Community Care Teams Research Articles

Factors influencing deprescribing in primary care for those towards the end of life: A qualitative interview study with patients and healthcare practitioners.

For people with limited lifetime expectancy, the benefit of many medications may be outweighed by their potential harms. Despite the relevance of reducing unnecessary medication use, deprescribing is poorly enacted in primary care practice. This study aims to describe factors, as identified by primary care professionals and patients, that influence deprescribing in the last phase of life. Semi-structured interviews were conducted and analysed using a thematic approach. This study was performed in primary care settings, including general practices, hospices and community care teams in The Netherlands. Purposefully identified primary care professionals (general practitioners, pharmacists, nurses) and patients with limited lifetime expectancy due to advanced chronic illness or cancer and their caretakers were interviewed. Three themes emerged detailing factors influencing deprescribing in the last phase of life in primary care: (1) non-maleficence, the wish to avoid additional psychological or physical distress; (2) reactive care, the lack of priority and awareness of eligible patients; and (3) discontinuity of care within primary care and between primary care and specialty care. Deprescribing is an incremental process, complicated by the unpredictability of life expectancy and attitudes of patients and health care professionals that associate continued medication use with clinical stability. Opportunities to facilitate the deprescribing process and its acceptance include the routinely systematic identification of patients with limited life expectancy and potentially inappropriate medications, and normalisation of deprescribing as component of regular primary care, occurring for all patients and continuing into end-of-life care.

Delivering Integrated Community Care for the Elderly: A Qualitative Case Study in Southern China.

The rapid aging and increasing care demands among the elderly population present challenges to China's health and social care system. The concept of aging in place has prompted the implementation of integrated community care (ICC) in the country. This study aims to provide empirical insights into the practices of integrated care policies and approaches at the community level. Data for this study were collected through six months of participatory observations at a local community health service center in a southern Chinese city. Semi-structured interviews were conducted with the multidisciplinary community care team to gather frontline formal caregiver perceptions of ICC, thereby facilitating a better understanding of the obstacles and opportunities. Qualitative analysis revealed four themes: the ICC delivery model and development strategies within the community care scheme, the person-centered guiding principle, and the challenges and struggles encountered by formal caregivers within China's current ICC system. The case study presented herein serves as a notable example of the pivotal role of primary care in the successful implementation of elderly care within a community setting. The adoption of a private organization-led approach to medico-social integration care in the community holds significant potential as a service delivery model for effectively addressing a wide range of elderly care issues.

What can nurses learn from patient's needs and wishes when developing an evidence-based quality improvement learning culture? A qualitative study.

Patient participation is fundamental in nursing care and has yielded benefits for patient outcomes. However, despite their compassionate care approach, nurses do not always incorporate patients' needs and wish into evidence-based practice, quality improvement or learning activities. Therefore, a shift to continuous quality improvement based on evidence-based practice is necessary to enhance the quality of care. The patient's opinion is an essential part of this process. To establish a more sustainable learning culture for evidence-based quality improvement, it is crucial that nurses learn alongside their patients. However, to promote this, nurses require a deeper understanding of patients' care preferences. To explore patients' needs and wishes towards being involved in care processes that nurses can use in developing an evidence-based quality improvement learning culture. A qualitative study was conducted in two hospital departments and one community care team. In total, 18 patients were purposefully selected for individual semi-structured interviews with an average of 15 min. A framework analysis based on the fundamental of care framework was utilised to analyse the data deductively. In addition, inductive codes were added to patients' experiences beyond the framework. For reporting this study, the SRQR guideline was used. Participants needed a compassionate nurse who established and sustained a trusting relationship. They wanted nurses to be present and actively involved during the care delivery. Shared decision-making improved when nurses offered fair, clear and tailored information. Mistrust or a disrupted nurse-patient relationship was found to be time-consuming and challenging to restore. Results confirmed the importance of a durable nurse-patient relationship and showed the consequences of nurses' communication on shared decision-making. Insights into patients' care preferences are essential to stimulate the development of an evidence-based quality improvement learning culture within nursing teams and for successful implementation processes.

Strategies for Creating Multidisciplinary Community Care Teams to Address Barriers to Providing Family Based Treatment of Eating Disorders.

