discharge processes: Insights from patients, caregivers, and staff in an Australian healthcare setting

Hospital discharge is a pivotal point in healthcare delivery, impacting patient outcomes and resource utilisation. Ineffective discharge processes contribute to unplanned hospital readmissions. This study explored hospital discharge process from the perspectives of patients, caregivers, and healthcare staff. Qualitative data were collected through semi-structured interviews with adult patients being discharged home from a medical ward, their caregivers, and healthcare staff at an Australian hospital. Thematic analysis followed established guidelines for qualitative research. A total of 65 interviews and 21 structured observations were completed. There were three themes: i) Communication, ii) System Pressure, and iii) Continuing Care. The theme ‘Communication’ highlighted challenges and inconsistencies in notifying patients, caregivers, and staff about discharge plans, leading to patient stress and frustration. Information overload during discharge hindered patient comprehension and satisfaction. Staff identified communication gaps between teams, resulting in uncertainty regarding discharge logistics. The theme ‘System Pressure’ referred to pressure to discharge patients quickly to free hospital capacity occasionally, even in the face of inadequate service provision on weekends and out-of-hours. The ‘Continuing Care’ theme drew attention to gaps in patient understanding of follow-up appointments, underscoring the need for clearer post-discharge instructions. The lack of structured systems for tracking referrals and post-discharge care coordination was also highlighted, potentially leading to fragmented care. The findings resonate with international literature and the current emphasis in Australia on improving communication during care transitions. Furthermore, the study highlights the tension between patient-centred care and health service pressure for bed availability, resulting in perceptions of premature discharges and unplanned readmissions. It underscores the need for strengthening community-based support and systems for tracking referrals to improve care continuity. These findings have implications for patient experience and safety and suggest the need for targeted interventions to optimise the discharge process.

Technology for advancing behavioral health integration: implications for behavioral health practice and policy.

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

Strategies to Reduce Frequent Emergency Department Use among Persons Experiencing Homelessness with Mental Health Conditions: a Scoping Review.

The USA has some of the highest utilization rates of the Emergency Department (ED) worldwide, leading to increased healthcare costs, constrained resources, and fragmented care. Many of the highest ED utilizers are persons experiencing homelessness (PEH) and those with mental health conditions, with even higher use by those with comorbid social challenges. This study reviewed the literature assessing interventional approaches in the ED to minimize the burden of ED utilization by PEH with associated mental health conditions. We first conducted an informal literature review of high ED utilizers and their most common presenting symptoms. We then conducted a scoping review of articles according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines; we used PubMed and Web of Science databases as well as Google Scholar. We screened the titles and abstracts of studies that evaluated programs that aimed to reduce ED usage by patients with mental illness who were also experiencing homelessness. Of the 1574 titles and abstracts screened, 49 full texts were examined for eligibility. Of those, 35 articles were excluded for a final count of 14 included studies. We found that the studies fell under two main interventional categories: housing support and care management. There were various approaches to reduce ED visits from PEH with mental illness around the world. Overall, these studies found varying degrees of success in reducing ED visits for both housing intervention and care management strategies. Comparison of these studies reveals that the success of related strategies like housing support often have different outcomes which can be attributed to the differences between the populations studied, previously available community resources, and other psychosocial factors affecting study participants. Overall, the most successful studies found that a tailored approach that addresses the unique needs of participants had the greatest impact on reducing ED visits and hospitalizations. Further research is needed to determine the best strategies for specific populations and how to promote health equity among PEH with associated mental health conditions.

Associations among claims-based care fragmentation, self-reported gaps in care coordination, and self-reported adverse events

BackgroundFragmentation of care (that is, the use of multiple ambulatory providers without a dominant provider) may increase the risk of gaps in communication among providers. However, it is unclear whether people with fragmented care (as measured in claims) perceive more gaps in communication among their providers. It is also unclear whether people who perceive gaps in communication experience them as clinically significant (that is, whether they experience adverse events that they attribute to poor coordination).MethodsWe conducted a longitudinal study using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including a survey on perceptions of healthcare (2017–2018) and linked fee-for-service Medicare claims (for the 12 months prior to the survey) (N = 4,296). We estimated correlation coefficients to determine associations between claims-based and self-reported numbers of ambulatory visits and ambulatory providers. We then used logistic regression to determine associations between claims-based fragmentation (measured with the reversed Bice-Boxerman Index [rBBI]) and self-reported gaps in care coordination and, separately, between claims-based fragmentation and self-reported adverse events that the respondent attributed to poor coordination.ResultsThe correlation coefficient between claims-based and self-report was 0.37 for the number of visits and 0.38 for the number of providers (p < 0.0001 for each). Individuals with high fragmentation by claims (rBBI ≥ 0.85) had a 23% increased adjusted odds of reporting any gap in care coordination (95% CI 3%, 48%) and, separately, a 61% increased adjusted odds of reporting an adverse event that they attributed to poor coordination (95% CI 11%, 134%).ConclusionsMedicare beneficiaries with claims-based fragmentation also report gaps in communication among their providers. Moreover, these gaps appear to be clinically significant, with beneficiaries reporting adverse events that they attribute to poor coordination.

