Collaborative Patient Care Research Articles

Application of interdisciplinary collaborative hospice care for terminal geriatric cancer patients: a prospective randomized controlled study.

Hospice care (HC) is specialized medical care for terminal patients who are nearing the end of life. Interdisciplinary collaborative hospice care (ICHC) is where experts from different disciplines and patients/caregivers form a treatment team to establish shared patient care goals. However, the ICHC efficacy has not been frequently studied in the terminal geriatric cancer patient (TGCP) population. This study aimed to gain insight into ICHC provided to TGCPs by an ICHC team and identify factors to ameliorate multidimensional HC. 166 TGCPs were randomized by a computer-generated random number table using an allocation ratio of 1:1. The patients were divided into the ICHC group and life-sustaining treatment (LST) group. The scores of these questionnaires, such as EORTC, QLQ-C30, Hamilton anxiety scale, the median survival time (MST), symptoms improvement, the median average daily cost of drugs (MADDC), the median total cost of drugs (MTDC) in the last 2days, and medical care satisfaction were observed in both groups. After treatment, the improvement of emotional function and symptoms in the ICHC group were statistically higher than those in the LST group (P < 0.05). The MADDC and the MTDC in the last 2days were statistically lower in the ICHC group than those in the LSTs group (P < 0.01). In addition, the overall satisfaction situation and the cooperation ability in the ICHC group were statistically higher than those in the LST group (P < 0.01). The ICHC could provide TGCPs with coordinated, comfortable, high-quality, and humanistic care.

Interprofessional student hotspotting: preparing future health professionals to deliver team-based care for complex patients.

Interprofessional student hotspotting involves experiential and longitudinal learning about team-based care for patients with complex medical and social needs. As an emerging strategy for interprofessional education, there have been few research studies to examine student perspectives. This study used a descriptive qualitative approach to examine the experiences and perspectives of health professions students who participated in a six-month interprofessional student hotspotting program. At the end of the program, focus group interviews were conducted with 24 health professions students from medicine, social work, pharmacy, nursing, and health psychology. Thematic analysis revealed four themes: Observed benefits of interprofessional collaboration; Gained skills for collaborative care; Experienced difficulty managing group dynamics; and Learned approaches to caring for complex patients. The hotspotting program helped deepen students' appreciation for interprofessional team-based care. Repeated practice of teamwork skills during the six-month clinical learning experience resulted in students feeling more prepared to provide collaborative care for complex patients.

Trauma-informed Collaborative Care for African American Primary Care Patients in Federally Qualified Health Centers: A Pilot Randomized Trial.

African Americans have nearly double the rate of posttraumatic stress disorder (PTSD) compared with other racial/ethnic groups. To understand whether trauma-informed collaborative care (TICC) is effective for improving PTSD among African Americans in New Orleans who receive their care in Federally Qualified Health Centers (FQHCs). In this pilot randomized controlled trial, we assigned patients within a single site to either TICC or to enhanced usual care (EUC). We performed intent to treat analysis by nonparametric exact tests for small sample sizes. We enrolled 42 patients from October 12, 2018, through July 2, 2019. Patients were eligible if they considered the clinic their usual source of care, had no obvious physical or cognitive obstacles that would prevent participation, were age 18 or over, self-identified as African American, and had a provisional diagnosis of PTSD. Our primary outcome measures were PTSD measured as both a symptom score and a provisional diagnosis based on the PTSD Checklist for DSM-5 (PCL-5). Nine months following baseline, both PTSD symptom scores and provisional PTSD diagnosis rates decreased substantially more for patients in TICC than in EUC. The decreases were by 26 points in EUC and 36 points in TICC for symptoms (P=0.08) and 33% in EUC and 57% in TICC for diagnosis rates (P=0.27). We found no effects for mediator variables. TICC shows promise for addressing PTSD in this population. A larger-scale trial is needed to fully assess the effectiveness of this approach in these settings.

The Case for Interprofessional Teaching in Graduate Medical Education.

