Care Coordination Research Articles

Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery.

The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions. Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics. Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts. Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

CDSS Adoption and the Role of Artificial Intelligence in Saudi Arabian Primary Healthcare

The integration of advanced Clinical Decision Support Systems (CDSS) is crucial in healthcare, especially in developing countries. However, the challenges to CDSS implementation in these settings are often overlooked, leading to implementation gaps. This study investigates the adoption of CDSS in primary healthcare facilities in Saudi Arabia through in-depth interviews with general practitioners. The advancement of primary healthcare systems in developing nations necessitates appropriate technological solutions to address issues such as equitable access, service quality, and patient satisfaction. The adoption of CDSS can potentially improve patient satisfaction and enhance medical consultations. Artificial intelligence -driven technologies like the Velys robot are transforming the medical field by assisting doctors in surgical procedures. In healthcare, Artificial intelligence (AI) can address issues related to complex diseases, aging populations, and workforce shortages. AI solutions can streamline patient flow, improve care coordination, and support personalized healthcare management. By assessing the impact of AI on patient care, healthcare efficiency, and effectiveness can be enhanced. This research highlights the challenges and opportunities in CDSS adoption in developing countries, with implications for healthcare improvement in Saudi Arabia.

Outpatient management of pediatric epistaxis: A cost analysis and clinical model.

Pediatric epistaxis is a common, often non-operative condition encountered by Otolaryngologists. The present study seeks to (1) describe our outcomes of epistaxis management, (2) estimate the associated healthcare burden, and (3) propose a clinical model to optimize care coordination with primary care and advanced practice providers. Retrospective case series of pediatric patients treated outpatient for epistaxis by a single otolaryngologist from 2021 to 2022. The primary outcome after treatment with nasal lubricants was defined as (1) refractory epistaxis, (2) improvement, or (3) complete resolution. Cost data for office versus operative nasal cautery were analyzed. In total, 122 patients were included for analysis. Over a follow-up duration of 20.5 months (IQR 8-36), 24.6% of patients experienced refractory epistaxis, 41.8% of patients found improvement, and 33.6% had complete resolution (n = 122). Refractory epistaxis was associated with a family history of coagulopathy (p = .007), daily epistaxis episodes (p = .043), and anemia (p <.001). Average direct hospital costs associated with nasal cautery were $187 for in-office cauterization and $2179 for intraoperative cauterization. Estimated patient/third party payors savings were $1617 and $15,412 for in-office and intraoperative procedures, respectively, and $541.59 for specialty office visits alone. The average charge for laboratory work-up was $576. Approximately 75% of patients with epistaxis experienced improvement or resolution of symptoms with nasal lubrication alone. Refractory epistaxis was associated with a family history of coagulopathy, daily epistaxis episodes, and anemia. Otolaryngology visits for epistaxis were associated with a direct healthcare expense burden. Adaptation of our clinical model may mitigate these costs while improving patient care. Level of Evidence: 4.

Metabolic Monitoring for Children and Adolescents Prescribed Second-Generation Antipsychotics: A Qualitative Study with Child Psychiatrists.

Introduction: Professional guidelines recommend that providers routinely monitor children prescribed second-generation antipsychotics (SGA) to reduce the risk of adverse metabolic events associated with the medication. Despite this guidance, many studies show low rates of monitoring compliance. In this study, we interviewed child psychiatrists for their views of possible barriers to monitoring. Methods: Semi-structured qualitative interviews, developed according to the Regehr model of influences upon patient-provider decision making, were conducted with child and adolescent psychiatrists in current practice and recruited by convenience and snowball sampling. Interviews were conducted through internet video meetings and were recorded. Interview data were analyzed following Framework Analysis qualitative methods. Results: We recruited and completed interviews with 17 psychiatrists. Patient-level barriers included travel difficulties, limited family time for health care appointments, patient fear of blood draws, and more. Provider-level barriers included professional judgment versus guideline guidance, perceived family burden, assumption of low-risk, short-term SGA use, and more. Organizational level barriers included lack of organizational mandates or incentives, limited appointment time per patient, lack of care coordination, lack of co-located labs, personnel turnover, and more. Barriers at the social and cultural level include stigma and low health literacy. Conclusion: These practicing prescribers provided a wide range of possible barriers to metabolic monitoring in children and adolescents prescribed SGAs. The next step is to explore which may be present in certain settings, and to pilot quality improvement interventions. Addressing barriers can reduce risk of metabolic disorders arising from long-term use of SGAs in children and adolescents.