Pregnant People-Infant Linkage for Surveillance

Objectives and ApproachAs maternal mortality and morbidity continue to progress, better data is needed to comprehensively understand the problem, especially in underserved populations who are differentially impacted. Surveillance in safety-net populations is complicated by care fragmentation and interoperability challenges between primary care and hospital settings. . AllianceChicago (AC), a health center-controlled network, supports a common data infrastructure across a set of Federally Qualified Health Centers (FQHCs) in Chicago that is further linked to a distributed query infrastructure connecting Chicago’s major health systems known as CAPriCORN. Leveraging electronic health record (EHR) data collected by the AC and CAPriCORN consortium, the objective of this surveillance effort was to connect infant data with maternal data while protecting privacy. We developed a deterministic matching algorithm that utilized multiple approaches and technologies for Pregnant People-Infant (PPI) pair identification. The linkage process involved a five-step method in which each step is recorded within the linkage database and the confidence interval is calculated. ResultsPreliminary analyses are ongoing. Through each step of the linkage process, the confidence interval increased with the increase of matching nodes, highlighting its accumulative accuracy. The result demonstrates the feasibility of linking maternal and baby healthcare characteristics using a range of clinical and demographic variables captured in pseudonymized hospital and ambulatory data. Conclusions and ImplicationsOur approach improves the capacity of EHR data for surveillance while protecting patient privacy and preserving data confidentiality. Triangulating outcomes recorded in different settings can help improve data quality for research and surveillance.

Neonatal limited bedding and nesting experience may lead to a sex-dependent increase in panic-like defensive behaviours in adult mice.

In humans, adverse physical and/or psychological traumas in childhood may predispose to developing psychiatric disorders in adulthood, including panic disorder. To model early life adversity in mice, we subjected male and female C57BL/6J mice to a limited bedding and nesting (LBN) protocol between postnatal days 2-9 and investigated its effect on responsiveness to panicogenic challenges in adulthood. Panic-like escape behaviour was assessed during exposure to a high concentration of CO2 (20%) or in the beetle mania task (BMT), used to model respiratory and non-respiratory-related types of panic respectively. Neonatal exposure to LBN increased panic-like jumping during the CO2 challenge in male but not female mice. In an initial pharmacological validation of the BMT as a panic-inducing paradigm, undirected jumping and horizontal escape behaviours were reduced significantly by the panicolytic alprazolam (0.05 and 0.1mg.kg-1 i.p.) whilst tolerance to the close proximity of the aversive robo-beetle increased. The anxiolytic diazepam (1mg.kg-1i.p.) reduced only the number of horizontal escape attempts. In both sexes, previous experience of LBN significantly enhanced the number of horizontal escape episodes, indicating a pro-panic phenotype. Directed escape to access a safe ledge on the wall of the test arena, which was seen only in males, was also reduced significantly following LBN. These findings indicate that early life adversity produced by fragmented and unpredictable maternal care promotes a sex-specific increase in susceptibility to panic-like behaviour in adulthood. Whilst non-respiratory-related panic-like behaviour was enhanced in both sexes, females were resilient to respiratory-related challenges.

Determinants of polydoctoring among multimorbid older adults; a cross‐sectional study in an urban area of Japan

