Continuity Of Care For Patients Research Articles

Changes in patient care through flexible and integrated treatment programs in German psychiatric hospitals: meta-analyses based on a series of controlled claims-based cohort studies

BackgroundGlobal treatment budgets, i.e. predefined budgets for patients treated in hospital independent of the setting within the hospital, together with flexible and integrated treatment (FIT) have been introduced in some German psychiatric hospitals since 2013. We investigated pooled changes in inpatient, day-care, outpatient treatment, and continuity of care for patients with mental disorders in 12 FIT-hospitals.MethodsWe conducted a series of 12 controlled cohort studies regarding FIT hospitals using anonymized patient claims data from more than 70 German statutory health insurance funds. Each study compared one FIT-hospital to matched patients from equivalent non-FIT-hospitals (routine care). We included only those patients without treatment in the respective hospital within two years prior to first hospital treatment (either FIT or routine care). We contrasted results between the year prior to with the first and second year after patient’s first treatment (treatment continuity: only group comparison) using multivariate multi-level models. To approximate the difference-in-difference effect in the meta-analysis, we used the interaction terms group (FIT hospital vs. routine care) x time (year before vs. first or second patient year after study inclusion) in the Poisson models.ResultsThe 12 studies included 36,069 patients with 2,358 patients from a Department of child and adolescent psychiatry. The pooled effect revealed a 5.1 days lower increase in inpatient treatment in FIT-hospitals during the first patient year compared to routine care. Results were statistically significant for adult care FIT-hospitals but not for child and adolescent FIT-hospitals. Utilization of day-care treatment increased more in most FIT-hospitals during the first year, while outpatient contacts increased in some and decreased in others. The odds of treatment continuity increased by 1.4 in FIT-hospitals compared to non-FIT-hospitals.ConclusionsGlobal treatment budgets lead to the intended changes in mental health care in the majority of FIT-hospitals compared to routine care in this large real-world evidence study from Germany. For child and adolescent psychiatry, more evidence is needed to draw firm conclusions.Trial registrationThis study was registered in the database “Health Services Research Germany” (trial number: VVfD_EVA64_15_003713).

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

Background and ObjectiveCOVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.Design and ParticipantsThis was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19–2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18–2/28–19; n = 1,536,954).Main MeasuresWe assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.Key ResultsPrior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.ConclusionsDisparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Continuity of care for patients with dementia during COVID-19 pandemic: flexibility and integration between in-person and remote visits.

During the pandemic, the Cognitive Disorders Unit of San Raffaele Hospital (Milan, Italy) offered patients the opportunity to undergo neuropsychological evaluations and cognitive training through telemedicine. We conducted an investigation to assess how patients responded to this option and to determine if telemedicine could ensure continuity of care. Between October 2019 and May 2022, a total of 5,768 telemedicine appointments and 8,190 in-person outpatient appointments were conducted, resulting in an increase in the rate of telemedicine activity from 16.81% in January 2020 to 23.21% in May 2022. Peaks in telemedicine activity reached 85.64% in May 2020 and 83.65% in February 2021, both representing a significant portion of the total activity. Interestingly, there was a notable positive correlation between telemedicine activity and the worsening of the Italian pandemic (r = 0.433, p = 0.027). During the peaks of contagion, the total number of visits remained stable, highlighting that telemedicine effectively served as a valuable and efficient tool to ensure continuity of care for vulnerable patients. This was evident from the integration of remote visits with in-person appointments.

The effectiveness of continuity of care in patients with inflammatory bowel disease: a systematic review