Single-center retrospective review of standard versus minimal monitoring for hepatitis C direct-acting antiviral therapy

BackgroundHighly effective direct-acting antiviral (DAA) therapies have transformed the landscape of hepatitis C virus (HCV) treatment. However, there continues to be limited data regarding the efficacy and safety of required in-person clinic visits (standard monitoring) versus completely telehealth clinic visits (minimal monitoring) during HCV therapy, which could delay practice adoption. ObjectivesThis study aimed to assess the rates of undetectable HCV ribonucleic acid (RNA) in sustained viral load 12 weeks after therapy (SVR12) in standard versus minimal monitoring approaches during DAA. MethodsA 12-month, single-center retrospective cohort study was conducted in treatment-naïve HCV-infected adults who received DAA therapy between May 1, 2020, and April 30, 2021. The standard monitoring group had ≥1 in-person clinic visit with HCV RNA laboratory monitoring during DAA treatment. The minimal monitoring group had entirely telehealth visits without HCV RNA laboratory monitoring during treatment. Both groups received telephonic touchpoints throughout DAA treatment from a clinical pharmacist practitioner and a nurse care coordinator. The primary outcome was SVR12. ResultsFrom May 2020 to April 2021, 133 patients with HCV met inclusion criteria and were treated with DAA (standard, n = 56; minimal, n = 77), with no differences in baseline demographics. Overall, total encounters during DAA treatment remained significantly higher in the standard than minimal monitoring group (standard, 2.1 ± 0.8, vs. minimal, 1.7 ± 0.9; P < .01). Although minimal monitoring had higher loss to follow-up rates (standard, 7.1%, vs. minimal, 18.2%; P = 0.06), the modified intention-to-treat analysis showed no differences in sustained virologic response (SVR) between standard and minimal monitoring approaches (standard, 98.1%, n = 51, vs. minimal, 95.3%, n = 60; P = 0.41). ConclusionsThis single-center retrospective cohort study demonstrated that minimal monitoring during HCV treatment was as effective in achieving SVR cure rates as standard monitoring. Eliminating required in-person clinic visits during DAA therapy alongside a collaborative approach may play a major role in overcoming barriers to HCV care in select patients.

Defining the complex needs of families with rare diseases-the example of telomere biology disorders.

Families with rare diseases, such as telomere biology disorders (TBDs), may have extensive unmet needs given the heterogeneity, chronicity, and potential severity of illness. TBDs are rare inherited syndromes associated with high risk of bone marrow failure, cancer, pulmonary fibrosis, and other severe, chronic complications. To identify gaps in clinical care, we aimed to ascertain the perceived unmet needs of adults and family caregivers, current or bereaved, of individuals with TBDs. Participants were aged ≥18 years with a self-reported TBD diagnosis and/or ever caregivers to one or more family members with a TBD. Participants completed an online survey (N = 35) and/or an audio-recorded telephone interview (N = 32). We calculated descriptive statistics in SPSS and thematically analyzed interview transcripts. Quantitative and qualitative data were analyzed concurrently. Most participants were aged ≥35 years, female, highly educated, and medically insured. Survey respondents reported numerous unmet needs in psychosocial, medical, financial, and daily activity domains. In interviews, participant descriptions validated and contextualized the salience of these unmet needs. Both qualitative and quantitative data identified critical shortfalls in addressing chronic family distress and specialty care coordination. Adults and caregivers of individuals with TBDs have a high risk of adverse psychosocial sequelae given extensive unmet needs. These findings provide a foundation for understanding the range and extent of gaps in care for families with rare diseases, especially TBDs but that are likely applicable to others. Tailored multi-disciplinary interventions involving patients, families, clinicians, researchers, and patient advocacy communities are required to appropriately address care needs for all rare diseases.

Oncologists’ management of non-cancer conditions: An observational study.