Eating disorders, especially anorexia nervosa, are complex and devastating illnesses. Although eating disorders have a high mortality rate and are relatively common, there are many barriers for those seeking treatment. Provider training and education, weight bias among health care providers, geographical and language barriers, and a lack of options because of insurance restrictions prevent many families from receiving appropriate care, especially in smaller or rural communities. In those areas, providers are left to piece together treatment using a small number of other providers from different disciplines who have a willingness to work with this population. Outpatient family based treatment is an evidenced-based treatment of anorexia nervosa and relies on a multidisciplinary approach to care. Community-based care teams can be an effective way to treat those with eating disorders seeking family based treatment. There are several strategies for building collaborative teams that can provide comprehensive and accessible care to those with few options. [Pediatr Ann. 2024;53(1):e22-e27.].

Penerapan Sistem Pengendalian Berbasis IoT (Internet Of Things) Untuk Meningkatkan Efisiensi Proses Pengeringan Pupuk Granul Berbahan Eco Enzim

In Indonesia, we see a lot of waste in society that can actually still be reused. By using Eco Enzym, the waste can be processed into many derivative products. Residents of RW VII Gombel Permai, Ngesrep Village, Banyumanik District, Semarang have processed this product, but have experienced problems in the drying process, which is still done manually in the sun. The Community Care Team took the initiative to apply IoT technology to this technology-based dryer. The convenience is that using this tool does not require sunlight, uses UV light so it can kill bad bacteria and can be monitored remotely. Residents are enthusiastic about using it because the process is faster, doesn't require too much physical effort and is cheaper to make.

Uptake and Use of Care Companion, a Web-Based Information Resource for Supporting Informal Carers of Older People: Mixed Methods Study.

Informal carers play a major role in supporting relatives and friends who are sick, disabled, or frail. Access to information, guidance, and support that are relevant to the lives and circumstances of carers is critical to carers feeling supported in their role. When unmet, this need is known to adversely affect carer resilience and well-being. To address this problem, Care Companion was co-designed with current and former carers and stakeholders as a free-to-use, web-based resource to provide access to a broad range of tailored information, including links to local and national resources. This study aimed to investigate the real-world uptake and use of Care Companion in 1 region of England (with known carer population of approximately 100,000), with local health, community, and social care teams being asked to actively promote its use. The study had a convergent parallel, mixed methods design and drew on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data included metrics from carers' use of Care Companion, surveys completed by users recruited through general practice, and interviews with carers and health and social care providers regarding their views about Care Companion and their response to it. Quantitative data were analyzed using descriptive statistics. Interview data were analyzed thematically and synthesized to create overarching themes. The qualitative findings were used for in-depth exploration and interpretation of quantitative results. Despite awareness-raising activities by relevant health, social care, and community organizations, there was limited uptake with only 556 carers (0.87% of the known carer population of 100,000) registering to use Care Companion in total, with median of 2 (mean 7.2; mode 2) visits per registered user. Interviews with carers (n=29) and stakeholders (n=12) identified 7 key themes that influenced registration, use, and perceived value: stakeholders' signposting of carers to Care Companion, expectations about Care Companion, activity levels and conflicting priorities, experience of using Care Companion, relevance to personal circumstances, social isolation and networks, and experience with digital technology. Although many interviewed carers felt that it was potentially useful, few considered it as being of direct relevance to their own circumstances. For some, concerns about social isolation and lack of hands-on support were more pressing issues than the need for information. The gap between the enthusiastic views expressed by carers during Care Companion's co-design and the subsequent low level of uptake and user experience observed in this evaluation suggests that the co-design process may have lacked a sufficiently diverse set of viewpoints. Numerous factors were identified as contributing to Care Companion's level of use, some of which might have been anticipated during its co-design. More emphasis on the development and implementation, including continuing co-design support after deployment, may have supported increased use.