AimTo investigate the effectiveness of continuity of care in patients with inflammatory bowel disease.BackgroundThe prevalence of inflammatory bowel disease(IBD) is increasing by years, especially in China. Moreover, IBD is prolonged and difficult to heal, which seriously impairs the quality of life of patients. Some studies have identified that continuity of care could contribute to the improvement of the quality of life, but the results remains inconclusive in patients with IBD.MethodsPRISMA guidelines was the outline of this study. Review Manager Software (version 5.3) was used to carry out the data analysis. Outcome assessments included quality of life (QoL), remission rates, number of outpatient clinic visits, and medication adherence.ResultsUltimately, 12 studies involving 2415 patients were brought into this meta-analysis. The results indicated there was no significant difference for continuity of care to improve the QoL in intervention group (SMD = 0.02, 95% CI: -0.08, 0.12). Besides, the remission rates of disease had no difference with those patients in the two groups (OR = 1.07, 95% CI: 0.72, 1.60). However, continued care could contribute to the number of outpatient clinic visits (MD = -0.84, 95% CI: -1.19, -0.49) and patients’ adherence to medication significantly (OR = 2.40, 95% CI: 1.16, 4.95).ConclusionsIBD patients could benefited from continuity of care with reducing their number of clinic visits and improving medication adherence. Nonetheless, there was no evidence of continuity of care contribute to QoL and remission of disease for these patients.

Improving patient experience for people prescribed medicines with a risk of dependence or withdrawal: co-designed solutions using experience based co-design

BackgroundSignificant concerns have been raised regarding how medications with a risk of dependence or withdrawal are managed and how care is experienced by patients. This study sought to co-design solutions to improve the experience of care for patients prescribed benzodiazepines, z-drugs, opioids for chronic non-cancer pain, gabapentinoids and antidepressants.MethodTwenty patients and fifteen healthcare professionals from five different GP practices were recruited to take part. The study used Experience Based Co-Design. Patients and healthcare professionals completed semi-structured interviews and took part in feedback groups and co-design workshops to collaboratively identify priorities for improvement and to co-design solutions to improve the experience of care.ResultsPoor patient experience was common among people prescribed medications with a risk of dependence or withdrawal. Patients and healthcare professionals identified three main priority areas to improve the experience of care: (i) ensuring patients are provided with detailed information in relation to their medication, (ii) ensuring continuity of care for patients, and (iii) providing alternative treatment options to medication. Solutions to improve care were co-designed by patients and healthcare staff and implemented within participating GP practices to improve the experience of care.ConclusionGood patient experience is a key element of quality care. This study highlights that the provision of in-depth medication related information, continuity of care and alternative treatment to medication are important to patients prescribed medicines with a risk of dependence or withdrawal. Improving these aspects of care should be a priority for future improvement and delivery plans.

A Delphi Study to Construct an Index of Practice for Community Nurses Providing Transitional Home Care for Patients with Chronic Diseases.

Community nurses play a key role in providing continuous home care for patients with chronic diseases. However, a perfect system of responsibilities and requirements has not yet been formed, and nurses cannot provide high-quality nursing services for home-based patients. We attempted to construct an index of the scope of practice for community nurses providing home-based transitional care for patients with chronic diseases and to guide nurses in playing an active role in transitional care work. From March to May 2023, 14 representative community nurses from the Shanghai Community Health Service Center were selected for group interviews and 2 rounds of Delphi consultation. A total of 14 valid questionnaires were collected. The authority coefficients were 0.94 and 0.93, and the Kendall coefficients were 0.56 and 0.59 for the 2 rounds of expert consultation (P < .05). Finally, an index system, including 6 primary indices (transitional caring provider, patient self-management facilitator, community group intervention organizer, home caregiver supporter, family physician team collaborator and supervisor of home medical equipment use, and medical waste disposal) was constructed for community nurses involved in providing home-based transitional care for patients with chronic diseases. The weight values of the 6 indices were 0.19, 0.17, 0.21, 0.13, 0.14 and 0.16, respectively (CR = 0.035, and the consistency test was passed), and 16 secondary indicators and 42 tertiary indicators were identified. In this Delphi study, an index system that can be used to determine community nurses' roles in providing home-based transitional and continuous care for patients with chronic diseases was successfully established. The index system is considered reliable and easy to use and will provide a meaningful reference for community nurses and policy-makers.

Advances in Research on Continuity of Care for Patients with Type 2 Diabetes Mellitus

Advances in Research on Continuity of Care for Patients with Type 2 Diabetes Mellitus

Retainment of U.S. Orthopaedic Surgeons in Academia from 2016 to 2022.

