Complex Chronic Care Research Articles

Patient Experiences with an mHealth App for Complex Chronic Disease Care: Connections Despite Lack of Traditional Clinical Interactions

Patient Experiences with an mHealth App for Complex Chronic Disease Care: Connections Despite Lack of Traditional Clinical Interactions

Predictive analytics support for complex chronic medical conditions: An experience-based co-design study of physician managers’ needs and preferences

PurposeThe literature suggests predictive technology applications in health care would benefit from physician and manager input during design and development. The aim was to explore the needs and preferences of physician managers regarding the role of predictive analytics in decision support for patients with the highly complex yet common combination of multiple chronic conditions of cardiovascular (Heart) and kidney (Nephrology) diseases and diabetes (HND). MethodsThis qualitative study employed an experience-based co-design model comprised of three data gathering phases: 1. Patient mapping through non-participant observations informed by process mining of electronic health records data, 2. Semi-structured experience-based interviews, and 3. A co-design workshop. Data collection was conducted with physician managers working at or collaborating with the HND center, Danderyd University Hospital (DSAB), in Stockholm, Sweden. HND center is an integrated practice unit offering comprehensive person-centered multidisciplinary care to stabilize disease progression, reduce visits, and develop treatment strategies that enables a transition to primary care. ResultsInterview and workshop data described a complex challenge due to the interaction of underlying pathophysiologies and the subsequent need for multiple care givers that hindered care continuity. The HND center partly met this challenge by coordinating care through multiple interprofessional and interdisciplinary shared decision-making interfaces. The large patient datasets were difficult to operationalize in daily practice due to data entry and retrieval issues. Predictive analytics was seen as a potentially effective approach to support decision-making, calculate risks, and improve resource utilization, especially in the context of complex chronic care, and the HND center a good place for pilot testing and development. Simplicity of visual interfaces, a better understanding of the algorithms by the health care professionals, and the need to address professional concerns, were identified as key factors to increase adoption and facilitate implementation. ConclusionsThe HND center serves as a comprehensive integrated practice unit that integrates different medical disciplinary perspectives in a person-centered care process to address the needs of patients with multiple complex comorbidities. Therefore, piloting predictive technologies at the same time with a high potential for improving care represents an extreme, demanding, and complex case. The study findings show that health care professionals’ involvement in the design of predictive technologies right from the outset can facilitate the implementation and adoption of such technologies, as well as enhance their predictive effectiveness and performance. Simplicity in the design of predictive technologies and better understanding of the concept and interpretation of the algorithms may result in implementation of predictive technologies in health care. Institutional efforts are needed to enhance collaboration among the health care professionals and IT professionals for effective development, implementation, and adoption of predictive analytics in health care.

Enhancing caregivers self-management for their children who require medical technology: A feasibility study for the COPE-STAR intervention

PurposeTo test feasibility of the Creating Opportunities for Personal Empowerment: Symptom and Technology Management Resources intervention for caregivers of children who require medical technologies of tracheostomies and feeding tubes. Design and methodsQuasi-experimental one group design with measures at baseline and at 4 weeks. Intervention feasibility was tested from August 2019–June 2021, including recruitment, retention, and adherence, and caregiver satisfaction. Caregiver and child characteristics and outcomes were assessed. ResultsCaregivers were enrolled (n = 22) and completed (n = 16) the study. Caregivers were primarily female (n = 21), were predominately Caucasian (n = 14, 64%) followed by African-American (n = 8, 36%), and Non-Hispanic/Latino (n = 18, 82%). Feasibility indicators of recruitment (92%), retention (73%), and adherence (100%) were satisfactory. Outcome measures of management of child's chronic condition, caregiver beliefs about managing their child's symptoms and medical technology, anxiety, and depressive symptoms remained stable. Caregivers agreed that the intervention was useful, easy to use, and acceptable, and had positive feedback. ConclusionsThis is a feasible and acceptable intervention. With further development and efficacy testing, the intervention has potential for use and expansion to a larger population of caregivers of children who require medical technology. Practice implicationsChildren who require medical technology have multiple complex chronic conditions and complex care needs at home. This intensive and focused care is provided by informal caregivers who need education and resources for their child's care. This intervention addressed caregiver management of common symptoms and medical technologies of children in the home setting.

A photo-based communication intervention to promote diet-related discussions among older adults with multi-morbidity.