Interprofessional education has been promoted as a strategy to dismantle professional silos and promote collaborative patient care. Citing this, medical educators have emphasized the widespread integration of interprofessional education into undergraduate medical education curricula. However, in the current residency training environment, little reinforcement exists for principles gleaned from interprofessional education, and little is known about the role that interprofessional providers have in resident education. In this perspective, we offer the concept and practice of interprofessional teaching to bolster the benefits of interprofessional education during residency training. Interprofessional teaching, relatively unexplored and potentially underutilized, may offer many of the same benefits of interprofessional education but is more readily adapted for the graduate medical education setting. The intensive care unit, characterized by a culture of multidisciplinary teamwork and complex patient care, is an ideal setting in which to use interprofessional teaching. Prior to enthusiastically implementing interprofessional teaching interventions, careful consideration should be paid to the setting, strategies, and impact on all key stakeholders.

Learning to swallow together: Medical and speech and language therapy student interprofessional learning about dysphagia

BACKGROUND: Interprofessional education (IPE) is considered to be a necessary step in preparing the healthcare workforce for collaborative patient care. Dysphagia, a complex health condition, requires collaboration between disciplines such as medicine (MED) and speech and language therapy (SLT). Therefore, both disciplines must have a shared understanding of dysphagia management within the context of interprofessional care. OBJECTIVE: This study investigated MED and SLT students’ shared learning about dysphagia management following an IPE workshop. The student experience of IPE was also explored. METHODS: Fifty students participated in one 3-hour classroom-based IPE dysphagia workshop which was appraised through a questionnaire completed immediately before and following the workshop. Within- and Between-Group analysis evaluated change in knowledge about dysphagia management. Comments related to student learning experiences were examined using a qualitative description approach. RESULTS: 98%of students (24 MED; 25 SLT) completed pre- and post-workshop questionnaires. Wilcoxon Signed-Rank tests indicated statistically significant post-workshop growth in knowledge of symptoms (p &lt; 0.001) and medical conditions (p &lt; 0.001) related to dysphagia. Students reported increased confidence in their ability to identify dysphagia (p &lt; 0.001). Greater understanding of interprofessional roles was observed post-workshop, notably nursing (p &lt; 0.05), pharmacy (p &lt; 0.05), occupational therapy (p &lt; 0.05) and physiotherapy (p &lt; 0.001). While recognised as beneficial to shared learning and appreciation of different discipline perspectives, both cohorts found IPE challenging. CONCLUSIONS: Classroom-based IPE is an appropriate approach for shared learning about complex health conditions which require interprofessional care. Including patient-facing activities would further enhance student learning. While students found IPE challenging, they identified several benefits related to their professional development.

The role of a pharmacy residency program in global health: Establishing pediatric clinical pharmacy services in a Malawian hospital

To describe the establishment of pediatric clinical pharmacy services in a Malawian hospital as part of a pharmacy residency program's engagement in global health. While pharmacy is expanding its role in global health through the introduction of international advanced pharmacy practice experience (APPE) rotations at US schools of pharmacy, international experiences for pharmacy residents are currently very limited. Such programs are advantageous for pharmacists planning for a career in public or global health, and there is also great opportunity for clinical pharmacists to work with international partners for professional development and to help advance pharmacy practice. The University of North Carolina at Chapel Hill Eshelman School of Pharmacy recently expanded its international APPE rotation in Malawi into the postgraduate training space through creation of a pediatric pharmacy residency training program, with the specific aim of working with partners in Malawi to introduce pediatric pharmacy services at Kamuzu Central Hospital. As this was the first time there was a pharmacist involved in patient care on the pediatric wards, the focus for the participating pharmacy resident was on establishing a positive relationship with the medical team through providing high-quality collaborative patient care for the pediatric population. In addition to working to establish pediatric clinical pharmacy services, the resident further contributed to sustainable improvements in pediatric patient care by identifying areas for quality improvement. We discuss several considerations for the successful implementation of international experiences and their impact on participating residents. Pharmacy has an opportunity to build on the success of international APPE rotations and expand postgraduate offerings. Through collaboration with other institutions already involved in global health and identifying international rotation sites, residency programs across the country can create similarly beneficial global health experiences for their pharmacy residents.