Academic medical centers greatly benefit from retaining their physicians; that ensures continuity in patient care, enhances resident education, and maintains a pool of experienced clinicians and researchers. Despite its importance, little research has been published on the retainment of academic faculty in orthopaedics. To address this gap, this study investigates the demographic trends of academic orthopaedic surgeons from 2016 to 2022. By analyzing data pertaining to gender distribution, years of practice, research productivity, and institutional rankings, we aimed to gain insights into the factors influencing faculty retainment, institution changes, and new entrants into academic orthopaedics. A retrospective cross-sectional analysis of U.S. academic orthopaedic surgeons affiliated with programs under the Accreditation Council for Graduate Medical Education (ACGME) in 2016 and 2022 was performed. Faculty present in both the 2016 and the 2022 data were classified as being "retained" in academia; those present only in 2016, as having "left" academia; and those present only in 2022, as being "new" to academia. The retained group was then divided into movers (those who moved to other institutions) and non-movers. Retained orthopaedists had fewer years of practice, a higher h-index (Hirsch index), and more publications. Non-fellowship-trained orthopaedists had less retainment in academia, and orthopaedists with fellowships in oncology had more retainment in academia. Additionally, movers also had fewer years in practice but an equal level of scholarly productivity when compared with non-movers. Lastly, higher-ranked academic programs retained a greater proportion of orthopaedic surgeons. Over the study period, a majority of orthopaedists (56.99%) chose to remain in academia. Those retained tended to be in the earlier stages of their careers, yet demonstrated higher research output. Notably, the representation of female orthopaedists in academic orthopaedics is on the rise. Conversely, lower-ranked programs faced higher turnover rates, highlighting the challenges that they encounter in retaining faculty members. Academic medical centers benefit from retaining orthopaedic surgeons by maintaining patient relationships, having consistency in resident education, and building on clinical and research expertise. Likewise, orthopaedists benefit from understanding the trends in current academic employment, in order to optimize career planning decisions.

Constructing an Osseointegrated Prosthetic Leg.

Constructing an osseointegrated prosthetic leg is the necessary subsequent phase of care for patients following the surgical implantation of an osseointegrated prosthetic limb anchor. The surgeon implants the bone-anchored transcutaneous implant1,2 and the prosthetist constructs the prosthetic leg, which then attaches to the surgically implanted anchor. An osseointegration surgical procedure is usually considered in patients who are unable to use or are dissatisfied with the use of a socket prosthesis. This present video article describes the techniques and principles involved in constructing a prosthetic leg for transfemoral and transtibial amputees, as well as postoperative patient care. Preoperatively, as part of a multidisciplinary team approach, the prosthetist should assist in patient evaluation to determine suitability for osseointegration surgery. Postoperatively, when approved by the surgeon, the first step is to perform an implant inspection and to take patient measurements. A temporary loading implant is provided to allow the patient to start loading the limb. When the patient is approved for full-length leg to begin full weight-bearing, the implant and prosthetic quality are evaluated, including torque, implant position, bench alignment, static alignment in the standing position, and initial dynamic alignment. This surgical procedure also requires long-term, continued patient care and prosthetic maintenance. For patients who are dissatisfied with the use of a socket prosthesis, adjustments can often be made to improve the comfort, fit, and performance of the prosthesis. Non-osseointegration surgical options include bone lengthening and/or soft-tissue contouring. Osseointegration can be provided for amputees who are expressing dissatisfaction with their socket prosthesis, and typically provides superior mobility and quality of life compared with nonoperative and other operative options3,4. Specific differences between the appropriate design and construction of osseointegrated prostheses versus socket prostheses include component selection, component fit, patient-prosthesis static and dynamic alignment, tolerances and accommodations, and also the expected long-term changes in patient joint mobility and behavior. Providing an osseointegrated prosthesis according to the principles appropriate for socket prostheses may often leave an osseointegrated patient improperly aligned and provoke maladaptive accommodations, hindering performance and potentially putting patients at unnecessary risk for injury. Review articles describing the clinical outcomes of osseointegration consistently suggest that patients with osseointegrated prostheses have improved prosthesis wear time, mobility, and quality of life compared with patients with socket prostheses. Importantly, studies have shown that osseointegrated prostheses can be utilized in patients with short residual limbs that preclude the use of a socket prosthesis, allowing them to regain or retain function of the joint proximal to the short residuum5,6. Osseoperception improves patient confidence during mobility7. Because there is an open skin portal, low-grade soft-tissue infection can occur, which is usually treated with a short course of oral antibiotics. Much less often, soft-tissue debridement or implant removal may be needed to treat infection8. Periprosthetic fractures can nearly always be treated with familiar fracture fixation techniques and implant retention9,10. Falls can lead to periprosthetic fractures.Malalignment can lead to unnecessary pathologic joint forces, soft-tissue contractures, and an accommodative gait.Inadequately sophisticated components can leave patients at a performance deficit.Wearing the prosthetic leg while sleeping may lead to rotational forces exerted on the limb, which may cause prolonged tension on the soft tissue. QTFA = Questionnaire for Persons with a Transfemoral AmputationLD-SRS = Limb Deformity Modified Scoliosis Research SocietyPROMIS = Patient-Reported Outcomes Measurement Information SystemEQ-5D = EuroQol 5 Dimensions.