Development of a coordinating model for home care of stroke patients by family and community care teams using the appreciation influence control technique

Background: Stroke patients and their caregivers face huge challenges from patients’ health problems when they leave the hospital to rehabilitate at home. Objective: To develop a model for coordinating the participation of family and community care teams to support stroke patients at home. Methods: We conducted a qualitative study applying the Appreciation Influence Control technique. Purposive sampling was employed to select 120 key informants comprised of 50 family medicine members, 10 community leaders, 30 stroke patients, and 30 patient caregivers. Data collection consisted of interviews and focus group discussions. Patients and caregivers were followed up at 1, 3, and 6 months after discharge from the hospital. Data were analyzed by content analysis. Results: The coordinating model of the health care team provided standard guidelines for home care of stroke patients, improved the referral system from hospital to home, trained public health volunteers and caregivers about caring stroke patients at home, and organized community leaders to support patient equipment and rehabilitation facilities. The collaboration between the health care team and community leaders, as well as with patients and caregivers, improved the quality of life for stroke survivors.

Community nurses’ perspectives on a novel blended training approach: a qualitative study

BackgroundTransiting into the community setting often presents novel difficulties for nurses because the role demands skills that might not have been obtained through usual clinical experience or training. The Ageing-in-Place Community Care Team (AIP-CCT) Community Nurse Basic Training programme was developed to address this learning gap. This training programme prepares nurses to lead in a multi-disciplinary team in delivering patient-centred care to patients with progressive or life-limiting conditions in the community setting. This study evaluated the inaugural training programme provided to a group of nurses from an acute hospital in Singapore.MethodsQualitative in-depth interviews were carried out with 13 participants from the training programme three-months after completion of the AIP-CCT Community Nurse Basic Training programme provided by an acute hospital to understand the programme’s impact on their knowledge, skills and clinical practice, as well as barriers and facilitators to learning.ResultsOverall, perception towards the training course was mixed. Course content was found to be relevant, and participants reported that training led to improvement in their practice. However, experienced nurses felt that the content of some modules were lacking in depth. This could have explained why only junior nurses tended to hold favourable attitudes and felt that the training led to increase in their confidence level. Although medical content was assessed favourably, the course was not able to address some of the constraints faced by community nurses such as managing expectations and handling difficult patients in the home care setting. For some modules, face-to-face training was preferred and e-learning components can be improved to increase communication and interaction.ConclusionThis study provided insights into how a community nurse training programme could be developed to meet the needs of community nurses. The training was able to reinforce skills and knowledge, address knowledge gaps and provide new clinical care approaches and communication strategies. These incremental effects on experienced community nurses could be extrapolated to have greater benefits for inexperienced community nurses. Based on findings of the study, potential changes to the training programme were discussed to improve training outcomes.

Pharmacists’ perceptions of the Canadian opioid regulatory exemptions on patient care and opioid stewardship

Background:This study explored the perceptions of Canadian pharmacists about the barriers and facilitators of providing opioid stewardship activities in pharmacy practice, considering the subsection 56(1) class exemption under Health Canada’s Controlled Drugs and Substances Act (CDSA).Methods:Qualitative key informant telephone interviews were conducted with a convenience sample of pharmacists from across Canada. We included community or primary health care team-based pharmacists who self-identified as having experience with providing care for patients using opioids via the exemptions. All transcripts were de-identified, and thematic analysis was conducted to identify themes. Ethics approval was obtained.Results:Twenty pharmacists from community and primary health care teams, from all provinces and from urban and rural practices were interviewed. The following themes emerged: 1) optimization of opioid-related patient care, 2) jurisdictional impact and 3) awareness and education. Barriers and facilitators for opioid stewardship activities were identified.Discussion:The exemptions facilitated the pharmacists’ ability to provide opioid stewardship and positively affect patient care by providing continuity of and timely access to care. Our research demonstrated that pharmacists can responsibly and independently manage opioid prescriptions within this expanded scope, demonstrating the valuable contribution pharmacists can have in opioid stewardship.Conclusion:Pharmacists were willing and able to care for patients receiving opioid medication and thereby played a role in helping address the opioid crisis. The benefits of these exemptions were demonstrated beyond situations related to the COVID-19 pandemic and warrant consideration for consistent implementation across provincial and territorial jurisdictions, thereby ensuring equitable access to care for all Canadians.

Value-based chronic care model approach for vulnerable older patients with multiple chronic conditions.