Management of Neurogenic Orthostatic Hypotension in Neurodegenerative Disorders: A Collaboration Between Cardiology and Neurology.

Treatment of patients with α-synucleinopathies (e.g., Parkinson disease, multiple system atrophy, diffuse Lewy body disease) may require clinicians to manage both neurologic and cardiovascular issues due to autonomic dysfunction. In addition to the underlying neurodegenerative condition, patients often experience blood pressure dysregulation, such as neurogenic orthostatic hypotension (nOH) and/or supine hypertension. This commentary details the collaborative care between a cardiologist and neurologist to effectively manage medically complex patients with nOH by illustrating the case of a 76-year-old man with a history of multiple system atrophy who experienced recurrent syncope when standing or sitting and falls with loss of consciousness. The patient could walk only a few steps before experiencing a substantial drop in systolic blood pressure (100 mmHg). He also had features of profound parkinsonism (e.g., tremor, facial masking) that required treatment with levodopa, but orthostatic symptoms related to the blood pressure drop needed improvement first. The neurologist and cardiologist collaborated to diagnose nOH and initiate droxidopa treatment, which led to resolution of syncope, control of orthostatic symptoms, and improvement of orthostatic blood pressure. Considerations in the collaborative care of patients with nOH are outlined, including screening protocols, treatment goals and options, mitigation of supine hypertension risk (a condition that frequently coexists with nOH), and management of other comorbidities. In conclusion, collaboration between neurologists and cardiologists is an efficient method to improve outcomes for patients with nOH because this care model allows specialist providers to leverage their areas of expertise to manage the wide spectrum of clinical features associated with nOH. Further, communication and cooperation of the patient care team can lead to reduced patient morbidity, optimal relief of nOH symptoms, improvements in activities of daily living and quality of life, and decreased caregiver burden. Management of Neurogenic Orthostatic Hypotension in Neurodegenerative Disorders: A Collaboration Between Cardiology and Neurology (MP4 73511 kb)Supplementary InformationThe online version contains supplementary material available at 10.1007/s40120-021-00270-3.

Measuring Collaboration Through Concurrent Electronic Health Record Usage: Network Analysis Study.

BackgroundCollaboration is vital within health care institutions, and it allows for the effective use of collective health care worker (HCW) expertise. Human-computer interactions involving electronic health records (EHRs) have become pervasive and act as an avenue for quantifying these collaborations using statistical and network analysis methods.ObjectiveWe aimed to measure HCW collaboration and its characteristics by analyzing concurrent EHR usage.MethodsBy extracting concurrent EHR usage events from audit log data, we defined concurrent sessions. For each HCW, we established a metric called concurrent intensity, which was the proportion of EHR activities in concurrent sessions over all EHR activities. Statistical models were used to test the differences in the concurrent intensity between HCWs. For each patient visit, starting from admission to discharge, we measured concurrent EHR usage across all HCWs, which we called temporal patterns. Again, we applied statistical models to test the differences in temporal patterns of the admission, discharge, and intermediate days of hospital stay between weekdays and weekends. Network analysis was leveraged to measure collaborative relationships among HCWs. We surveyed experts to determine if they could distinguish collaborative relationships between high and low likelihood categories derived from concurrent EHR usage. Clustering was used to aggregate concurrent activities to describe concurrent sessions. We gathered 4 months of EHR audit log data from a large academic medical center’s neonatal intensive care unit (NICU) to validate the effectiveness of our framework.ResultsThere was a significant difference (P<.001) in the concurrent intensity (proportion of concurrent activities: ranging from mean 0.07, 95% CI 0.06-0.08, to mean 0.36, 95% CI 0.18-0.54; proportion of time spent on concurrent activities: ranging from mean 0.32, 95% CI 0.20-0.44, to mean 0.76, 95% CI 0.51-1.00) between the top 13 HCW specialties who had the largest amount of time spent in EHRs. Temporal patterns between weekday and weekend periods were significantly different on admission (number of concurrent intervals per hour: 11.60 vs 0.54; P<.001) and discharge days (4.72 vs 1.54; P<.001), but not during intermediate days of hospital stay. Neonatal nurses, fellows, frontline providers, neonatologists, consultants, respiratory therapists, and ancillary and support staff had collaborative relationships. NICU professionals could distinguish high likelihood collaborative relationships from low ones at significant rates (3.54, 95% CI 3.31-4.37 vs 2.64, 95% CI 2.46-3.29; P<.001). We identified 50 clusters of concurrent activities. Over 87% of concurrent sessions could be described by a single cluster, with the remaining 13% of sessions comprising multiple clusters.ConclusionsLeveraging concurrent EHR usage workflow through audit logs to analyze HCW collaboration may improve our understanding of collaborative patient care. HCW collaboration using EHRs could potentially influence the quality of patient care, discharge timeliness, and clinician workload, stress, or burnout.

Efficacy of Blended Collaborative Care for Patients With Heart Failure and Comorbid Depression

Depression is often comorbid in patients with heart failure (HF) and is associated with worse clinical outcomes. However, depression generally goes unrecognized and untreated in this population. To determine whether a blended collaborative care program for treating both HF and depression can improve clinical outcomes more than collaborative care for HF only and physicians' usual care (UC). This 3-arm, single-blind, randomized effectiveness trial recruited 756 participants with HF with reduced left ventricular ejection fraction (<45%) from 8 university-based and community hospitals in southwestern Pennsylvania between March 2014 and October 2017 and observed them until November 2018. Participants included 629 who screened positive for depression during hospitalization and 2 weeks postdischarge and 127 randomly sampled participants without depression to facilitate further comparisons. Key analyses were performed November 2018 to March 2019. Separate physician-supervised nurse teams provided either 12 months of collaborative care for HF and depression ("blended" care) or collaborative care for HF only (enhanced UC [eUC]). The primary outcome was mental health-related quality of life (mHRQOL) as measured by the Mental Component Summary of the 12-item Short Form Health Survey (MCS-12). Secondary outcomes included mood, physical function, HF pharmacotherapy use, rehospitalizations, and mortality. Of the 756 participants (mean [SD] age, 64.0 [13.0] years; 425 [56%] male), those with depression reported worse mHRQOL, mood, and physical function but were otherwise similar to those without depression (eg, mean left ventricular ejection fraction, 28%). At 12 months, blended care participants reported a 4.47-point improvement on the MCS-12 vs UC (95% CI, 1.65 to 7.28; P = .002), but similar scores as the eUC arm (1.12; 95% CI, -1.15 to 3.40; P = .33). Blended care participants also reported better mood than UC participants (Patient-Reported Outcomes Measurement Information System-Depression effect size, 0.47; 95% CI, 0.28 to 0.67) and eUC participants (0.24; 95% CI, 0.07 to 0.41), but physical function, HF pharmacotherapy use, rehospitalizations, and mortality were similar by both baseline depression and randomization status. In this randomized clinical trial of patients with HF and depression, telephone-delivered blended collaborative care produced modest improvements in mHRQOL, the primary outcome, on the MCS-12 vs UC but not eUC. Although blended care did not differentially affect rehospitalization and mortality, it improved mood better than eUC and UC and thus may enable organized health care systems to provide effective first-line depression care to medically complex patients. ClinicalTrials.gov Identifier: NCT02044211.

How do care providers evaluate collaboration? - qualitative process evaluation of a cluster-randomized controlled trial of collaborative and stepped care for patients with mental disorders

BackgroundCollaborative and stepped care (CSC) models are recommended for mental disorders. Their successful implementation depends on effective collaboration between involved care providers from primary and specialist care. To gain insights into the collaboration experiences of care providers in CSC against the backdrop of usual mental health care, a qualitative process evaluation was realized as part of a cluster-randomized controlled trial (COMET) of a collaborative and stepped care model in Hamburg (Germany).MethodsSemi-structured interviews were conducted with N = 24 care providers from primary and specialist care (outpatient psychotherapists and psychiatrists, inpatient/ day clinic mental health providers) within and outside of COMET at the trial’s beginning and 12 months later. Interviews were analyzed applying a qualitative structuring content analysis approach, combining deductive and inductive category development.ResultsUsual mental health care was considered deficient in resources, with collaboration being scarce and mainly taking place in small informal networks. Within the COMET trial, quicker referral paths were welcomed, as were quarterly COMET network meetings which provided room for exchange and fostered mutual understanding. Yet, also in COMET, collaboration remained difficult due to communication problems, the unfavorable regional distribution of the COMET care providers and interprofessional discrepancies regarding each profession’s role, competencies and mutual esteem. Ideas for improvement included more localized networks, the inclusion of further professions and the overall amelioration of mental health care regarding resources and remuneration, especially for collaborative activities.ConclusionsThe process evaluation of the COMET trial revealed the benefits of creating room for interprofessional encounter to foster collaborative care. Despite the benefits of faster patient referrals, the COMET network did not fulfill all care providers’ prior expectations. A focus should be set on interprofessional competencies, mutual perception and role clarification, as these have been revealed as significant barriers to collaboration within CSC models such as COMET.Trial registrationThe COMET trial (Collaborative and Stepped Care in Mental Health by Overcoming Treatment Sector Barriers) has been registered on July 24, 2017 under the trial registration number NCT03226743.

Barriers to Comprehensive Multidisciplinary Head and Neck Care in a Community Oncology Practice.

Complex, coordinated, and collaborative care of patients with head and neck cancer can be challenging yet amazingly rewarding and successful. The high symptom burden across multiple functional domains in patients with head and neck cancer, even in early stages of disease, mandates a multidisciplinary team approach that harnesses the combined contributions of physicians and ancillary providers to drive greater patient-centered care, addressing factors that heavily influence morbidity, mortality, and quality of life. Well-organized community-based multidisciplinary teams fulfill this unmet need and benefit patients with conveniently located comprehensive services that are typically found in large academic centers. Equivalent, if not superior, outcomes can be achieved in a unified community-based multidisciplinary team with shared patient-centered and outcomes-based goals. However, implementing true multidisciplinary team care in today's complex health care environment is fraught with challenges and pitfalls. So how have some community-based practices managed to create safe and efficient programs with successful outcomes? The purpose of this review is to discuss barriers to reaching this success and emphasize practical solutions to such challenges.

Quality of Life and its Determinants in Patients with Diabetes Mellitus from Two Health Institutions of Sub-himalayan Region of India.

Background:Diabetes mellitus (DM) causes serious deterioration in general quality of life (QoL) mainly affecting the health-related quality of life (HRQOL). Routine assessment of QoL improves communication with the patient, helps to predict treatment response, and supports clinical decision-making. QoL can predict an individual's capacity to manage the disease and maintain long-term health and wellbeing.Aims:To find out the QoL and its socio-demographic, anthropometric, and clinical determinants among DM patients attending health institutions from sub-Himalayan region, catering rural population.Settings and Design:This cross-sectional study was conducted in two hospitals mostly catering rural population from 2014 to 2018. Purposive sampling technique was used.Materials and Methods:Socio-demographic, anthropometric, and clinical data of DM patients (N = 300) were collected. They were administeredHindi translation of QoL Instrument for Indian Diabetes Patients (QOLID) and Patient Health Questionnaire-9 (PHQ-9). All statistical analyses were carried out using Statistical Package for Social Sciences (SSPS) (Version 17.0, USA).Results:About 10% had very poor, 13% poor, 11% average, 16% good, and 50% very good QoL on QOLID. General health (GH) and treatment satisfaction (TS) were the most affected domains. Fatigue was the most common symptom (79%) reported in QOLID. Age more than 55 years, rural background, and PHQ-9 score of more than 7 were predictors of poorer QoL.Conclusion:There is a need for a holistic and collaborative care of DM patients, to maintain a good HRQoL. Screening of depression, fatigue, and regular assessment of QoL should be emphasized.

A mixed methods approach to determine the climate of interprofessional education among medical and health sciences students

BackgroundHigh-quality patient care is a complex phenomenon that requires collaboration among healthcare professionals. Research has shown that Interprofessional Education (IPE) carries promise to improve collaborative work and patient care. So far, collaboration among various health professionals remains a challenge. Very few focus group discussions to determine the medical students’ readiness and positive attitudes towards IPE have been reported from the Arabian context.MethodsA two-staged sequential mixed methods study was conducted among medical, dental, pharmacy, and health sciences students of the University of Sharjah United Arab Emirates. The perspectives of students toward IPE and collaborative practice were first gathered by administering a validated instrument, Readiness for Interprofessional Learning Scale (RIPLS). This was followed by focused group discussions. A quantitative as well as a qualitative data analysis was performed.ResultsThis study cohort included 282 students. All respondents showed readiness to adopt IPE as all statements of the RIPLS inventory scored high median scores. All participants showed positive attitudes and readiness towards IPE. Three main domains of themes were generated from focus group discussions; prior knowledge, need for IPE framework and its implementation. Information workload, lack of clarity and less focused teaching pedagogies of IPE were considered as perceived barriers.ConclusionThis study demonstrated a substantial agreement of medical and health sciences students towards readiness and perceived effectiveness of IPE. Educators are urged to embed new IPE programs into existing curricular frameworks, which can potentially enhance collaborative learning and improve quality of patient care.

Primary Care and Behavioral Health Provider Communication: Strategy for Improvement

Limited communication between primary care and behavioral health providers was identified as a barrier to access care and effective collaborative care of patients seeking behavioral health treatment in the Matanuska-Susitna Borough, Alaska. A 1-group, pretest–posttest design, quality improvement project was created to develop and implement a standardized communication template to facilitate communication and collaboration between behavioral health and primary care providers in the project group. Relational coordination within the group as a whole improved 11.07% from pre- to postintervention. Significant cultural differences, most notably in understanding the application of Health Insurance Portability and Accountability Act, were identified between the 2 provider types.

Impact of Interprofessional Care Conferences Across Primary Care and Mental Health Organizations on Family Medicine Resident Learning.

Patients with severe mental illness often lack care coordination between primary care and mental health providers which can negatively impact patient outcomes. Team-based care is integral in the effective management of patients with multiple comorbidities, with the family physician central in coordinating holistic care. Family medicine residency programs must provide models of effective interprofessional collaboration and mental health treatment to prepare residents to navigate an evolving health care landscape. The objective of this study was to evaluate family medicine residents' learning about providing holistic care with an interprofessional team and medication safety monitoring from the interprofessional cross-organizational care conference experience. To bridge care and cultivate the necessary skills, a family medicine clinic and mental health clinic implemented monthly interprofessional care conferences to coordinate care for their shared patients during 2019. Residents who participated in the care conference each (n=11) completed a retrospective pre/postsurvey (11/11=100% response rate) to gather perceptions of what they learned from the interprofessional care conference experience. After participating in the care conference, all residents agreed they understood the elements that must be considered to provide holistic patient care, were confident conducting medication safety monitoring for their patients taking second-generation antipsychotics (eg, lipids, A1C, ECG), and agreed the care conference helped them develop a more comprehensive patient-centered care plan. Additionally, they all intend to work collaboratively across professions in the future. Interprofessional and cross-organizational care conferences create an authentic learning environment that enhances family medicine residents' understanding and confidence in providing collaborative and holistic care for patients with severe and persistent mental illness.

Health-economic evaluation of collaborative orthogeriatric care for patients with a hip fracture in Germany: a retrospective cohort study using health and long-term care insurance claims data

BackgroundEvidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence on cost-effectiveness is limited and based on small datasets. The aim of our study was to conduct an economic evaluation of the German OGCM for geriatric hip fracture patients.MethodsThis retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a hip fracture in 2014, and were treated in hospitals providing OGCM (OGCM group) or standard care (control group). Health care costs from payer and societal perspective, life years gained (LYG) and cost-effectiveness were investigated within 1 year. We applied weighted gamma and two-part models, and entropy balancing to account for the lack of randomisation. We calculated incremental cost-effectiveness ratios (ICER) and employed the net-benefit approach to construct cost-effectiveness acceptability curves.Results14,005 patients were treated in OGCM, and 10,512 in standard care hospitals. Total average health care costs per patient were higher in the OGCM group: €1181.53 (p < 0.001) from payer perspective, and €1408.21 (p < 0.001) from societal perspective. The ICER equalled €52,378.12/ LYG from payer and €75,703.44/ LYG from societal perspective. The probability for cost-effectiveness would be 95% if the willingness-to-pay was higher than €82,000/ LYG from payer, and €95,000/ LYG from societal perspective.ConclusionSurvival improved in hospitals providing OGCM. Costs were found to increase, driven by inpatient and long-term care. The cost-effectiveness depends on the willingness-to-pay. The ICER is likely to improve with a longer follow-up.

Pre-Post Evaluation of Collaborative Oncology Palliative Care for Patients With Stage IV Cancer

ContextThe Collaborative Care Model improves care processes and outcomes but has never been tested for palliative care. ObjectivesTo develop and evaluate a model of collaborative oncology palliative care for Stage IV cancer. MethodsWe conducted a pre-post evaluation of Collaborative Oncology Palliative Care (CO-Pal), enrolling patients with Stage IV lung, breast or genitourinary cancers and acute illness hospitalization. CO-Pal has 4 components: 1) oncologist communication skills training; 2) patient tracking; 3) palliative care needs assessment; and 4) care coordination stratified by high vs. low palliative care need. Health record reviews from hospital admission through 60 days provided data on outcomes - goals-of-care discussions (primary outcome), advance care planning, symptom treatment, specialty palliative care and hospice use, and hospital transfers. ResultsWe enrolled 256 patients (n = 114 pre and n = 142 post-intervention); 60-day mortality was 32%. Comparing patients pre vs post-intervention, CO-Pal did not increase overall goals-of-care discussions, but did increase advance care planning (48% vs 63%, P = 0.021) and hospice use (19% vs 31%, P = 0.034). CO-Pal did not impact symptom treatment, overall treatment plans, or 60-day hospital transfers. During the intervention phase, high-need vs low-need patients had more goals-of-care discussions (60% vs. 15%, P < 0.001) and more use of specialty palliative care (64% vs 22%, P < 0.001) and hospice (44% vs 16%, P < 0.001). ConclusionCollaborative oncology palliative care is efficient and feasible. While it did not increase overall goals-of-care discussions, it was effective to increase overall advance care planning and hospice use for patients with Stage IV cancer.

Transitions in Palliative Care Provision Across Healthcare Settings in the US: A Grounded Theory of Interdependence Between Specialist and Generalist Palliative Care Teams (SCI932)

Background: Individuals requiring palliative care near the end of life often receive that care in multiple healthcare settings, from both specialist and generalist palliative care teams. There is a need to better understand the processes that take place between the two teams that create or disrupt continuity of palliative care provision. Aim: The aim of this study was to develop a substantive theory of the psychosocial processes that occur between inpatient specialist palliative care teams and generalist teams outside the hospital setting who care for palliative patients after discharge. Methods: Semi-structured interviews were conducted with interdisciplinary clinicians from specialist palliative care teams and generalist healthcare teams in the U.S. Purposeful and theoretical sampling was used to recruit 21 clinicians. Data were analysed using constructivist grounded theory methods including constant comparative analysis of iterative levels of coding, memoing and diagramming, and abductive analysis of the literature. Results: A grounded theory of interdependence identified the psychosocial processes that contribute to team perception and function, and the outcomes of those processes. Specialist and generalist palliative care teams function with different degrees of interdependence in relation to other teams caring for shared patients based on how they perceive themselves as a team. When teams function more interdependently across healthcare setting boundaries, clinicians perceive outcomes to be more positive for patients, families, and themselves. In contrast, when teams function more independently within boundaries, outcomes are perceived to be more negative. Additionally, a team’s self-perception and way of functioning further perpetuate that self-perception and way of functioning over time. Conclusion: This substantive theory contributes new insights into how palliative care specialists and generalists should work and communicate with each other across healthcare settings to provide continuous and collaborative care for patients and families experiencing advanced illness. It provides a theoretical starting point for additional research to explore interventions that impact teams’ relationships and collaboration across healthcare settings.