Effects of metformin on arterial elasticity and pro-inflammatory markers in black diabetes patients.

Pro-inflammatory markers are linked with the development and progression of type 2 diabetes mellitus and arterial stiffening. Pulse Wave Velocity (PWV) and Augmentation Index (Aix) are non-invasive standard markers of arterial elasticity and predictors of cardiovascular mortality and morbidity. To investigate the effects of metformin alone and in combination with glimepiride on arterial elasticity, pro-inflammatory cytokines in black type 2 diabetes mellitus patients. Participants were enrolled from Sefako Makgatho Health Sciences University community, Gauteng, South Africa. PWV and Aix were measured using the AtCor SphygmoCor® system (AtCor Medical, Inc., Sydney, Australia). Cytokines levels were measured using Multiplexing with Bio-Plex Pro™ human inflammation panel I assay. Treatment naïve type 2 diabetes participants were divided into two groups: metformin (M) (n = 10) and metformin glimepiride (MS) (n = 14). The study participants were followed up at 4 and 8 months after treatment initiation. In the M and MS, IL-1β increased significantly at four months (58.19 ± 0.03 pg/ml, 58.35 ± 0.30 pg/ml) when compared to baseline (33.05 ± 18.56 pg/ml, 34.79 ± 18.77 pg/ml) then decreased significantly at eight months (29.25 ± 11.64 pg/ml, 32.54 ± 14.26 pg/ml) when compared to four months (58.19 ± 0.03 pg/ml, 58.35 ± 0.3 pg/ml) (p < 0.05). There were no significant changes in PWV, Aix, IL-1ra, IL-2, IL-6, IL-8, TNF-α and hs-CRP levels at both treatment intervals. Metformin alone or in combination with glimepiride did not improve arterial elasticity and did not reduce pro-inflammatory cytokines levels in T2DM black South African patients. The context-based knowledge generated by the current study is expected to enhance the continuum of care for T2DM patients.

Information sharing following discharge of psychiatric inpatients: Improving the quality of discharge summaries

Abstract: BACKGROUND: Discharge summaries are valuable clinical documents providing information not only about the acute presentation and progression but also suggestions for future management to maintain the continuity of care. This is important in multidisciplinary, multiagency mental healthcare. AIM: It was intended to evaluate the discharge summaries for adult psychiatric inpatients, about the information shared such as the reason for admission, diagnoses, medications, progress in the ward, and legal status with an overarching aim to inform about the quality improvement of discharge summaries. METHODS: It was a service evaluation of a stratified random sample of 86 discharges from younger adult psychiatry wards, from which 73 discharge summaries were evaluated. RESULTS: The sample had 44 male and 42 female patients, with an average inpatient stay of 27.3 ± 40.8 days. Most (81.4%) of the patients had informal admission. Most patients (96.5%) had a psychiatric diagnosis; the common diagnoses were schizophrenia (24.4%), bipolar disorder (15.1%), personality disorder (17.4%), and depression (11.6%). Discharge summaries were sent on an average of 21.3 + 17.7 days (median 15 days). Most discharge summaries mentioned psychiatric diagnoses (97.3%), list of medications and dosage (95.9%), legal status during admission (74.0%), reason for admission (97.3%), and progress in the ward (97.3%). CONCLUSIONS: There is a scope to improve discharge summaries by adopting an appropriately structured format containing essential clinical information, which can be useful for maintaining continuity of patient care.

Perspectives of family caregivers, health professionals, and support providers on partnership issues in adult psychiatry

Family caregivers play an essential role in the continuity of care for patients with mental health problems. However, the lack of consideration for their role and difficulties in their collaboration with health professionals impact their involvement. The purpose of this study is to identify the issues underlying the family-professional partnership. A qualitative and exploratory study is used to collect data from providers of support services, family caregivers of patients with psychiatric disorders, and mental health professionals. Semi-structured interviews and focus groups conducted from October 2017 to August 2018 were analyzed to determine key issues surrounding this partnership. A total of thirty-two family caregivers, nine healthcare professionals, and eleven providers participated in the study. The central concerns related to the partnership are information, continuity of care, and the relationship between patients, family members, and professionals. The relational dimension appears to be an important element for all three groups of participants, who nevertheless point out difficulties with regard to their positioning in this tripartite relationship. In the context of the current healthcare system, the concept of partnership creates obstacles to family caregivers being able to contribute their expertise while feeling recognized by the other actors.

Exploring primary mental healthcare nurses’ perceptions of the post-treatment needs of women admitted for psychiatric treatment

Primary mental healthcare nurses are an essential workforce that provide necessary inpatient psychiatric treatment. Continuity of care has become a significant aspect of the provision of mental health services. However, caring for South African healthcare users comes with challenges, including difficulties accompanying the provision of care for acutely ill patients with complex mental health problems. Therefore, this study explored the perceptions and experiences of primary mental healthcare nurses concerning the continuity of care required in post-inpatient psychiatric treatment for mental health users from low-income communities in the Western Cape. Through undertaking a study using a qualitative exploratory design and purposive sampling technique, and in which nine primary mental healthcare nurses from two psychiatric hospitals in the Western Cape were interviewed, the researchers were able to obtain a deeper understanding of the participants’ experiences. Four themes were identified during the reflexive thematic analysis namely: the roles and responsibilities of primary mental healthcare nurses, the lack of support within the current continuity-of-care system, barriers to continuity of care for women patients, and suggested improvements for quality of mental healthcare. It was evident that both women patients and primary mental healthcare nurses experienced various forms of marginalisation, discrimination, and gendered oppression. This intersectionality accentuates systemic issues within the current public healthcare system and highlights the stigmatisation of mental illness, especially among women. Overall, primary mental healthcare nurses have a plethora of roles and responsibilities within the primary healthcare sector, which hinder their ability to provide mental health services to women patients. Their reports highlight the needs of a specific patient population that first need to translate into changes that will assist in improving their roles as primary mental healthcare nurses. Their shared experiences of a lack of support from South Africa’s healthcare system were the focal points of this study.

Caredoc Community Intervention Teams - Multidisciplinary Approaches to Delivering Care in the Community