"Old age, itself, is not a disease" (Suborne 2007). The rising rate of the global aging population is predicted to create a health care crisis within the next three decades. Vulnerable older adults suffer from multiple chronic conditions (MCCs) in addition to cognitive and physical decline during the process of aging resulting in an inability to optimally achieve self-management. In terms of resource utilization, complex inpatient, and outpatient care results in higher physician visits, polypharmacy, and higher prescription costs. Health literacy has become known as an important social determinant of health affecting the older population. Both reductions in health literacy and self-management are associated with poorer health outcomes. The patient activation measure (PAM) has been coined "a vital sign" to ascertain a patient activation level throughout the continuum of care with the introduction of an intervention's progress. In this review, we conceptualize a systematic approach of the development of a "tailored" integrated community and care team to develop a partnership in assisting senior adults with MCCs. Through this intervention the value-based chronic care model (CCM) and PAM allows for an adaptable integration between the activated patient, their caregivers, and the community. The Model for Improvement (MFI) serves as a well-recognized technique for developing and executing quality improvement strategies in this "tailored" engaged and activated individual and community care team approach in achieving health outcomes and quality of life among the vulnerable older adult population worldwide.

Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT-2) trials.

AimWe conducted a prospective cohort study to evaluate the effectiveness of an integrated care model on delaying chronic kidney disease (CKD) progression in routine clinical practice in rural primary care setting.MethodsAfter enrolment, patients with stages 3 to 4 CKD patients from five district hospitals in a northern province of Thailand (400 km from Bangkok) received integrated care comprising hospital multidisciplinary care and home visits by community care teams. Clinical characteristics and biochemical data were collected at baseline and every 3‐month interval thereafter for 36 months. The primary outcome was the rate of estimated glomerular filtration rate (eGFR) decline.ResultsNine hundred and fourteen stage −3 and − 4 CKD patients were enrolled. The mean age of our cohort was 62 years. Diabetic kidney disease (DKD) was the main cause of CKD (53%) whereas hypertension was the most common co‐morbidity (92%). The mean rate of eGFR decline was −0.92 mL/min/1.73 m2/year. The rate of eGFR decline among patients with DKD was about three times faster than patients without DKD. Patients with higher blood pressure, metabolic acidosis, proteinuria or anaemia had a faster rate of eGFR decline.ConclusionThis integrated care model at the community level was effective in delaying CKD progression in routine clinical practice situation.

Distinguishing psychogenic nonepileptic, mixed, and epileptic seizures using systemic measures and reported experiences

ObjectivesOur primary objective was to better discern features that can differentiate people with ‘mixed’ symptomatology from those who experience epileptic seizures (ES) or functional/psychogenic nonepileptic seizures (PNES) alone, in a population of patients referred for video-telemetry. We wished to see if we could establish the prevalence of PNES in this population of interest as well as compare both objective (e.g. videotelemetry reports and heart rate measurements) and subjective, patient-centered measures (reported symptoms and experiences). MethodsData were sourced from a database of all video-telemetry patients admitted to the John Radcliffe Hospital (Oxford, UK) between 1st Jan 2014 and 31st Jan 2016; video-electroencephalogram (vEEG) reports for the above patients; neurology clinic letters; multidisciplinary Team (MDT) reports; psychology assessments and patient notes for all vEEG patients referred for surgical work up. Mixed cases with a dual ES/PNES diagnosis were carefully evaluated again by the Consultant Neurologist under whose care each respective patient was, through case-by-case evaluation of EEG and telemetry reports. We compared mean heart rate during attacks captured on vEEG, number of physical symptoms reported, episode length, and postictal confusion between the three groups (ES; PNES; ES and PNES (mixed)). We evaluated the groups in terms of demographic and psychological parameters as well as prescription of anti-seizure medication. Pearson correlation significance was examined at 95% level of significance for p-values corrected for multiple comparisons. ResultsOverall, mixed cases reported experiencing a significantly lower number of physical symptoms compared to PNES cases (p = 0.018). The heart rate of PNES cases was significantly lower than that of mixed cases during the attacks (p = 0.003). ES patients exhibited the highest heart rate of all three groups and a greater degree of postictal confusion (adjusted p = 0.003 and p < 0.001, respectively) compared to those with PNES. There was no statistically significant difference in episode length between mixed and ES cases, while PNES patients had significantly longer episode duration (p = 0.021) compared to the mixed group. We noted that 81.6% of PNES patients were taking at least one anti-seizure medication. ConclusionPatients with mixed seizures seem to be part of a spectrum between ES and PNES cases. Mixed cases are more similar to the ES group with regard to episode length and number of symptoms reported. In the PNES cohort, we found an over-reporting of ictal symptoms (e.g. palpitations, diaphoresis) disproportionate to recorded heart rate, which is lower in PNES than in epileptic attacks. This seems consistent with PNES cases experiencing a degree of impaired interoceptive processing, as part of a functional disorder spectrum. We noted that there was tendency for overmedication in the PNES group. The need for ‘de-prescribing’ should be addressed with measures that include better liaison with the community care team. With regard to potential autonomic dysregulation in the mixed cases, it might be interesting to see if vagus nerve stimulation could be accompanied by normalization of cardiovascular physiology parameters for people with both epileptic and psychogenic nonepileptic seizures.