Collaborative, interprofessional nutritional care within head and neck cancer teams: an international multi-site qualitative study

ABSTRACT Evidence-based guidelines (EBGs) for patients with head and neck cancer (HNC) recommend that nutritional care is delivered by an interprofessional team inclusive of dietitians, doctors, nurses, and speech pathologists. Barriers to collaboration exist within interprofessional teams. However, research on this is currently lacking in the HNC setting, particularly with regard to the provision of nutritional care. This study aimed to explore what facilitates collaborative nutritional care for patients with HNC from the perspectives of different healthcare professionals. This qualitative study used a grounded theory approach. Healthcare professionals from two radiotherapy departments in the United States and two in Australia were interviewed. Forty-six interviews were completed with 17 radiation-oncologists, 12 nurses, eleven dietitians, and 6 speech-pathologists. Collaborative nutritional care for patients with HNC was underpinned by three categories and six sub-categories: access to dietitians (facilitated by funding for dietitians and the strength of evidence), communication (facilitated by team meetings, communication systems, and multidisciplinary clinics), and role-clarity (facilitated by non-clinical activities and respect). This study highlights opportunities for enhancing collaborative nutritional care within HNC teams. Further studies on the impact of the dietitian, interprofessional education, team meetings, and multidisciplinary clinics are required to promote collaborative nutritional care for HNC patients.

Preparing Graduates for Interprofessional Practice in South Africa: The Dissonance Between Learning and Practice.

With South Africa's tumultuous history and resulting burden of disease and disability persisting post-democracy in 1994, a proposed decentralization of heath care with an urgent focus on disease prevention strategies ensued in 2010. Subsequently a nationwide call by students to adapt teaching and learning to an African context spoke to the need for responsive health professions training. Institutions of higher education are therefore encouraged to commit to person-centered comprehensive primary health care (PHC) education which equates to distributed training along the continuum of care. To cope with the complexity of patient care and health care systems, interprofessional education and collaborative practice has been recommended in undergraduate clinical training. Stellenbosch University, South Africa, introduced interprofessional home visits as part of the students' contextual PHC exposure in a rural community in 2012. This interprofessional approach to patient assessment and management in an under-resourced setting challenges students to collaboratively find local solutions to the complex problems identified. This paper reports on an explorative pilot study investigating students' and graduates' perceived value of their interprofessional home visit exposure in preparing them for working in South Africa. Qualitative semi-structured individual and focus group interviews with students and graduates from five different health sciences programmes were conducted. Primary and secondary data sources were analyzed using an inductive approach. Thematic analysis was conducted independently by two researchers and revealed insights into effective patient management requiring an interprofessional team approach. Understanding social determinants of health, other professions' roles, as well as scope and limitations of practice in a resource constrained environment can act as a precursor for collaborative patient care. The continuity of an interprofessional approach to patient care after graduation was perceived to be largely dependent on relationships and professional hierarchy in the workplace. Issues of hierarchy, which are often systemic, affect a sense of professional value, efficacy in patient management and job satisfaction. Limitations to using secondary data for analysis are discussed, noting the need for a larger more comprehensive study. Recommendations for rural training pathways include interprofessional teamwork and health care worker advocacy to facilitate collaborative care in practice.