Little is known about how to best communicate with older adults about dietary behaviors and related factors in complex chronic disease care. Photo-based communication could promote efficient information exchange and activate patients to effectively communicate their lived experiences. We conducted a pilot study to assess the feasibility and acceptability of a photo-based patient-clinician communication intervention to promote dietary discussions in geriatric primary care. Older adult patients with 2+ concurrent chronic conditions received in-person training on photo-taking with a smartphone before taking photos in response to the prompt, "What aspects of your everyday life affect what you eat and how much you have to eat?" Patients then shared photos and their narratives with their primary care clinician during a clinic visit. Patients and clinicians completed separate audio-recorded post-visit interviews to assess perspectives on the intervention. Interview transcripts were analyzed using a thematic analysis approach. Fourteen patient-clinician dyads completed the study. All except one patient-clinician dyad (93%) completed the intervention as trained. 93% of patients and 86% of clinicians reported that they would "definitely" or "probably" be willing to engage in a future visit with photo-sharing. Patients and clinicians shared similar perspectives on how sharing of photos during the visit enhanced communication and information exchange about dietary practices and other health-related factors, influenced clinical recommendations made during the visits, and strengthened the patient-clinician relationship. Incorporation of a photo-based patient-clinician communication intervention to promote discussions regarding diet and other health-related factors could be a patient-centered strategy to help deliver comprehensive geriatric primary care.

Principal Care Management: Care Management Services for a Single Disease

Code descriptors and instructions for care management services have been evolving since the initial codes for complex chronic care management and transitional care management were introduced in 2013.

Pain Among an Inpatient Complex Chronic Care Population of Residents with and without Missing Limbs.

PurposeLimb loss occurs for various reasons (trauma, infection, vascular diseases, tumors, congenital absence). Limb loss is known to result in several types of pain. Little is known about pain in residents with missing limbs admitted to complex chronic care (CCC) facilities. This study examined the presence of pain and its intensity in CCC residents with and without missing limbs.MethodsThe Continuing Care Reporting System was accessed for data from residents admitted to Ontario com\\plex chronic care facilities assessed with the Resident Assessment Instrument Minimum Data Set, V2.0. Propensity score matching (1:1 ratio) was used to identify a control resident without missing limbs for each case. McNemar’s test was used for dichotomous pain (Y/N) and Wilcoxon Signed Ranks test for ordinal pain (4-level and 7-level pain variables). Binary and multinomial logistic regression were used to quantify the relationship between missing limbs and reports of pain.ResultsMissing limbs were reported by 2961 residents (2.1%, original n=139,920) resulting in 2212 propensity matched pairs. A significantly higher proportion of missing limb cases had pain (80%) versus controls (70%), χ2=64.43, p<0.001. Significantly higher pain levels were found in cases versus controls (z=8.47, p<0.001 for 4-level pain; z=8.57, p<0.001 for 7-level pain). Residents with missing limbs were 1.46 (95% CI: 1.26–1.70) times more likely to report pain than controls, p<0.001.ConclusionThe results point to the need to better manage pain in CCC residents with missing limbs.

Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study

Introduction Pediatric complex chronic care patients present unique challenges regarding healthcare provision: complex medical regimes, complicated family/provider dynamics, and multiple healthcare teams that can result in inconsistent care. This study examined subspecialty providers’ perspectives regarding pediatric complex chronic care patients and compared them with acute care providers while exploring opportunities to better facilitate care provided to pediatric complex chronic care patients. Methods This survey study occurring within a Canadian tertiary care pediatric center, utilized REDCap to deploy surveys involving Likert Scale and short answer questions. The Kruskal–Wallis test compared subspecialty provider perspectives when providing care to pediatric complex chronic care patients versus non-pediatric complex chronic care patients; and perspectives between subspecialty and acute care providers. Results Survey response rate was 24/46 (52.2%). Eight overarching themes emerged from Likert scale questions. Short answer questions revealed factors that may facilitate care provided to pediatric complex chronic care patients: access to funding; discharge planning; communication methods between specialists; and healthcare provider continuity. Several differences were identified when working with pediatric complex chronic care patients, compared to non-pediatric complex chronic care patients: increased time/resource burden; managing expectations of patients/families; navigating discrepancies in goals of care; complexity of coordination between services; increased efforts in coordinating discharge from hospital and working with medicalized patients/families. Discussion Exploring pediatric subspecialty provider perspectives of pediatric complex chronic care patients revealed opportunities to enhance care provided: increased resources to ease the strain of care provision for parents, implementation of a discharge coordinator, complex care clinics with a pediatrician to “quarterback” care, and co-management between the complex care pediatrician and acute care physician when admitted to an acute care service. Implementation of these initiatives may improve the care provided to pediatric complex chronic care patients.