Experiences of nurses caring for patients with COVID-19 in Turkey: A phenomenological enquiry.

This study aims to reveal the experiences of nurses who care for COVID-19 patients during this process. Nurses actively carry out their duties with regard to infection control and critical patient care in the frontlines since the pandemic. A phenomenological qualitative design was followed throughout the study. The study involved 19 nurses. The data were analysed through Colaizzi's seven-step method. Five themes were identified after the interviews; first meeting and getting caught unprepared, social isolation and loneliness, dilemma and conflict in professional roles, nursing: power born from difficulties and organisational expectations. Also, eleven sub-themes were identified. The study showed the main findings regarding the experiences of the nurses in crisis instances. Although nurses felt stronger professionally, they needed the cooperation and psychosocial support of the community and health care team members. Nurses had expectations for the development of personal and social rights. It is thought that these results can act as a guide to understand the problems and needs of nurses as health care providers and to engender solutions so that a safe and reliable health care system that can effectively respond to future global disasters can be established.

A Multidisciplinary NHS COVID-19 Service to Manage Post-COVID-19 Syndrome in the Community

The National Institute for Health and Care Excellence (NICE) describe “post COVID-19 syndrome” or “Long COVID” as a set of persistent physical, cognitive and/or psychological symptoms that continue for more than 12 weeks after illness and which are not explained by an alternative diagnosis. These symptoms are experienced not only by patients discharged from hospital but also those in the community who did not require inpatient care. To support the recovery of this group of people, a unique integrated rehabilitation pathway was developed following extensive service evaluations by Leeds Primary Care Services, Leeds Community Healthcare NHS Trust and Leeds Teaching Hospital NHS Trust. The pathway aligns itself to the NHS England “Five-point plan” to embed post-COVID-19 syndrome assessment clinics across England, supporting the comprehensive medical assessment and rehabilitation intervention for patients in the community. The pathway was first of its kind to be set up in the UK and comprises of a three-tier service model (level 1: specialist MDT service, level 2: community therapy teams and level 3: self-management). The MDT service brings together various disciplines with specialist skill sets to provide targeted individualized interventions using a specific core set of outcome measures including C19-YRS (Yorkshire Rehabilitation Scale). Community and primary care teams worldwide need such an integrated multidisciplinary comprehensive model of care to deal with the growing number of cases of post-COVID-19 syndrome effectively and in a timely manner.

Joves migrats en contextos rurals. Per a una nova ruralitat global i culturalment diversa: polítiques d'inclusió social dels joves emigrats sols als municipis petits

&lt;p&gt;A partir de la seva experiència de treball en el servei de primera acollida de persones estrangeres de l’Equip d’Inclusió i Atenció a la Comunitat de l’àrea de Benestar del Consell Comarcal de l’Alt Empordà, les autores reflexionen sobre el suport als joves emigrats sols, especialment quan aquest s’ha de prestar des de municipis rurals. La seva experiència de treball en aquest àmbit i des d’aquests contextos ha estat pionera: el desembre del 2018 van posar en marxa la taula comarcal de joves sense referents adults, per coordinar&lt;br /&gt;tots els agents que treballen a l’Alt Empordà amb aquests joves. En aquest article s’apunten tres línies de treball que poden facilitar l’acollida i inclusió social dels joves emigrats sols: 1) el disseny i la implementació de polítiques locals que garanteixin els drets dels joves i el seu empoderament; 2) polítiques pensades des de la proximitat i l’acció comunitària; i 3) polítiques emmarcades en una visió estratègica global del desenvolupament social i sostenible dels municipis rurals amb eines de diagnòstic concretes. Les autores, a més, aporten una eina per al diagnòstic i la promoció de les accions comunitàries orientades a la inclusió social d’aquests joves. Finalment, apunten les que entenen que seran les línies de treball en un futur proper.&lt;/p&gt;

Co-location, an enabler for service integration? Lessons from an evaluation of integrated community care teams in East London.

In an attempt to support care integration that promotes joined up service provision and patient‐centred care across care boundaries, local health and social care organisations have embarked on several initiatives and approaches. A key component of service integration is the co‐location of different professional groups. In this study, we consider the extent to which co‐location is an enabler for service integration by examining multi‐professional community care teams. The study presents findings from a qualitative evaluation of integrated care initiatives in a borough of East London, England, undertaken between 2017 and 2018. The evaluation employed a participatory approach, the Researcher‐in‐Residence model. Participant observation (n = 80 hr) and both semi‐structured individual (n = 16) and group interviews (six groups, n = 17 participants) were carried out. Thematic analysis of the data was undertaken. The findings show that co‐location can be an effective enabler for service integration providing a basis for joint working, fostering improved communication and information sharing if conditions such as shared information systems and professional cultures (shared beliefs and values) are met. Organisations must consider the potential barriers to service integration such as differing professional identity, limited understanding of roles and responsibilities and a lack of continuity in personnel. Co‐location remains an important facet in the development of multi‐professional teams and local service integration arrangements, but as yet, has not been widely acknowledged as a priority in care practice. Organisations that are committed to greying care boundaries and providing joined up patient care must ensure that sufficient focus is provided at the service delivery level and not assume that decades of silo working in health and social care and strong professional cultures will be resolved by co‐location.

System level interventions to reduce utilization of general anesthesia to treat dental caries: a practice brief.

Dental caries are the most common chronic disease of childhood. Untreated caries can result in severe pain and infection; and in some cases, difficulties in eating, speech, and education. Hospitalization and general anesthesia are often necessary for treating extensive disease in young children, which adds significant risk and expense. Interventions, such as community-based preventative care, utilization of pre-authorizations for treatment, and at-risk contracts, have been deployed as innovative strategies to reduce the incidence of caries and the cost of treatment. Value-based payment structures give payors flexibility to design a multipronged system to impact the health of consumers. This practice brief will identify interventions at a systems level that reduced the utilization of general anesthesia treating dental caries in children under the age of six. Dental claims data from the period of Q1 2011 to Q2 2020 were utilized to analyze the trends in utilization of the operating room (OR) to treat dental conditions among children under 6 years. Fixed effects analysis was utilized to identify key over time changes in the reduction of children's OR utilization. A reduction in utilization of general anesthesia and hospitalization for treating dental caries in young children was seen. The expansion of the community care team, metrics to reinforce the systems of provider education and training, and the use of incentive payments were all associated with reductions in the rate of OR utilization. Between 2012 and 2017, multiple initiatives were implemented without a systematic approach to quality improvement to evaluate.

31 Strengthening care for infants with medical complexity during the transition from the neonatal intensive care unit to the community

Abstract Background With advances in technology and innovative medical treatments, infants who previously would have died in early infancy are living longer. These infants have significant needs in the medical system and pose challenges in coordinating care from multiple providers, especially after discharge from NICU. Objectives To engage neonatal-to-early-childhood care-transition stakeholders in implementing system-level change to champion the successful transition of infants with medical complexity into early childhood. We believe this engagement activity will spark action amongst stakeholders to adopt best practices leading to improvements in care for this vulnerable patient population. Design/Methods We explored four key care transition related questions: We organized journey mapping and focus groups with NICU alumni families whose children have medical complexity. We conducted a literature review to identify evidence-based interventions. We compiled this information to create evidence briefs that were presented to an interprofessional group of senior stakeholders using the deliberative dialogue approach. Following presentation of the evidence briefs surveys were administered to measure stakeholder intention to act on solutions presented. Results Twenty-five opportunities for improving transitions between hospital and community care teams were identified through engagement with families and project team members (graphic A). These opportunities focused on facilitating clinical navigation, navigating community services, and improving parental mental health. Forty-two stakeholders representing a children’s and women’s hospital, families, community care providers, and provincial bodies were engaged in this project. A rapid review of the literature was carried out using multiple databases searches to ensure comprehensiveness and flexible search strategies to ensure literature was found for all issues. This included a broader search of NICU discharges and nine targeted searches with medical complexity populations. Proposed solutions from stakeholders were further validated through comparisons with the literature and ultimately thirty-five papers were included in the evidence briefs. Specific care interventions were recommended to key healthcare decision makers, such as providing post-discharge care coordination in a specialized complex care clinic, implementing patient-oriented discharge summaries, and facilitating access to mental health resources. Using a seven point Likert scale the majority of stakeholders agreed that both the evidence briefs and deliberative dialogues were very successful in achieving their aim. Stakeholder intention to act on solutions presented in evidence briefs and deliberative dialogues were rated as very likely. Conclusion

Augmenting Evidence-Based Care With a Texting Mobile Interventionist: A Pilot Randomized Controlled Trial.

This study aimed to evaluate the feasibility and clinical utility of training intensive psychiatric community care team members to serve as "mobile interventionists" who engage patients in recovery-oriented texting exchanges. A 3-month pilot randomized controlled trial was conducted to compare the mobile interventionist approach as an add-on to assertive community treatment (ACT) versus ACT alone. Participants were 49 individuals with serious mental illness (62% with schizophrenia/schizoaffective disorder, 24% with bipolar disorder, and 14% with depression). Clinical outcomes were evaluated at baseline, posttreatment, and 6-month follow-up, and satisfaction was evaluated posttreatment. The intervention appeared feasible (95% of participants assigned to the mobile interventionist arm initiated the intervention, texting on 69% of possible days and averaging four messages per day), acceptable (91% reported satisfaction), and safe (no adverse events reported). Exploratory posttreatment clinical effect estimations suggested greater reductions in the severity of paranoid thoughts (Cohen's d=-0.61) and depression (d=-0.59) and improved illness management (d=0.31) and recovery (d=0.23) in the mobile interventionist group. Augmentation of care with a texting mobile interventionist proved to be feasible, acceptable, safe, and clinically promising. The findings are encouraging given the relative ease of training practitioners to serve as mobile interventionists, the low burden placed on patients and practitioners, and the simplicity of the technology. The technical resources are widely accessible to patients and practitioners, boding well for potential intervention scalability. When pandemics such as COVID-19 block the possibility of in-person patient-provider contact, evidence-based texting interventions can serve a crucial role in supporting continuity of care.

Identifying and addressing gaps in the implementation of a community care team for care of Patients with multiple chronic conditions

BackgroundPatients with multiple chronic conditions represent a growing segment for healthcare. The Chronic Care Model (CCM) supports leveraging community programs to support patients and their caregivers overwhelmed by their treatment plans, but this component has lagged behind the adoption of other model elements. Community Care Teams (CCTs) leverage partnerships between healthcare delivery systems and existing community programs to address this deficiency. There remains a gap in moving CCTs from pilot phase to sustainable full-scale programs. Therefore, the purpose of this study was to identify the cognitive and structural needs of clinicians, social workers, and nurse care coordinators to effectively refer appropriate patients to the CCT and the value these stakeholders derived from referring to and receiving feedback from the CCT. We then sought to translate this knowledge into an implementation toolkit to bridge implementation gaps.MethodsOur research process was guided by the Assess, Innovate, Develop, Engage, and Devolve (AIDED) implementation science framework. During the Assess process we conducted chart reviews, interviews, and observations and in Innovate and Develop phases, we worked with stakeholders to develop an implementation toolkit. The Engage and Devolve phases disseminate the toolkit through social networks of clinical champions and are ongoing.ResultsWe completed 14 chart reviews, 11 interviews, and 2 observations. From these, facilitators and barriers to CCT referrals and patient re-integration into primary care were identified. These insights informed the development of a toolkit with seven components to address implementation gaps identified by the researchers and stakeholders.ConclusionWe identified implementation gaps to sustaining the CCT program, a community-healthcare partnership, and used this information to build an implementation toolkit. We established liaisons with clinical champions to diffuse this information. The AIDED Model, not previously used in high-income countries’ primary care settings, proved adaptable and useful.