Introduction: Caredoc Community Intervention Team (CIT) has been operating for 10 years and during that time has expanded its service to cover 6 regions in the South East of Ireland. A central objective of the service is delivering holistic and integrated care in the community that meets the needs of patients and their families. In 2021 the service model was enhanced to include Occupational Therapy and Physiotherapy professionals to the team to work collaboratively with Nursing colleagues, thereby reducing multiple hospital appointments and supporting early discharge from acute hospitals and community rehabilitation, particularly for elderly and clinically vulnerable patients, by shifting delivery of multidisciplinary care to patient’s homes.&#x0D; Aims, Objectives, Theory Or Methods: The CIT service is deployed 7 days a week, 365 days a year and bridges the gap between acute care and the patients who require it by providing access to timely, flexible, ongoing and personalised treatment in clients’ own homes for the duration of their illness, thus avoiding hospital admissions and enabling early supported discharge. For patients and their families this offers enormous relief and support, particularly while living with the Covid-19 pandemic, as the service provides a wide range of home-based assistance, from medication management to advice around necessary equipment and changes to the home environment to improve rehabilitation.&#x0D; Highlights Or Results Or Key Findings: Strong linkages with hospital and other community-based teams have been formed to ensure continuity of care for patients and optimisation of key healthcare resources – joint home visits with other CIT professionals involved in individual patients’ care have been coordinated to streamline and improve access to appropriate care. These links have also allowed for the co-design of structured referral pathways from local hospital clinics to the service, enabling the CIT Team to offer care to patients requiring regular monitoring at home, thereby reducing unnecessary hospital visits and supporting earlier supported discharge from acute hospitals. The impact of this interdisciplinary, collaborative approach has been hugely positive on patients’ health and wellbeing along with the additional benefit of decreasing pressure on hospital-based services.&#x0D; Conclusions: The diversity of disciplines within the CIT service ensures that all aspects of a patient’s recovery is managed, and the team’s on-going and effective communication strives to optimise individual treatment plans to achieve stabilisations, ensure patient safety, avoid hospital admission and enable supported earlier discharge. The team also provides acute nursing services to patients discharged to residential care, with the overall effect of increasing capacity and bed availability in local hospitals.&#x0D; Implications For Applicability/Transferability, Sustainability And Limitations: In just under a year of service the multidisciplinary CIT team carried out almost 10,000 visits to patient homes – each client referred to the service has an average of 3 encounters with the team, ensuring that multi-faceted reablement is achieved for patients while remaining in their own homes.

Enhancing transmural continuity of care for vulnerable patients with kidney problems. A mixed-methods multi-stakeholder needs-assessment

Summary: Research on supporting the (in)formal caregiver, in enabling autonomy and empowering of persons with a chronic kidney disorder and creating a bridge between primary care and specialized care in hospital settings. &#x0D; Background: Almost half (48%) of hospital readmissions is due to a lack of continuity of care ,e.g. no discharge conversation, poor communication at discharge, lack of patient education and no patient empowerment, a lack of information flow between the hospital setting and primary care, … Especially vulnerable patients with e.g. low health literacy suffer from a not optimally organized transition from the hospital setting to home. More attention is needed for: patient and informal care giver engagement and education, person-centered support, coordination of the transmural care process in order to deliver continuous and responsible care.&#x0D; Target group: Vulnerable patients with kidney problems in the province of Flemish Brabant (Belgium).&#x0D; Involved and engaged stakeholders: Patients, informal care givers, hospital kidney department (doctors, nurses, physiotherapists, social workers, …), primary care professionals (GPs, nurses, physiotherapists, social workers, …).&#x0D; Intervention: A needs-assessment is performed regarding the continuity of care of vulnerable patients with kidney problems. Patients, informal care givers, primary care as well as hospital professionals are surveyed and interviewed.&#x0D; Results: Preliminary results show the need for optimized transmural care from the patient, informal caregiver and professional perspectives. Continuity of care is mainly lacking regarding its informational and therapeutic dimensions. The minimal or even absent information flow (informational continuity) results in therapeutic differences between the services offered by hospital and primary care professionals (therapeutic continuity). Special attention is needed for patient education and empowerment. Relational continuity between the patient and professionals is more fixed, but professionals often do not have fixed partnerships with each other, both within primary care as well as across the primary and hospital care settings.&#x0D; Lessons for international audience: &#x0D; - A multi-perspective needs-assessment uncovers the, sometimes hidden, needs with regard to continuity of care.&#x0D; - Transmural care is often still quite discontinuous, especially from the perspective of the vulnerable patient, informal care giver and primary care professional.&#x0D; - System-wide change is needed in terms of vision, goals, adapting to local health needs, using people as partners, redefining professional responsibilities and (re)training care professionals, and reconfiguring care delivery.&#x0D; Next steps: The information gathered through the needs-assessment is used to co-develop a continuity-enhancing intervention that optimizes the transmural care process with relevant stakeholders (patients and informal care givers or their representatives, primary care professionals, hospital professionals). The intervention is implemented and evaluated through a patient and professionals questionnaire and interviews.

