Care In Different Settings Research Articles

Developing and Evaluating a Care Pathway for Improving Palliative Care in Western Norway.

Background: To operationalize the palliative care approach and improve care across services, a palliative care pathway (PCP) was developed in Western Norway. The PCP is an evidence-based framework for palliative care assessment and interventions in the form of a web-based flowchart. Measures: An electronic questionnaire aimed at health care professionals (HCPs) examined perceived usability and content. We registered PCP webpage activity and conducted an evaluation seminar and group interviews. Intervention: The pathway was developed (2015) and piloted in two cities (2017-2018/2020). Outcomes: HCPs perceived that the PCP contributed to increased palliative care knowledge and skills and worked as a reference and educational tool. They found the PCP easily accessible but asked for a search option and easier webpage navigation. Conclusions/Lessons Learned: An available PCP can support a common language for palliative care in different settings and enhance patient-centered care. HCPs need time to familiarize themselves with its content and use.

The future of education in Preventive Cardiology. A Statement of the European Association of Preventive Cardiology (EAPC) of the ESC.

In recent years, major advances in our understanding of risk factors implicated in the development of cardiovascular disease (CVD), in available tools for early detection of CVD, and in effective interventions to prevent subclinical or clinically manifest disease, have led to an increasing appreciation of prevention as a major pillar of cardiovascular medicine. Preventive cardiology has evolved into a dynamic sub-specialty focused on the promotion of cardiovascular health through all stages of life, and on the management of individuals at risk of developing CVD or experiencing recurrent cardiovascular events, through interdisciplinary care in different settings. As the level of knowledge, specialized skills, experience, and committed attitudes related to cardiovascular prevention has exceeded core cardiology training, the European Association of Preventive Cardiology (EAPC) has placed major emphasis on continuous education and training of physicians and allied professionals involved in cardiovascular prevention, with the aim of setting standards for practice and improving quality of care. The EAPC recognizes the need for comprehensive educational offer across different levels of training (from core cardiology to sub-specialty to expert training) as well as the need for interdisciplinary approaches that will promote synergies among allied professionals involved in cardiovascular prevention. This statement by the EAPC aims to highlight current gaps and unmet needs, and to describe the framework to help standardize, structure, and deliver comprehensive, up-to-date, interactive, high-quality education using a combination of traditional and novel educational tools. The document aims to form the basis for ongoing refinements of the EAPC educational offer, with the ultimate goal to ensure that new evidence in the field will translate to better cardiovascular practice and improved outcomes for our patients.

Parental stress, depression, anxiety and participation to care in neonatal intensive care units: results of a prospective study in Italy, Brazil and Tanzania

BackgroundStudies comparing the frequency of different mental health conditions across different settings and evaluating their association with parental participation in newborn care are lacking. We aimed at evaluating the frequency...

Artificial Intelligence for Patient Flow

Why Is This an issue? Inefficient patient flow contributes to the overcrowding of health care settings and negative clinical outcomes and patient experiences downstream. Patient flow management aims to achieve seamless patient movement through the health care system and between acute and long-term settings, ensuring timely access to quality care. What Is the Technology? Artificial intelligence (AI)-based patient flow management tools are interventions designed to forecast and monitor patient movement from admission to discharge as they progress through different care settings. AI-driven tools can leverage big data and digital information systems (e.g., electronic health records) to facilitate effective patient flow. AI-based patient appointment scheduling tools, which can help improve patient flow, are created to automate appointment scheduling and optimize it by minimizing wait times and matching the demand for health services and hospital capacity. What Is the Potential Impact? AI tools for patient flow management can support volume forecasting of patients with various conditions, especially those experiencing chronic conditions that require different types of treatment or care in different settings over a long period of time. These AI tools can predict admissions, patient movement from the emergency department to inpatient beds, discharge, and transfers to different health care settings. Evidence for their effectiveness in patients with emergency admissions and those transferred to tertiary and quaternary care, as well as inpatients from the general, cardiology, and mental health departments, was reported. In addition, evidence suggested that AI tools can optimize appointment scheduling in general outpatient settings and operating rooms. In health care systems in Canada, AI tools are being used or investigated to enhance patient flow by predicting emergency admissions, transfers to alternate levels of care, and general inpatient discharges, as well as optimizing capacity planning for patients receiving oncology care. AI appointment scheduling tools are currently being used in some oncology care settings and operating rooms across Canada. The implementation of AI systems generally requires an upfront investment of time and other resources in addition to the financial cost of the system itself for set-up, integration, and staff training. The goal of these systems is to improve efficiency and save money, time, and human resources in the long run. What Else Do We Need to Know? Patient privacy and data security issues are concerns regarding widespread implementation of AI tools trained on electronic health records systems and patient datasets. AI algorithms trained on datasets lacking adequate representation of all relevant patients may not predict their flow accurately. Training datasets with sufficient data from all relevant patient groups can ensure the inputs and outputs of the algorithms accurately reflect patient care needs and mitigate potential bias. To accurately predict the care needs of local patients, AI algorithms, once deployed, should be retrained on site-specific datasets containing data for the patient populations that are representative of the hospital or health system in which they are being used. Not all institutions have the hardware or computing power available to adequately or efficiently process the large amounts of data that are required by these AI systems, or the infrastructure needed to use big data (e.g., from electronic health records), and may require additional resources for implementation, as well as for ongoing maintenance and updating of the systems.

French mental health care system: Analysis of care utilisation patterns and the case for a stepped care approach

ContextIn France, spending on mental health and psychiatric care, in proportion to GDP, is close to the EU average. However, there are complaints that the French system is overwhelmed and potentially underfunded. ObjectiveTo describe the utilisation of psychiatric and mental health care in different settings to consider the appropriateness of care provision and resource allocation. MethodsFor the year 2018, several national databases on the use of all type of psychiatric care provision (full and part-time hospitalisations, private and public, public ambulatory care, private office-based psychiatrists) were cross-tabulated with diagnosis categories for different age groups and illness severity in order to assess the use of resources and evaluate the appropriateness of resource allocation. ResultsA sizable proportion of patients with mild and moderate mental disorders are treated in psychiatric care whilst there is insufficient continuity of care for patients with severe disorders, who are not adequately followed up after discharge from hospitals. This contributes to increase the rate of re-hospitalisations, the use of emergency departments, and longer stays in hospitals. ConclusionThe several components of the French mental health care system are used inappropriately, not only in geographical terms but also in terms of service use. We argue that strengthening the access to affordable psychotherapy and the implementation of a stepped-care approach could contribute to solve this issue.

Geroscience: Aging and Oral Health Research.

Research in aging has significantly advanced; scientists are now able to identify interventions that slow the biologic aging processes (i.e., the "hallmarks of aging"), thus delaying the onset and progression of multiple diseases, including oral conditions. Presentations given during the 3-part session "Geroscience: Aging and Oral Health Research," held during the 2023 American Association for Dental, Oral, and Craniofacial Research meeting, are summarized in this publication. Speakers' topics spanned the translational research spectrum. Session 1 provided an overview of the geroscience and health span (disease-free and functional health throughout life) concepts. The common molecular mechanisms between oral cancer and aging were discussed, and research was presented that showed periodontal microflora as a potential factor in Alzheimer's disease progression. Session 2 focused on behavioral and social science aspects of aging and their oral health significance. The keynote provided evidence that loneliness and isolation can have major health effects. These social conditions, along with poor oral health, tooth loss, and cognitive decline, could potentially affect healthy eating ability and systemic health in older adults. Research could help elucidate the directions and pathways connecting these seemingly disparate conditions. Session 3 focused on the delivery of oral care in different settings and the many barriers to access care faced by older adults. Research is needed to identify and implement effective technology and strategies to improve access to dental care, including new delivery and financing mechanisms, workforce models, interprofessional provider education and practice, and use of big data from medical-dental integration of electronic health records. Research to improve the "oral health span," reduce oral health disparities, and increase health equity must be tackled at all levels from biologic pathways to social determinants of health and health policies.

The case of B.M.: delirium across different settings of care

Delirium is a serious acute neuropsychiatric syndrome, characterized by acute and fluctuating inattention, other cognitive deficits, and alterations in level of consciousness, that is independently associated with several adverse outcomes. Delirium is a transdisciplinary condition since it can affect vulnerable people in all settings of care. This clinical case is the basis for a special issue on this topic in which the negative consequence of delirium and the methods to manage people affected by this condition are described across various settings of care.

The care planning umbrella: The evolution of advance care planning.

The care planning umbrella: The evolution of advance care planning.

Primary care patterns among dual eligibles with Alzheimer's disease and related dementias.

Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level. Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting. Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits. A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care.