Hypertensive Hypoalgesia in a Complex Chronic Disease Population.

Hypertension-related hypoalgesia, defined as lower pain sensitivity in individuals with high blood pressure, has yet to be examined in a large-scale study of complex care residents. Here, the Continuing Care Reporting System database, which contains health information on residents of Canadian complex chronic care facilities, was used for assessment. Hypertension was reported among 77,323 residents (55.5%, total N = 139,920). Propensity score matching, with a 1:1 ratio, was used to identify a control record without hypertension for each case. Multinomial logistic regression was used to quantify the effects of hypertension and sex on four-level ordinal pain variables, controlling for potential confounders. The matched dataset included n = 40,799 cases with hypertension and n = 40,799 without hypertension, with 57% female. Residents with hypertension had significantly lower odds of reporting pain (yes/no) (OR = 0.85, 95% CI 0.81–0.90, p < 0.001), including on measures of severe pain (OR = 0.69, 95% CI 0.63–0.76, p < 0.001). A significant interaction between hypertension and sex (OR = 1.17, 95% CI 1.03–1.32, p = 0.014) indicated that a significantly greater proportion of females without hypertension reported severe pain (8.71%). The results confirm the relationship between hypertension and reduced pain sensitivity on a population level.

A qualitative exploration of priorities for quality improvement amongst Aboriginal and Torres Strait Islander primary health care services

BackgroundAchieving quality improvement in primary care is a challenge worldwide, with substantial gaps between best practice and actual practice. Within the context of Australia, Aboriginal and Torres Strait Primary Health Care (PHC) services have great variation across settings, structures and context. Research has highlighted how these contextual differences can critically influence the success of Quality Improvement (QI) interventions and outcomes. Less understood is the interaction between local context and other factors, which may impact the implementation of QI interventions. This paper aims to explore the strengths and challenges in QI for Aboriginal and Torres Strait Islander PHC services and their priorities for improvement.MethodsA multiple case study design was adopted, working with eight Aboriginal and Torres Strait Islander PHC services in Northern Territory, Queensland and Western Australia. Data were collected via a health service survey, semi-structured interviews with health service staff and service users and researcher observations, to explore QI and perceptions of care quality at the service level. Data reported here were analysed using an iterative thematic technique, within-case and across-case.ResultsA total of 135 interviews were conducted with health service staff, service users and community members. Participants emphasised the centrality of resilient community, committed workforce and valued Aboriginal and Torres Strait Islander team members in delivering care. A shared purpose around improving the health of community was a significant driver. Key challenges included staff turnover and shortages, a complex and overwhelming acute and chronic care workload, building relationships and trust between health services and the community. Service-suggested priority areas for improvement were categorised into five themes: i) cultural safety (community driving health and planning for culturally safe services); ii) community engagement (through clinical activities in the community); iii) shared ownership and a team approach around QI; iv) strengthening systems and consistent ways of doing things in the health service; and v) strengthening local workforce (and resources for a culturally safe workforce).ConclusionsThese findings advance understandings of relational, community and cultural factors which are identified priorities for the delivery of quality care in Aboriginal and Torres Strait Islander PHC services across varied contexts.

Negotiations in the Care of Chronically Ill Children: Building Possibilities in a Setting of Uncertainty

Abstract Interested in exploring the construction of the negotiations present in the decision relationships in complex chronic care in pediatric outpatient settings, we approach Anselm Strauss and the concept of negotiated order and Annemarie Mol with the concept of decision logic associated with Latour actor-network theory. We used an ethnographic perspective of health research in the pediatric and stomatherapy outpatient clinics of a hospital located in the city of Rio de Janeiro, from July to December 2017. The interpretation of the field converged to two major axes: diagnosis and therapeutic itineraries, where care was performed through negotiation networks. These concerned the organization of the lives of people related to this care. This whole negotiation process took place in a hybrid scenario, marked by blurring across borders, where caregivers constantly negotiated the recognition of their children. Depending on the spaces and times of interaction, the actors moved through different identities, in a negotiation between how they recognized themselves and how they were recognized by people in complex chronic care. Negotiations in the observed care relationships took place between the uncertainties inherent to the health condition and the possibilities of living with that diagnosis.

Coding Challenge: Chronic Care Management Services 2021

Can you assign the correct 2021 chronic or complex chronic care management (CCM) codes to the scenarios described in the Challenge Table?

Association Between Multimorbid Disease Patterns and Pain Outcomes Among a Complex Chronic Care Population in Canada.

PurposeDisease multimorbidity and pain is a complex, yet common, problem for the aging population, and a significant burden on the health-care systems around the world. Despite this, disease comorbidity and the association with pain in a complex chronic care population is not well understood. This study examined the most prevalent disease combinations and their association with pain.Patients and MethodsThe study initially included 139,920 residents, aged 18–101 years, admitted to publicly funded hospital facilities for complex chronic care in Canada between the years 2006 and 2016. Data were acquired through the Canadian Institute for Health Information (CIHI) Facility-Based Continuing Care Reporting System (CCRS). Descriptive and chi-square statistics were used to summarize and compare the sample characteristics. Binary logistic regression analyses were used to examine the association between multimorbid disease categories and pain outcomes.ResultsThe sample consisted of 139,573 residents (57% female), mostly older (mean age = 77.32 years), married (40%), or widowed (36%). Residents took an average of 11.9 medications and 77% were using analgesic medications. On average, residents had diagnoses from 3.06 disease categories (SD = 1.43). Heart/circulation diseases were the most prevalent among the sample (73%), with neurological second (46%) and musculoskeletal third (44%). Overall, 73% of residents reported pain, with 43% reporting moderate pain severity. Residents with multiple disease categories were more likely to report the presence of pain (OR = 1.08, 95% CI: 1.07–1.08, p < 0.001), with each additional disease category associated with an 8% increase in the odds of reporting pain.ConclusionThe findings from this study help identify common comorbid disease patterns related to pain in an institutionalized, complex chronic care population. This information contributes to both the pain and multimorbidity literature, and is invaluable for creating care plans to meet the demands of a challenging population.

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study.

Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics. To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care. A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews. The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities. Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.

Experiences of Complex Patients With Telemonitoring in a Nurse-Led Model of Care: Multimethod Feasibility Study.

BackgroundTelemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs.ObjectiveThis study aims to evaluate the feasibility and patients’ perceived usefulness of a multi-condition TM platform in a nurse-led model of care.MethodsA pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor.ResultsIn total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs.ConclusionsMulti-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team.

Exploring an Innovative Care Model and Telemonitoring for the Management of Patients With Complex Chronic Needs: Qualitative Description Study.

BackgroundThe growing number of patients with complex chronic conditions presents an urgent challenge across the Canadian health care system. Current care delivery models are overburdened, struggling to monitor and stabilize the complex needs of this growing patient population.ObjectiveThis qualitative study aimed to explore the needs and perspectives of patients and members of the care team to inform the development of an innovative integrated model of care and the needs of telemonitoring (TM) for patients with complex chronic conditions. Furthermore, we explored how these needs could be successfully embedded to support this novel model of complex chronic care.MethodsA qualitative description design was utilized to conduct and analyze 29 semistructured interviews with patients (n=16) and care team members (CTM) (n=13) involved in developing the model of care in an ambulatory care facility in Southern Ontario. Participants were identified through purposive sampling. Two researchers performed an iterative thematic analysis using NVivo 12 (QSR International; Melbourne, Australia) to gain insights from examining multiple perspectives of different participants on complex chronic care needs.ResultsThe analysis revealed 3 themes and 13 subthemes, including the following: (1) adequate health care delivery remains challenging for patients with complex care needs, (2) insights into how to structure an integrated care model, and (3) opportunities for TM in an integrated model of care. Participants not only identified continued challenges in accessing and navigating care in a fragmented and disconnected delivery system but also identified the need for more self-management support. Patients and CTM described the structure of an integrated model of care, including the need for a clear referral and triage processes and composing a tight-knit circle of collaborating interdisciplinary providers led by a nurse practitioner (NP). Finally, opportunities for TM in an integrated model of care were identified, including increasing access and communication, the ability to monitor specific signs and symptoms, and building a clinical workflow around TM-enabled care.ConclusionsDespite entrenched health care service delivery models, a new model of care is acutely needed to care for patients with complex chronic needs (CCN). NPs are in a unique position to lead TM-enabled integrated models of care. TM can facilitate frequent and necessary monitoring of patients with CCN with more than one condition in integrated models of care.

The Billing Boys Tell All: Preparing to Succeed with Medicare and the Billers at Home (TH334)

•Describe five commonly used groups of billing codes applicable to palliative care teams' clinical work.•Understand the new Medicare documentation guidelines and how they can help save time and increase revenue.•Optimize billing code selection in all clinical settings, to take full advantage of all the tools now available from Medicare and commercial health plans. Palliative Care (PC) programs are growing nationally. Once niche services well under the fiscal radar, many PC programs now have seven-figure budgets and a dozen or more clinicians. As programs cost more, sponsoring institutions' expectations for clinical revenue grow, leaving PC team members working longer hours to see more patients to help close the yawning budgetary gap. Most PC providers have become accustomed to basic billing and coding practices, but significant opportunities exist, even for seasoned clinicians and program leads, in the rapidly expanding array of billing revenue opportunities. In follow-up to a standing-room-only session at the 2019 Assembly, two PC physicians responsible for the financial health of their teams will elevate clinicians' knowledge of billing and clinical revenue to the next level. The session will open with a brief review of commonly used billing codes—Evaluation and Management, Advance Care Planning, Face-to-Face and Non-Face-to-Face Prolonged Service Codes, and Chronic and Complex Chronic Care Management Codes. Relative Value Units (RVU) for these codes will be unpacked and explained, with an emphasis on optimal code selection in common visit scenarios. Presenters will also discuss the updated Medicare documentation guidelines, which offer real opportunities to save time and increase revenue. The session will then transition to lively case-based learning with extensive audience interaction. Inpatient, outpatient, and home care scenarios will be described and dissected and, when different codes or combinations of billing codes could be compliantly chosen, RVU differences will be highlighted to show which billing codes might be selected to optimize revenue. The time has ended when PC programs' costs were nothing more than an organization's financial rounding error. It is critical for all clinicians to understand billing at a deeper level, and this session will help attendees feel comfortable with more complex billing topics.

High-intensity end-of-life care among children, adolescents, and young adults with cancer who die in the hospital: A population-based study from the French national hospital database.

Efforts to improve the quality of end-of-life (EOL) care depend on better knowledge of the care that children, adolescents, and young adults with cancer receive, including high-intensity EOL (HI-EOL) care. The objective was to assess the rates of HI-EOL care in this population and to determine patient- and hospital-related predictors of HI-EOL from the French national hospital database. This was a population-based, retrospective study of a cohort of patients aged 0 to 25years at the time of death who died at hospital as a result of cancer in France between 2014 and 2016. The primary outcome was HI-EOL care, defined as the occurrence of ≥1 chemotherapy session <14days from death, receiving care in an intensive care unit ≥1 time, >1 emergency room admission, and >1 hospitalization in an acute care unit in the last 30days of life. The study included 1899 individuals from 345 hospitals; 61.4% experienced HI-EOL care. HI-EOL was increased with social disadvantage (adjusted odds ratio [AOR], 1.30; 95% confidence interval [CI], 1.03-1.65; P=.028), hematological malignancies (AOR, 2.09; 95% CI, 1.57-2.77; P<.001), complex chronic conditions (AOR, 1.60; 95% CI, 1.23-2.09; P=.001) and care delivered in a specialty center (AOR, 1.70; 95% CI, 1.22-2.36; P=.001). HI-EOL was reduced in cases of palliative care (AOR, 0.31; 95% CI, 0.24-0.41; P<.001). A majority of children, adolescents, and young adults experience HI-EOL care. Several features (eg, social disadvantage, cancer diagnosis, complex chronic conditions, and specialty center care) were associated with HI-EOL care. These findings should now be discussed with patients, families, and professionals to define the optimal EOL.

The XYZs of Billing and Clinical Revenue: Going Way Beyond the ABC’s (TH335)

•Describe five commonly used groups of billing codes applicable to palliative care teams’ clinical work.•List the 3 components of a relative value unit (RVU) and compare the relative differences between commonly used codes.•Consider the clinical components of a billable encounter to choose the correct billing code or codes to compliantly maximize revenue. Once niche services that flew well under the fiscal radar, many Palliative Care (PC) programs now have 7-figure budgets and a dozen or more clinicians. As programs cost more, sponsoring institutions’ expectations for clinical revenue grow, leaving PC team members working longer hours to see more patients and close yawning budgetary gaps. Most PC providers have become accustomed to basic billing and coding principles, but significant revenue opportunities exist among rapidly expanding breadth of professional fee codes, even for seasoned clinicians and program leaders. How do programs tap these opportunities? In this concurrent session, two PC physicians responsible for the financial health of their teams and a nationally-recognized billing-and-coding expert will elevate clinicians with a fundamental knowledge of billing and clinical revenue to the next level. We will open with a brief review of the billing codes now available to PC providers – Evaluation and Management (E/M), Advance Care Planning, Face-to-Face and Non-Face-to-Face Prolonged Service Codes, and Chronic and Complex Chronic Care Management Codes. Relative Value Units (RVUs) for these codes will be unpacked, explained and compared as well. The session will then transition to lively case-based learning with extensive audience interaction. Inpatient, outpatient, and home care clinical scenarios will be described and dissected and, when different codes or combinations of billing codes could be compliantly chosen, RVU differences will be highlighted to show which billing codes might be selected to optimize revenue. Attention will also be paid to using complexity- and time-based codes (alone and in combination), documentation, and billing for team based care. The time has ended when PC programs’ costs were nothing more than an organization’s financial rounding error. It is incumbent on program leaders and seasoned clinicians to understand clinical billing at a deep level, to maximize revenue that will sustain and grow their teams.

Impact of a complex chronic care patient case conference on quality and utilization.

There is need for effective venues to allow teams to coordinate care for high-risk or high-need patients. In addition, health systems need to assess the impact of such approaches on outcomes related to chronic health conditions and patient utilization. We evaluate the clinical impact of a novel case conference involving colocated trainees and supervisors in an interprofessional academic primary care clinic. The study utilized a prospective cohort with control group. Intervention patients (N = 104) were matched with controls (N = 104) from the same provider's panel using propensity scores based on age, gender, risk predictors, and prior utilization patterns. Clinical outcomes and subsequent utilization patterns were compared prior to and up to 6 months following the conference. In terms of utilization, intervention patients demonstrated increased visits with primary care team members (p = .0002) compared with controls, without a corresponding increase in the number of primary care providers' visits. There was a trend towards decreased urgent care and emergency visits (p = .07) and a significant decrease in the rate of hospitalizations (p = .04). Patients with poorly-controlled hypertension saw significant decreases in mean systolic blood pressure from 167 to 146 mm Hg. However, there were no differences between the intervention and control groups. Intervention patients with diabetes demonstrated a nonsignificant trend towards decreased hemoglobin A1c from 9.8 to 9.4, when compared with controls. Interprofessional case conferences have potential to improve care coordination and may be associated with improved disease management, decreased unplanned care, and overall reduced hospitalizations.

“I’m just trying to cope for both of us”: Challenges and supports of family caregivers in participant-directed programs

ABSTRACTRecently, national attention has focused on the needs of family caregivers providing complex chronic care, noting the necessity to better understand the scope of challenges they encounter. Although a robust body of literature exists about the scope of family caregiving, little is known specifically about the experiences and perspectives of family caregivers who support participant directed (PD) participants, particularly across the caregiving trajectory. Therefore, the aim of this qualitative descriptive study was to describe what family caregivers of individuals with developmental disabilities, physical disabilities, aging, or chronic health conditions identify as the challenges they experience as complex, and their perceptions of the effectiveness and gaps in family support resources in PD. Semi-structured interviews were audio-recorded with a purposive sample of caregivers. Transcribed interviews were analyzed using conventional content analysis. Fifty-four caregivers of individuals with a range of disabilities participated (age 34–78, M 59.9 ± 8.8; male 19%; spouse 17%, parent 61%). Six categories emerged from the analysis: contextualizing complexity, complexity in transitions, coping with complexity: advocacy & isolation, supportive support, unsupportive support, and systems challenges. Caregivers emphasized the interplay between unpredictability, transitions, and complexity and the interaction between the person receiving support, the caregiver’s own situation, and the environment. Findings highlight the need, and provide a guide, for family assessment and for tailoring interventions matched to the profiles and self-identified challenges of families living with disability. Social workers can learn what families see as complex and what support broker behaviors families find helpful, and which not.