Telemedicine and homeopathy united for wellness and health in Brazilian veterinary.

The objective of this work is to argue about the possibility of remote work and the utilization of communication technology, enabling Tele-veterinary homeopathy to emerge as a specialized field for prescribing medical materials, primarily in cases of behavioral changes. However, the institutions regulating veterinary telemedicine and veterinary medical activities assert that face-to-face care remains the gold standard for practicing veterinary medical procedures. Teleconsultation is only permissible in cases where there exists a prior Veterinary-Animal-Responsible Relationship (RPVAR) that has been established through face-to-face interactions and duly registered.The administration of medicines is considered safe, as they are non-toxic and devoid of side effects due to their ultra-diluted and dynamized formulation, exclusive to this scientific modality. Furthermore, when recommended by a professional specialist and facilitated through telemedicine resources, the continuity of patient care and monitoring will face no hindrances. It is important to emphasize that even though the prescribed medications for veterinary patients are safe, they should be vigilantly monitored by a specialist. This monitoring involves assessing the expected symptoms and effects associated with the prescription, allowing the specialist to intervene and decide whether to modify or continue with the chosen medication.

Relational continuity may give better clinical outcomes in patients with serious mental illness – a systematic review

BackgroundContinuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.MethodsEleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.ResultsWe identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.ConclusionsThe results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

Impact of Care Fragmentation after Major Lower Extremity Amputation

Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease. Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges. We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4years old vs. 69.7years old, P=0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P<0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P<0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P<0.001 and 54.7% vs. 42.0%, P<0.001, respectively). On their first postamputation readmission, LOS (16.3days vs. 14.7days, P=0.004) and hospital charge ($48,964 vs. $44,388, P=0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P<0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P<0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P=0.36). CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.

Using the consolidated framework for implementation research (CFIR) to guide implementation of cardio-oncology services.

Cardio-oncology focuses on diagnosing and preventing adverse cardiovascular outcomes in cancer patients. Interdisciplinary cardio-oncology services address the spectrum of prevention, detection, monitoring, and treatment of cancer patients at risk of cardio-toxicity and aim to improve the continuum of cardiac care for oncology patients. The goal of this study was to engage clinician and administrative stakeholders to assess multilevel needs, barriers, and expectations regarding cardio oncology services. We interviewed clinicians and administrators at an academic medical center using the Consolidated Framework for Implementation Research (CFIR) to understand multilevel determinants influencing cardio-oncology service implementation. We also conducted a web-based survey to assess the knowledge, attitude, and perceptions of cardio-oncology services held by local and regional clinicians who may refer cardio-oncology patients to the study site. Multiple facilitators to cardio-oncology service implementation emerged. Interview participants believed cardio-oncology services could benefit patients and the organization by providing a competitive advantage. A majority (74%) of clinicians surveyed thought a cardio-oncology service would significantly improve cancer patients' prognoses. Implementation barriers discussed included costs and a siloed organizational structure that complicated cross-service collaboration. In the clinician survey, differences in the views toward cardio-oncology services held by cardiology versus oncology providers would need to be negotiated in future cardio-oncology service development. For example, while most providers accepted similar risk of cardio-toxicity when consenting patients for cancer therapy in a curative setting, cardiologists accepted significantly higher levels of risk than oncologists in an incurable setting: 75% of oncologists accepted 1-5% risk; 77% of cardiologists accepted ≥5% risk). Participants supported implementation and development of cardio-oncology services. Respondents also noted multi-level barriers that could be addressed to maximize the potential for success. Engaging administrators and clinicians from cardiology and oncology disciplines in the future development of such services can help ensure maximal relevance and uptake.

Perinatal Psychopharmacology: Innovative Approaches to Care Delivery.

Perinatal mental health conditions are the most common complications of childbirth and have well-established enduring negative effects. Obstetric (Ob) clinicians care for patients with perinatal mental health conditions across a spectrum of acuity, severity, and complexity. Ob and psychiatric clinicians can collaborate to create a cohesive continuum of psychopharmacologic care for perinatal patients. This chapter provides an overall framework for Ob-psychiatric clinician collaboration with examples of innovation in care delivery.