AbstractBackgroundMultimorbidity increases with age, leading to various adverse outcomes, including higher mortality, care dependency, hospitalizations, and healthcare costs. Polydoctoring, managing a patient with multimorbidity by multiple healthcare providers, can be a risk of fragmented care and increased healthcare expenditures. This study aims to identify patient‐related factors contributing to polydoctoring in older adults with multimorbidity.MethodsThis study is a cross‐sectional study using baseline data from the Kawasaki Aging and Wellbeing Project. Participants were residents of Kawasaki City aged 85–89 years, without disability in basic activities of daily living, and being able to visit study site. The regularly visited facilities (RVF) index was employed to quantify polydoctoring. Polydoctoring was defined as having two or more RVFs. Poisson regression analysis was conducted to assess the association between polydoctoring and patient demographics, including types of chronic conditions and socioeconomic factors.ResultsA total of, 968 participants with multimorbidity were analyzed. Increased RVF was significantly associated with eye diseases (rate ratio [RR] 1.27, 95% confidence interval [CI] 1.12–1.44), osteoporosis (RR 1.22, 95% CI 1.08–1.38), prostate diseases (RR 1.22, 95% CI 1.07–1.40), and osteoarthritis (RR 1.16, 95% CI 1.05–1.27). No significant correlation was found with educational status or financial hardship.ConclusionThe study indicated that certain chronic conditions are linked to increased polydoctoring among multimorbid older adults in Japan. However, most of those conditions are considered to be within a scope of family medicine/general practice. Training general practitioners to manage these conditions could reduce healthcare costs and the treatment burden, indicating a direction for future healthcare policy and medical education.

Caring for Persons with Alzheimer's Disease during a Pandemic

The population experiencing Alzheimer's disease (AD) and their caregivers have been tremendously impacted by the global COVID-19 pandemic. Outpatient services became less accessible during the pandemic lockdown which caused increased caregiver burden more than usual. Further examination discovered that caregivers were unable to properly take care of themselves because of the need to provide around-the-clock care to loved ones, who pre-pandemic were able to receive supplemental caregiving services. The purpose of this integrative review was to provide a synthesis of information regarding caregiver experiences, during a time of limited resources, such as with the COVID-19 global pandemic. A comprehensive search of the literature databases Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline was completed yielding qualitative and mixed-methods studies. The literature search yielded 14 articles which met the criteria. Three themes emerged during this review. They include: Deprivation of self-care and social connectedness, Fragmented care and resources, and Improved policy development. Multiple gaps in caregiver needs have been identified throughout the literature. Outpatient services, home health aides, and respite care remain necessary elements of care for those with AD and for the relief of the caregiver. Forward planning should include government policies to support caregiving of those with AD, especially in the light of service restrictions or unavailable services.

Clinician perceptions on barriers and facilitators to 1-year surveillance colonoscopy completion in survivors of colorectal cancer.

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States. Surveillance colonoscopy is recommended 1-year after surgical resection for patients with stage I-III CRC; however, only 18%-61% of CRC survivors complete this test. This study describes clinician-identified barriers and facilitators to surveillance colonoscopy among CRC survivors. We conducted semi-structured interviews with clinicians until thematic saturation was achieved. Interviews were analyzed using the social cognitive theory. Thirteen clinicians were interviewed, and all identified health system-level barriers to surveillance colonoscopy completion; the most common being fragmented care due to patients receiving care across many health systems. Clinicians also identified social determinants of health barriers (e.g., geographical distance between patients and health systems) to 1-year surveillance colonoscopy completion. Clinicians identified several potentially modifiable barriers to 1-year surveillance colonoscopy completion which, if addressed, could improve post-treatment care and outcomes among stage I-III CRC survivors.

Public perceptions of reportable safety events and risks in United States primary care

Introduction: Patients may not feel responsible for reporting safety events, and social norms may prevent patients from questioning health care providers’ judgment. There is a paucity of research regarding public awareness of reportable safety events/risks. Educating the public about reporting is paramount in error prevention. Because more than 70% of errors (e.g., errors in diagnosis, communication errors, unsafe medication practices, and care fragmentation) occur in primary care settings, the purpose of this study was to explore public perceptions of when to report safety events/risks in these settings. Method: System-level primary and outpatient facility safety incident scenarios conducive to safety events/risk reporting were developed and administered via online survey methodology. Following completion of the scenario questions, participants were asked a single open-text item: “As you were reading the scenarios above, what did you think makes an event/risk ‘reportable’?” Results: At least one-third of participants responded incorrectly in 70% of the scenarios. The percentage of incorrect responses ranged from 5.2% to 62.3% with “unwitnessed falls” and “nursing scope of practice” queries incorrectly reported at 44.5% and 53.9%, respectively. Rationales for inappropriate events/risk reporting included “risk prediction at the management/system level,” “legal repercussions/protection (e.g., negligence, legal responsibility to patient),” “violations of scope of practice/professional expectations,” “degree of potential/actual lethality,” and “personnel errors.” Conclusion: This study revealed a gap between understanding why to report an event/risk and when to correctly report (or not report) an actual healthcare issue. Practical applications: Awareness of reasons for correctly reporting incidents and how correct reporting builds a culture of safety needs to be strengthened.

Linkage facilitation for opioid use disorder in criminal legal system contexts: a primer for researchers, clinicians, and legal practitioners

At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS.