Clinic Care Network Research Articles

The effects of treatment, clinical and demographic factors on recovery of orientation after ECT: A care network study

BackgroundTime to reorientation after electroconvulsive therapy (ECT) has been shown to predict retrograde amnesia and is a useful measure for monitoring patients over the acute treatment course. This study investigated the effects of treatment, clinical and demographic factors on the recovery of orientation after ECT. MethodsData from 555 ECT patients across two different clinical CARE Network sites were analysed. The main outcome variable was recovery of orientation on the 10-Item Orientation Questionnaire assessed after every ECT treatment. A linear mixed-effects repeated measures model was used to predict the recovery of orientation across the ECT course based on multiple factors, including age, gender, electrode montage, ECT number and frequency, diagnosis, and baseline cognitive impairment. ResultsType of ECT demonstrated a significant effect (F(2, 2341) = 48.414, p = 0.000): individuals who received right unilateral (RUL) ultrabrief ECT or bifrontal ECT had higher orientation scores compared to those who received RUL brief pulse ECT. Older age groups and female patients had lower orientation scores. Baseline global cognitive functioning significantly influenced orientation scores (F(3, 2339) = 43.597, p = 0.000), with individuals with no or mild cognitive impairment exhibiting higher scores. LimitationsThe study involved a retrospective analysis of de-identified data, which may have introduced inherent biases with missing data. ConclusionsThis large-scale retrospective, real-world study showed that recovery of orientation after ECT was most affected by ECT type, though age, gender, and baseline level cognitive impairment also affected outcomes. These findings can inform the interpretation of post ECT orientation scores, facilitating its monitoring and optimisation of patient outcomes.

Low-dose naltrexone for post-COVID fatigue syndrome: a study protocol for a double-blind, randomised trial in British Columbia

IntroductionA significant proportion of individuals suffering from post COVID-19 condition (PCC, also known as long COVID) can present with persistent, disabling fatigue similar to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and...

Integrative Oncology and the Clinical Care Network: Challenges and Opportunities.

Integrative oncology is a new and growing field of cancer care. Integrative oncology is a patient-centered, evidence-based field of comprehensive cancer care that utilizes integrative therapies such as mind-body practices, acupuncture, massage, music therapy, nutrition, and exercise in collaboration with conventional cancer treatments. Patient interest and utilization has been growing over the past two decades. Clinical research has shown the benefits of these approaches to improving symptom management and quality of life, and is now being incorporated into national guidelines from the National Comprehensive Cancer Network (NCCN) and American Society for Clinical Oncology (ASCO). The availability of these services at cancer centers is growing, although the structure and implementation of integrative oncology remains highly variable. This article discusses the benefits of integrative oncology and provides an overview of the current state of integrative oncology programs nationwide. Current challenges and opportunities for cancer centers to provide integrative services is reviewed in the areas of programmatic structure, clinical service, education, and research.

Resuscitation in the “Periviable” Period—Commentary of Opposing Views

The periviable period is defined as delivery between 20 0/7 weeks and 25 6/7 weeks of gestation. It has long been considered a “gray area,” as there are still no clear guidelines on initial resuscitation and subsequent treatment of the newborn. This lack of guidance compounds the uncertainty in decision-making in low- and middle-income countries with limited resources. The decision to treat or not has far-reaching economic, social, cultural, and sometimes even religious implications for the parents and family. This review explores the perspectives of parents, caregivers, and policymakers in detail to utilize the existing evidence better. We present arguments for and against resuscitation in the periviable period, discussing concerns surrounding neurodevelopmental outcomes, cost, parental concerns, nonuniformity of evidence, and ethical considerations. A large survival gap exists between developed and developing countries, and the infrastructure and clinical care network in low- and middle-income country are not strong enough to provide adequate support for these infants and their families. Antenatal factors, socioeconomic and cultural issues, center capacity, and resuscitation capacity of birthing centers should be considered when making decisions. The neonatologists are expected to be impartial, provide information, and not advise based on their beliefs and outlook; while preserving the autonomy of parents. The only way forward is for parents and caregivers to work together to develop a logical and ethical approach that can be accepted as national and institutional policies.

Differentiating Bell's Palsy From Lyme-Related Facial Palsy.