TEACHING MEDICAL STUDENTS TO INCORPORATE THE 4MS OF AGE-FRIENDLY HEALTH SYSTEMS ACROSS THE CONTINUUM OF CARE

Abstract High quality and equitable health care for older adults involves patient-centered approaches that can improve the patient’s engagement, decision-making, and health outcomes. To educate future health professionals about patient-centered care across the continuum of care, a HRSA-Geriatric Workforce Enhancement Program created a four-week online elective course for third and fourth-year medical students using the Age-Friendly Health Systems 4Ms framework. Faculty identified geriatric tools and best practices in the 4M’s areas of What Matters, Mobility, Mentation, and Medication to develop self-directed asynchronous learning modules. Students were instructed on incorporating the 4Ms into patient assessments, care planning, interprofessional practice, and process improvement in different settings of care. Assignments included quizzes, case studies, discussion forums, and a patient experience interview with an older adult or caregiver. At course completion, students self-assessed their knowledge and skills and rated the course materials and assignments using five-point Likert-type items. Ninety-six students participated in the course between July 2020 and March 2022. Ninety-eight percent of respondents (n=80) felt the assignments were helpful, and 100% agreed the course improved their knowledge about Age-Friendly Health Systems and different care settings and processes. Also, 100% felt the content was applicable to their future practice and 96% would recommend the course. Qualitative thematic analysis of open-ended questions showed preferences for interactive elements, such as case presentations and guided interviews with older adults, as well as ways to improve student engagement. Educating students about Age-Friendly Health Systems can prepare future health professionals for collaborative patient-centered geriatrics care across a variety of settings.

Describing settings of care in the last 100 days of life for cancer decedents: a population-based descriptive study.

Few studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death. A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada. Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home. In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience.

Disparities in health utilities among hepatitis C patients receiving care in different settings.

BACKGROUND: Although chronic hepatitis C (CHC) disproportionately affects marginalized individuals, most health utility studies are conducted in hospital settings which are difficult for marginalized patients to access. We compared health utilities in CHC patients receiving care at hospital-based clinics and socio-economically marginalized CHC patients receiving care through a community-based program. METHODS: We recruited CHC patients from hospital-based clinics at the University Health Network and community-based sites of the Toronto Community Hep C Program, which provides treatment, support, and education to patients who have difficulty accessing mainstream health care. We elicited utilities using six standardized instruments (EuroQol-5D-3L [EQ-5D], Health Utilities Index Mark 2/Mark 3 [HUI2/HUI3], Short Form-6D [SF-6D], time trade-off [TTO], and Visual Analogue Scale [VAS]). Multivariable regression analysis was performed to examine factors associated with differences in health utility. RESULTS: Compared with patients recruited from the hospital setting (n = 190), patients recruited from the community setting (n = 101) had higher unemployment (87% versus 67%), history of injection drug use (88% versus 42%), and history of mental health issue(s) (79% versus 46%). Unadjusted health utilities were lower in community than hospital patients (e.g., EQ-5D: 0.722 [SD 0.209] versus 0.806 [SD 0.195]). Unemployment and a history of mental health issue(s) were significant predictors of low health utility. CONCLUSIONS: Socio-economically marginalized CHC patients have lower health utilities than patients typically represented in the CHC utility literature. Their utilities should be incorporated into future cost-utility analyses to better represent the population living with CHC in health policy decisions.

Practical management of frailty in older patients with heart failure: Statement from a panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology.

The heart failure (HF) prognosis in older patients remains poor with a high 5-years mortality rate more frequently attributed to noncardiovascular causes. The complex interplay between frailty and heart failure contribute to poor health outcomes of older adults with HF independently of ejection fraction. The aim of this position paper is to propose a practical management of frailty in older patients with heart failure. A panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology conducted a systematic literature search on the interlink between frailty and HF, met to propose an early frailty screening by non-geriatricians and to propose ways to implement management plan of frailty. Statements were agreed by expert consensus. Clinically relevant aspects of interlink between frailty and HF have been reported to identify the population eligible for screening and the most suitable screening test(s). The frailty screening program proposed focuses on frailty model defined by an accumulation of deficits including geriatric syndromes, comorbidities, for older patients with HF in different settings of care. The management plan of frailty includes optimization of HF pharmacological treatments and non-surgical device treatment as well as optimization of a global patient-centred biopsychosocial blended collaborative care pathway. The current manuscript provides practical recommendations on how to screen and optimize frailty management in older patients with heart failure.

A qualitative inquiry into pregnant women’s perceptions of respectful maternity care during childbirth in Ibadan Metropolis, Nigeria

Women’s perceptions of respectful maternity care (RMC) are critical to its definition and measurement globally. We evaluated these in relation to globally defined RMC norms. We conducted a descriptive study involving eight focus group discussions with 50 pregnant women attending antenatal clinic at one primary and one secondary health facility each in the North-west and South-west local government areas of Ibadan Metropolis, Nigeria. One focus group each with primigravidae and multiparas were held per facility between 21 and 25 October 2019. Shakibazadeh et al’s 12 domains of RMC served as the thematic framework for data analysis. The women’s perceptions of RMC resonated well with seven of its domains, emphasising provider-client inter-personal relationships, preserving their dignity, effective communication, and non-abandonment of care, but with mixed perceptions for two domains. However, their perceptions deviated for four domains, namely maintaining privacy and confidentiality; ensuring continuous access to family support such as birth companions; obtaining informed consent; and respecting women’s choices about mobility during labour, food and fluid intake, and birth position. The physical environment was not mentioned as contributing to an experience of RMC. Whilst the perceptions of the Nigerian women studied about RMC were similar to those accepted internationally, there were significant deviations which may be related to cultural differences and societal disparities. Different interpretations of RMC may influence women’s demand for such care in different settings and challenge strategies for promoting a universal standard of care.

Out-of-Pocket Expenditure for Diabetes Mellitus and Its Determinants in Recent Times in India

Introduction: Diabetes is one of the major disease burdens in the world. Globally around 463 million people (at a prevalence of 9.3%) suffered from diabetes recently. Apart from morbidity and mortality, diabetes poses high economic burden on healthcare systems, especially on national economies in developing countries like India. Estimation of the cost burden of diabetes can help decision-makers to understand the magnitude of the problem, prioritize research efforts and interventions, and plan resource allocation, especially in resource-poor settings. The focus of our review was to summarize cost burden of diabetes and its determinants from existing literature in the last 10 years in India. Materials and Methods: All literatures published in the period 2010–2020 were accessed through two databases: PubMed and Google Scholar. Reference lists of the article were again searched for further literatures. Cost calculated in different times was converted to current price in 2020 for ease of comparison. Results: Studies reported a wide range of expenditures in different settings of care. Inequity of expenses across income quintiles among patients was found. Complication of diabetes, insulin therapy, treatment in private facility, and events of hospitalization were the factors associated to high expenditure burden. Conclusion: Financial risk protection for vulnerable people and control over medicine market price will reduce out-of-pocket expenditure for diabetes. Comprehensive strategy to delay onset of complication as well as its early detection can be an opportunity to cut down diabetes-related economic burden.

Determinants of intensive care unit admission of hospitalized patients with COVID-19 in Saudi Arabia: An analytic retrospective cohort

Background: In March 2020, Saudi Arabia (KSA) experienced a coronavirus disease 2019 (COVID-19) outbreak. The mitigation strategy aimed to reduce both the impact on vulnerable groups and the risk of admission to the intensive care unit (ICU). Risk factors, such as sequential organ failure, comorbidities, ventilation, and mortality, have not been described in different settings of care. Materials and Methods: A multicenter, retrospective chart review of 220 adults with COVID-19 admitted to the ICU included demographics and ICU admission factors (e.g., quick sequential organ failure assessment (qSOFA) score, ventilator status, comorbidities, days from laboratory confirmation to ICU admission, and days from hospitalization to ICU admission). Regression was utilized to identify predictors of need for mechanical ventilation (MV) and mortality in ICU patients. Results: ICU admission, COVID-19 hospital mortality, and ventilator-associated mortality rates were 26.5%, 44%, and 30.5%, respectively. The mean patients' age was 30 years. Across four cities, Jeddah patients were at the highest risk of MV (<0.001). Within the 1st day of hospitalization, without lymphocytopenia, non-Saudi patients with a qSOFA score of 2 and 3 were at the highest risk of ventilation (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.72–8.66; OR, 11.4; 95% CI, 2.35–55.47; and OR, 6.1; 95% CI, 1.0–37.33, respectively). Moreover, within the same period of hospital stay, mechanically-ventilated patients with a qSOFA score of 3 who received antiviral medications were significantly at the higher risk of death (OR, 2.8.4; 95% CI, 1.44–5.64; OR, 13.1; 95% CI, 1.23–39.68; and OR, 2.2; 95% CI, 1.14–4.14, respectively). Conclusions: The 1st day of hospitalization, along with an assessment of the dyspnea status using the qSOFA score, is the window of opportunity for minimizing ICU admission risk. Neither lymphocytopenia nor comorbidities are associated with the risk of mechanical ventilation. Factors were also discussed. Reviews are needed on the indications for the use of antiviral agents, intubation, and ventilation in hospitalized patients.

Sustainability and Well-being in Geriatrics: proposing a performance-based approach for the implementation of geriatric care activities

The evaluation and measurement of Sustainable Development and Well-being represent a widespread emerging theme in healthcare, especially concerning, among others, the concepts of social equity and universality of health from an intergenerational perspective. To achieve such goals, Geriatrics would play a prominent role, especially considering the growing portion of the senior population in developed countries. This work intends to explore the possibility to connect Sustainable Development Goals and dimensions of Well-being to a set of performance indicators which are representative of geriatric activities in different settings of care. To this purpose, a pattern of indicators from Emilia- Romagna Region (RER) in Italy is considered. Furthermore, a range of Transitional Care interventions is discussed and proposed in order to ameliorate (or keep stable) the performance.

Development and implementation of a transmural palliative care consultation service: a multiple case study in the Netherlands

BackgroundIn the Netherlands, healthcare professionals attending patients in the last phase of life, can consult an expert palliative care team (PCT) in case of complex problems. There are two types of PCTs: regional PCTs, which are mainly consulted by general practitioners, and hospital PCTs, which are mainly consulted by healthcare professionals in the hospital. Integration of these PCTs is expected to facilitate continuity of care for patients receiving care in different settings. We studied facilitators and barriers in the process of developing and implementing an integrated transmural palliative care consultation service.MethodsA multiple case study was performed in four palliative care networks in the southwest Netherlands. We aimed to develop an integrated transmural palliative care consultation service. Researchers were closely observing the process and participated in project team meetings. A within-case analysis was conducted for each network, using the Consolidated Framework for Implementation Research (CFIR). Subsequently, all findings were pooled.ResultsIn each network, project team members thought that the core goal of a transmural consultation service is improvement of continuity of palliative care for patients throughout their illness trajectory. It was nevertheless a challenge for hospital and non-hospital healthcare professionals to arrive at a shared view on goals, activities and working procedures of the transmural consultation service. All project teams experienced the lack of evidence-based guidance on how to organise the service as a barrier. The role of the management of the involved care organisations was sometimes perceived as unsupportive, and different financial reimbursement systems for hospital and out-of-hospital care made implementation of a transmural consultation service complex. Three networks managed to develop and implement a transmural service at some level, one network did not manage to do so.ConclusionsHealthcare professionals are motivated to collaborate in a transmural palliative care consultation service, because they believe it can contribute to high-quality palliative care. However, they need more shared views on goals and activities of a transmural consultation service, more guidance on organisational issues and appropriate financing. Further research is needed to provide evidence on benefits and costs of different models of integrated transmural palliative care consultation services.

EAPC Core Curriculum for Preventive Cardiology.

Preventive cardiology encompasses the whole spectrum of cardiovascular disease (CVD) prevention, at individual and population level, through all stages of life. This includes promotion of cardiovascular (CV) health, management of individuals at risk of developing CVD, and management of patients with established CVD, through interdisciplinary care in different settings. Preventive cardiology addresses all aspects of CV health in the context of the social determinants of health, including physical activity, exercise, sports, nutrition, weight management, smoking cessation, psychosocial factors and behavioural change, environmental, genetic and biological risk factors, and CV protective medications. This is the first European Core Curriculum for Preventive Cardiology, which will help to standardize, structure, deliver, and evaluate training in preventive cardiology across Europe. It will be the basis for dedicated fellowship programmes and a European Society of Preventive Cardiology (EAPC) subspecialty certification for cardiologists, with the intention to improve quality and outcome in CVD prevention.

Medicaid reimbursement for pharmacist services: A strategy for the pharmacy profession.

Reimbursement for pharmacist services is complex due to a different set of rules for each payer. State legislatures, regulators, and professional licensing bodies have expanded the scope of practice for pharmacists in many states, representing a significant opportunity for third-party payers, including the Centers for Medicare and Medicaid Services, to enable and expand patient access to, and receipt of, care from pharmacists. This paper will introduce the term "other licensed practitioner" and describe how a state Medicaid program may include covered services provided by a pharmacist practitioner using the Medicaid state plan amendment process. In recent years, states have made great strides in training and educating high-quality pharmacist practitioners, expanding the scope of practice in all states, incorporating a credentialing and privileging process, and expanding the use of collaborative practice agreements with physicians and nurse practitioners. Pharmacists are well-positioned, essential members of the healthcare team, providing a spectrum of clinical and prevention services that increase access to care and improve health outcomes. A broad coalition of stakeholders including states, the federal government, pharmacy organizations, and other parts of the health ecosystem, working together, can better address the health needs of a state and its Medicaid beneficiaries. Pharmacist practitioners across different settings of care can augment public health efforts, as well as primary and specialty care practices. State efforts should include enrollment and reimbursement of pharmacist practitioners as Medicaid providers for pertinent Medicaid-covered services.