To describe the etiology and clinical course of pediatric acute-onset unilateral peripheral facial palsy (FP), to define factors that distinguish Bell's palsy from Lyme-related FP (LRFP), and to determine if early corticosteroid use impacts facial strength recovery in Bell's palsy or LRFP. Retrospective cohort study of children 1 to 18 years old who received clinical care within our pediatric clinical care network (Lyme-endemic region) between 2013 and 2018 for acute-onset unilateral peripheral FP. The study included 306 children; 82 (27%) had LRFP, 209 (68%) had Bell's palsy, and 15 (5%) had FP of different etiology. Most children with LRFP presented between June and November (93%), and compared with Bell's palsy, more often had a preceding systemic prodrome, including fever, malaise, headache, myalgias, and/or arthralgias (55% vs 6%, P < .001). Neuroimaging and lumbar puncture did not add diagnostic value in isolated FP. Of the 226 children with Bell's palsy or LRFP with documented follow-up, FP was resolved in all but 1. There was no association between ultimate parent/clinician assessment of recovery and early corticosteroid use. Bell's palsy and LRFP were common causes of pediatric FP in our Lyme endemic region. Systemic prodrome and calendar month may help distinguish LRFP from Bell's palsy at FP onset, guiding antibiotic use. Early corticosteroid use did not impact our measures of recovery, although subtle abnormalities may not have been appreciated, and time to recovery could not be assessed. Future prospective studies using standardized assessment tools at regular follow-up intervals are necessary.

Creating a provincial post COVID-19 interdisciplinary clinical care network as a learning health system during the pandemic: Integrating clinical care and research.

IntroductionCoronavirus Disease‐2019 (COVID‐19) affects multiple organ systems in the acute phase and also has long‐term sequelae. Research on the long‐term impacts of COVID‐19 is limited. The Post COVID‐19 Interdisciplinary Clinical Care Network (PC‐ICCN), conceived in July 2020, is a provincially funded resource that is modelled as a Learning Health System (LHS), focused on those people with persistent symptoms post COVID‐19 infection.MethodsThe PC‐ICCN emerged through collaboration among over 60 clinical specialists, researchers, patients, and health administrators. At the core of the network are the post COVID‐19 Recovery Clinics (PCRCs), which provide direct patient care that includes standardized testing and education at regular follow‐up intervals for a minimum of 12 months post enrolment. The PC‐ICCN patient registry captures data on all COVID‐19 patients with confirmed infection, by laboratory testing or epi‐linkage, who have been referred to one of five post COVID‐19 Recovery Clinics at the time of referral, with data stored in a fully encrypted Oracle‐based provincial database. The PC‐ICCN has centralized administrative and operational oversight, multi‐stakeholder governance, purpose built data collection supported through clinical operations geographically dispersed across the province, and research operations including data analytics.ResultsTo date, 5364 patients have been referred, with an increasing number and capacity of these clinics, and 2354 people have had at least one clinic visit. Since inception, the PC‐ICCN has received over 30 research proposal requests. This is aligned with the goal of creating infrastructure to support a wide variety of research to improve care and outcomes for patients experiencing long‐term symptoms following COVID‐19 infection.ConclusionsThe PC‐ICCN is a first‐in‐kind initiative in British Columbia to enhance knowledge and understanding of the sequelae of COVID‐19 infection over time. This provincial initiative serves as a model for other national and international endeavors to enable care as research and research as care.

Changing hospital organisational culture for improved patient outcomes: developing and implementing the leadership saves lives intervention

BackgroundLeadership Saves Lives (LSL) was a prospective, mixed methods intervention to promote positive change in organisational culture across 10 diverse hospitals in the USA and reduce mortality for patients with...

A Practice Redesign Collaborative for Reducing Hospital Readmission for Chronic Obstructive Pulmonary Disease in an Affiliated Network of Health Care Organizations

Patients discharged following admissions for acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) frequently require unplanned readmissions, increasing costs and morbidity for thousands of patients suffering from COPD. The Hospital Readmissions Reduction Program provided financial incentives to reduce 30-day readmissions for AE-COPD, but although risk factors for readmission are known, few evidence-based interventions achieve this goal. Members of the Mayo Clinic Care Network (MCCN) formed a collaborative to seek ways to reduce 30-day readmission for patients admitted with AE-COPD. Seventeen MCCN organizations participated in an improvement collaborative in 2016 and 2017. Mayo Clinic subject matter experts shared improvement webinars, protocols, and educational materials related to AE-COPD and delivered individualized coaching to facilitate improvement at each site over a six-month engagement. Among other recommended interventions, organizations worked to increase the proportion of COPD patients who had a standardized disease severity staging during admission, inhaler appropriateness evaluations, a COPD treatment action plan, and clinical contact at < 48 hours and 10 ± 4 days postdischarge. Same-hospital readmission rates improved from 17.7% ± 3.6 to 14.5% ± 4.0 (weighted difference -4.38, p = 0.008, paired t-test). In addition, participating teams stated that the collaborative framework helped them develop strategies that improved patient care and organizational capacity for improvement in other domains. The collaborative framework, beginning with education delivered in person and via webinars, combined with telephonically delivered coaching and knowledge sharing, assisted most members to improve care. Fourteen of 17 participating sites experienced a reduced AE-COPD readmission rate.

Analysis and impact of a multidisciplinary lymphoma virtual tumor board

The aim is to prospectively evaluate the impact of a multidisciplinary lymphoma virtual tumor board. The utility of multi-site interactive lymphoma-specific tumor boards has not been reported. The Mayo Clinic Lymphoma Tumor Board is a component of the International Mayo Clinic Care Network (MCCN). The format includes the clinical case presentation, presentation of radiology and hematopathology findings by the appropriate subspecialist, proposed treatment options, review of the literature pertinent to the case, pharmacy contributions, and discussion followed by recommendations. Three hundred and nine consecutive highly selected real-time cases with a diagnosis of lymphoma were presented at the Mayo Clinic Lymphoma Tumor Board from January 2014 to June 2018 and decisions were prospectively tracked to assess its impact on the treatment decisions. A total of 309 cases were prospectively evaluated. One hundred and forty (45.3%) cases had some changes made or recommended. The total changes suggested were 179, as some cases had more than one recommendation. There were 93 (30%) clinical management recommendations, 45 (14.6%) additional testing recommendations, 29 (9.4%) pathology changes, and 6 (1.9%) radiology changes. In an electronic evaluation process, 93% of the responders reported an improvement in knowledge and competence, and 100% recommended no change in format of the board. A multidisciplinary lymphoma tumor board approach was found to have a meaningful impact on lymphoma patients while enhancing interdisciplinary interactions and education for multiple levels of the clinical care team.

Building Perspective‐Taking as an Organizational Capability: An Exploratory Study

Research ObjectivePerspective‐taking, or understanding the viewpoints of others, is associated with greater trust, cooperation, and creative problem‐solving within high‐functioning teams. High‐functioning teams have been associated with a range of positive quality, safety, and clinical outcomes. Perspective‐taking has largely been understood as an individual and interpersonal phenomenon, primarily based on laboratory studies outside of health care. Despite its potential for improving outcomes in health care, little is known about whether and how perspective‐taking might build from the interpersonal to a wider, shared capability within and across organizations. We present novel empirical data to describe perspective‐taking across teams and organizations and suggest hypothesis for future exploration.Study DesignLeadership Saves Lives was a 2‐year, mixed‐methods intervention study in 10 U.S. hospitals to achieve reductions in AMI mortality by supporting the implementation of evidence‐based strategies and fostering improvements in domains of organizational culture related to hospital performance. The qualitative component included in‐depth interviews at baseline, 6, and 18 months (n = 393 interviews with 197 staff) and observations (56 hours). We performed a secondary exploratory analysis of the longitudinal qualitative data using the constant comparative method, focusing on selected codes most potentially relevant to perspective‐taking.Population StudiedParticipants included members of the guiding coalitions in 10 hospitals in the Mayo Clinic Care Network. Coalitions included approximately 15 key staff involved in care of patients with AMI, from multiple departments (ie, cardiology, emergency medicine, pharmacy, quality improvement, cardiac rehabilitation), professions (ie, physicians, nurses, technologists, administrators), and levels of the organization (ie, senior executives to front‐line staff).Principal FindingsStaff described improved collective perspective‐taking at both the group and system levels over the intervention period. Perspective‐taking behaviors were reported by members from diverse departments, professions, and levels of the organization. Behaviors were apparent in each of the core dimensions of perspective‐taking: 1) affective empathic concern (eg, bonding over a common purpose, solidarity, 2) cognitive attributional understanding (eg, concrete, specific insights and knowledge about facts, roles, processes, and 3) motivational efforts to improve understanding (eg, structural conditions, psychological safety of the perspectives inherent to other organizational targets). Participants described these behaviors as new and attributed them to structural and cultural changes developed through the intervention.ConclusionsThe LSL intervention included training for intentionally diverse teams in engaging conflict productively, using levels of analysis to diagnose organizational challenges, fostering psychological safety, ensuring role clarity, and working with power and hierarchy. Organizations may foster perspective‐taking by building ecological structures and processes that build team capacity in these areas.Implications for Policy or PracticePerspective‐taking has implications for productively spanning boundaries and distances across teams and organizations. Such boundary spanning is becoming increasingly important given contemporary efforts to integrate health and social care.Primary Funding SourceThe medicines company.

Neurological Complications of Sturge-Weber Syndrome: Current Status and Unmet Needs

ObjectiveWe aimed to identify the current status and major unmet needs in the management of neurological complications in Sturge-Weber syndrome. MethodsAn expert panel consisting of neurologists convened during the Sturge-Weber Foundation Clinical Care Network conference in September 2018. Literature regarding current treatment strategies for neurological complications was reviewed. ResultsAlthough strong evidence-based standards are lacking, the implementation of consensus-based standards of care and outcome measures to be shared across all Sturge-Weber Foundation Clinical Care Network Centers are needed. Each patient with Sturge-Weber syndrome should have an individualized seizure action plan. There is a need to determine the appropriate abortive and preventive treatment of migraine headaches in Sturge-Weber syndrome. Likewise, a better understanding and better diagnostic modalities and treatments are needed for stroke-like episodes. As behavioral problems are common, the appropriate screening tools for mental illnesses and the timing for screening should be established. Brain magnetic resonance imaging (MRI) preferably done after age one year is the primary imaging modality of choice to establish the diagnosis, although advances in MRI techniques can improve presymptomatic diagnosis to identify patients eligible for preventive drug trials. ConclusionWe identified the unmet needs in the management of neurological complications in Sturge-Weber syndrome. We define a minimum standard brain MRI protocol to be used by Sturge-Weber syndrome centers. Future multicenter clinical trials on specific treatments of Sturge-Weber syndrome-associated neurological complications are needed. An improved national clinical database is critically needed to understand its natural course, and for retrospective and prospective measures of treatment efficacy.

Harmonizing care for rare diseases: How we developed the mitochondrial care network in the United States

The mitochondrial medicine society (MMS) has previously highlighted the clinical landscape and physician practice patterns of mitochondrial medicine in the US and attempted to develop consensus criteria for diagnosis and management to improve patient coordinated care. Most recently, and in collaboration with US-based patient advocacy groups, we developed a clinical care network to formally unify US-based clinicians who provide medical care to individuals with mitochondrial disease; to define, design and implement best practices in mitochondrial medicine building on the current consensus guidelines and to improve patients' clinical outcomes.Here we review the steps taken in collaboration with several stakeholders to develop goals and expectations for a mitochondrial care network (MCN), criteria for MCN site selection and formal launch of the network.

Impact of international collaboration utilizing E-consult and E-tumor board in the multidisciplinary management of cancer patients: A study from Mayo Clinic Care Network (MCCN) members.

e18261 Background: Multidisciplinary tumor board meetings have shown to improve quality and outcome in the care of cancer patients. Many tertiary centers conduct site specific tumor board meetings but not all the centers especially community oncology and international centers have the manpower capacity to hold site specific meetings, the overall impact of tumor boards on patients care may vary based on its structure and composition. We propose that institutional collaboration in the comprehensive care of cancer patients utilizing E-consult and E tumor board may help to improve patient care. Methods: Retrospective data of 134 patient cases seen at the American hospital Dubai between 2016-2018 was analyzed. Cases that were reviewed at the American Hospital multidisciplinary tumor board meeting (AHD-MDT) and also referred for second opinion utilizing Mayo e-consult/e-tumor board service were analyzed using electronic health record, AHD-MDT meeting minutes and reports of Mayo e-consult/e-tumor board. 3 major areas of case assessment for review were selected 1. Pathology . 2. Medical imaging. 3. Clinical recommendations. Variation in assessment and recommendations between AHD- MDT and Mayo Clinic were compared. Results: A total of 1018 cases were reviewed in the AHD-MDT between 2016 and 2018. 136 out of the 1018(13%) cases were referred for second opinion utilizing Mayo E-Consult or E-tumor board service. 117 cases were included in the analysis as there was missing data in 4 patients, 9 were duplicate and 4 were cancelled and 7 cases were not reviewed at AHD-MDT. In 78 cases pathology was reviewed at Mayo but 4 (5%) were not reviewed at AHD. In 74 (95%) cases, pathology was reviewed both at AHD and Mayo. There was change (Ch) in 2 (3%), 7(9%)updated(Ud) and no change(Ch) in 65 cases(88%). 97 cases of imaging had change(Ch) in 1 case (1%). 101 cases of e-consult/e-tumor board were assessed for clinical recommendations. There was change(Ch) in 3(3%), 2/3 cases had a change in plan due to change in the pathology. In 35(35%) the plan was updated (Ud) and 7 out of 35(20%) were due to updated(Ud) pathology. Conclusions: Our data indicates that international collaboration as part of MCCN has resulted in significant improvement in the patient care. In a select group of challenging cases, 35% had an improvement in the final treatment plan after utilization of e-consult/e-tumor board service.

An Analysis of a Multidisciplinary Lymphoma Virtual Tumor Board with Regional and International Participation

Introduction: Outcomes of multidisciplinary and molecular tumor boards have been reported. Lymphoma specific tumor board outcomes have not been reported in the molecular era. In addition, the utility of multi-site, interactive tumor boards using videoconference technology are not widely reported. We prospectively followed the outcomes of a multidisciplinary multi-site lymphoma tumor board in the molecular era and during a change in the revision of the World Health Organization Classification in first published in 2016.Methods: The Mayo Clinic Lymphoma Tumor Board is a component of the international Mayo Clinic Care Network (MCCN). The format includes the clinical case presentation, presentation of radiology and hematopathology findings by the appropriate specialist, proposed treatment options, review of the literature pertinent to the case, and discussion followed by recommendations. Requirement for presentation includes having a diagnosis of lymphoma with pathology reviewed at Mayo Clinic, Rochester, MN (MCR). Pathology and radiology material, when relevant to the case, are required to be reviewed at MCR and presented by MCR pathologists/radiologists. Patients must be presented prospectively, and have active clinical issues or questions to be addressed. Four cases are presented per 60-minute meeting. 309 consecutive highly selected cases with a diagnosis of lymphoma were presented at the Mayo Clinic Lymphoma Tumor Board from 2014 to 2018. The pathology material was independently reviewed by the presenting hematopathologists and radiology material by the presenting radiologist. Participants are office based and included multiple members of the health care team which also incudes pharmacists, clinical research associates affiliated with lymphoma research, and physicians in training. Recommendations were prospectively tracked for changes in radiology interpretation, pathologic diagnosis, and treatment approaches. Actual follow-up of all patients after the meeting was not allowed in the MCCN. Participation in the meeting can be either via in-room attendance at MCR, video conference at a participating MCCN site, or via non-participatory live-stream online.Results: 309 cases were presented were presented from 2014-2018. 258 cases were from MCR, and 51 were not physically seen at MCR. 16 cases were presented at a subsequent meeting for further recommendations in the course of their disease after the initial presentation. 54% of patients presented had changes in some aspect of their care as a result of the meeting. Changes in radiologic interpretation occurred in 5 (1.6%) patients. The pathologic diagnosis changed in 27 (8.7%). Additional testing was recommended in 44 (14%). Clinical management changes were recommended in 90 (29%) cases. These included alterations in treatment approach in 43 (14%), change from undecided to pursuit of treatment 10 (3%), change from undecided regarding treatment approach to further diagnostic testing 4 (1.3%), change from observation to treatment 9 (3%), change from treatment to observation 4 (1.3%), and treatment to further tests in 2 (0.6%) Site in room average attendance (internal/external) was 16.8/8.6. Non-participatory live-stream attendance was not possible to track. In an annual electronic evaluation of this activity, 93% of the responders reported an improvement in knowledge and competence, and 100% recommended no changes to the format of the conference. Enhancements over time have included Continuous Medical Education credit, an in room microscope, and real-time radiology images. Selected cases will now be on line on an international web site.Conclusion: In this highly selected group of lymphoma cases from multiple sites over a 4-year period, 54% of the (167/309) case presentations resulted in changes to some aspect of care as a direct result of this tumor board. A multidisciplinary lymphoma tumor board approach was of value, efficacious, and meaningfully impacted lymphoma patients while substantially enhancing interdisciplinary interactions. DisclosuresAnsell:Celldex: Research Funding; Seattle Genetics: Research Funding; Takeda: Research Funding; Bristol-Myers Squibb: Research Funding; Pfizer: Research Funding; Merck & Co: Research Funding; LAM Therapeutics: Research Funding; Regeneron: Research Funding; Trillium: Research Funding; Affimed: Research Funding.

Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning.

Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.

Prof. David Hayes: administrators must have in-depth understanding of the hospital and be fair, open-minded and transparent as leader

Prof. David Hayes ( Figure 1 ) was the Chair of Cardiovascular Diseases at Mayo Clinic for more than 8 years and now he is medical director of Mayo Clinic Provider Relations, which includes the Mayo Clinic Care Network with the mission to establish collaborative and clinically meaningful relationships with high-quality providers to benefit patients, accelerate innovation and increase value in health care (1). It was not originally his goal to be a physician administrator, but when offered the opportunity, Prof. Hayes felt it was critical to identify successful physician leaders within the organization and learn from them.

A Collaborative for Implementation of an Evidence-Based Clinical Pathway for Enhanced Recovery in Colon and Rectal Surgery in an Affiliated Network of Healthcare Organizations

In 2015 the Mayo Clinic Care Network (MCCN), in an effort to extend medical knowledge and share these best practices, embarked on an education mission to diffuse the clinical practice redesign involving the practice of colon and rectal surgery at Mayo Clinic (Rochester, Minnesota) to members of the MCCN. They elected to use a collaborative framework in an attempt to transfer knowledge to multiple teams in an efficient and supportive manner. Eight MCCN members assembled a multidisciplinary team, which participated in both a didactic learning session delivered by frontline experts, as well as follow-up remote sessions regarding Mayo Clinic's enhanced recovery pathway for colon and rectal surgery. Teams departed the group session with established immediate next steps, communication plans, and an awareness of potential barriers and strategies for mitigation. Monthly coaching calls followed in an effort to help all teams meet their time line and overall goals. Finally, all participants met again after six months to report their clinical outcomes, as well their unique individual organization's successes and barriers encountered. Participating teams felt overwhelmingly that the collaborative program exceeded their expectations and equipped them with the tools to be successful. They also felt that the extended support provided by the Mayo Clinic team was essential, and the collaboration with other members markedly enhanced their experience. Importantly, all teams were able to successfully reduce length of stay, which was the desired main clinical outcome. The collaborative format was instrumental in the rapid diffusion and successful implementation of a transformative practice redesign involving colorectal surgical care of patients.

Mayo Clinic Care Network: A Collaborative Health Care Model

By leveraging its experience and expertise as a consultative clinical partner, the Mayo Clinic developed an innovative, scalable care model to accomplish several strategic goals: (1) create and sustain high-value relationships that benefit patients and providers, (2) foster relationships with like-minded partners to act as a strategy against the development of narrow health care networks, and (3) increase national and international brand awareness of Mayo Clinic. The result was the Mayo Clinic Care Network.

A To-Do List for the New CEO of the Federal Health Insurance Marketplace

the program will expand to an additional 45 social workers, chaplains, nurses, and physicians. Major health systemsare also takingup the challenge. The Mayo Clinic has created amedical notedocumentingadvancedcare planning discussions between physicians and patients; these will be included in electronicmedical records and accessible to clinicians across clinic settings beginningnext year, said Cory Ingram, MD, medical director of palliative care at the Mayo Clinic in Rochester,Minnesota.Also, theMayoClinic is exploringusing telemedicine tobringpalliative care expertise into rural areas or to members of theMayo Clinic Care Network, as needed. “Palliative care is not esoteric,” Ingram said. “It can take a central role in the health caredelivery systemconcurrentwithhighly sophisticated, technologically advanced care, andMayo is committed to that across our system.” InTexas,BaylorHealthCareSystemhas achieved advanced certification in palliative care from the Joint Commission for medical centers inDallasandFortWorthand eventually plans to develop interdisciplinary palliative care teams at all of its hospitals. Two outpatient palliative care clinics haveopened inDallasandPlano,andthesystem is offering 9 hours of training in palliative medicine to hospitalists—the start of a targeted effort to educate specialists in the discipline. “We are trying to extend palliative care across the continuum of care, just like the IOM report recommends,” sa id Robert Fine, MD, Baylor’s clinical director for palliative care. He said the report provides much-needed support for these efforts. “Now, I can go to the hospital president and say ‘Hey, it’s not just Bob Fine talking about what we need to do: it’s the IOM.’”