23 Background: Cancer diagnoses introduce layers of complexity for care coordination. Oncologists often find themselves independently managing coincident, non-cancer illnesses. How often oncologists engage in direct management of non-cancer conditions, rather than coordinating with patients' other providers, is not well understood. We examined how often oncologists prescribe medications to manage non-oncologic conditions, as a proxy for assuming primary-care responsibilities. Methods: The cohort included all US physicians with a specialty of Hematology-Oncology or Medical Oncology from 2016-2020, available in the Centers for Medicare &amp; Medicaid Services Part D Prescribers dataset. Prescription drugs were categorized as “cancer-directed”, “cancer-related” (eg., opioid pain medications), or “non-cancer” (eg., antihypertensives). Primary outcomes included prescription of cancer-directed, non-cancer, and cancer-related medications. Multivariate logistic regression assessed the association between non-cancer medication prescriptions and provider location, medical school graduation year, gender, and practice affiliation during 2020. Results: A mean of 8.3% (median 5.3%, IQR 0% – 12.5%) of oncologists’ prescriptions were for non-cancer medications; this decreased during the study period, falling from 9.5% in 2016 to 7.4% in 2020 (p&lt;0.001 on Kruskal Wallis test for non-parametric data). Providers practicing in the Midwest (aOR 1.3, 95%CI [1.2-1.5]), Southeast (1.5 [1.3-1.7]), and Southwest (1.6 [1.4-1.9]) were more to prescribe non-cancer medications, as were providers who graduated &gt;10 years prior to the end of the study period, most notable in providers graduating 1990–1991 (2.2 [1.9-2.6]). Those at academic institutions (0.7 [0.6-0.8]) were less likely to prescribe non-cancer medications. Conclusions: A small but substantive portion of oncologists’ prescriptions are for medications unrelated to cancer care. The downtrend in non-cancer prescriptions may reflect that coordinated co-management of patients with cancer is increasing. The rise in telemedicine and digital health represents an opportunity to establish stronger multidisciplinary care for patients with cancer through hybrid cross-collaboration between primary care physicians and oncologists. This is especially advantageous in regions where in-person integration of physician groups may not be possible. Additionally virtual continuing medical education sessions may aid primary care physicians in managing non-cancer medications for the cancer population. Trends in oncologists’ prescribing patterns from 2016–2020: Mean per-provider proportion of non-cancer medication prescription (%). Medication Class 2016 2017 2018 2019 2020 Cancer-Directed 30.4 31.1 32.2 32.7 33.9 Non-Cancer 9.5 8.9 8.2 7.6 7.4

Understanding the extent of caregiver involvement and needs in treatment-impacting activities.

187 Background: Caregivers are known to be a significant part of patient care; however, the extent of their role is commonly underestimated and they often feel ‘invisible’. COLONTOWN (CT) is a virtual colorectal cancer community providing peer support and evidence-based education for both caregivers and patients. As such, we sought to understand caregivers’ involvement related to treatment decision making and care delivery, and related gaps in support. Methods: Our online anonymous survey was posted in May 2024 to members of CT’s international caregiver community, who may be more active in their patients’ care than typical of the broader CRC population. It included 33 questions on caregiving responsibilities, effect of cancer on other life activities, impacts, support received/needed and 13 demographic questions. We identified a subset of 9 questions specifically related to treatment that are reported here. Results: All data was self-reported based on their patient’s time in active treatment. Of 359 respondents, 88% were female and 86% significant others/spouses. Their patients were 90% Stage IV and 85% in the US with 17 other countries represented. Caregivers nearly always participate in and often have primary responsibility in treatment-impacting activities (Table). This includes researching treatment options, where among the 69% in a primary role 31% have complete responsibility, managing side effects, and recording and reporting symptoms. 88% were always or usually at appointments and/or otherwise in direct contact with the care providers. Caregivers' roles, however, are not always recognized by their patient’s care team. Only 6% felt completely supported and 21% felt completely respected by their patient’s care team. 66% felt “Enhanced communication and collaboration with healthcare providers” would aid in their role in patient care. 56% indicated “more education resources for caregivers” are needed. Conclusions: Caregivers report assuming primary responsibility in many critical activities in patient treatment. The gap in recognizing this dynamic contributes to the challenges of caregiving. CT embraces the vital role of caregivers by offering dedicated caregiver resources and engaging them as equal partners in development and offering of all programs . Acknowledgement of the depth of the caregiver role is needed and more caregiver support should become a standard component of the patient’s care plan. Any shared decision-making processes and education should appropriately recognize and include caregivers as critical stakeholders as requested by their patient. Caregivers’ reported role in treatment-impacting caregiving activities. Activity Primary Role % Split Evenly % Support Role % No Role % Researching treatment options 69 13 17 1 Researching/managing side effects 64 21 14 1 Symptom reporting 47 24 23 6 Coordinating care 44 27 25 4

Care Coordination in Primary Care: Views of Clinicians and Clinic Leaders.

Care coordination is an important strategy for addressing patient needs and improving outcomes of care. The Minnesota Care Coordination Effectiveness Study sought to better understand the perspectives and experiences of clinicians/clinic leaders regarding the value, barriers, and facilitators for care coordination in primary care. We conducted semi-structured interviews with 18 clinic managers, physicians, and advanced practice clinicians. Data were analyzed using a directed content analysis approach. Five themes arose in the interviews: financial issues were perceived as a primary barrier to care coordination; participants valued care coordination as an important asset; they employed significant variation in how care coordination was structured; they identified both medical and social needs of patients as important; and care coordinators' background, experience, and integration were viewed as critical to program success. Care coordination received strong support from clinicians and clinic leaders who viewed it as a valuable component of successful care delivery.

Improvements in Transitional Care Among Medicaid-Insured Patients With Serious Mental Illness.

The Thrive program is an evidenced-based care model for Medicaid-insured adults in the hospital-to-home transition. A substantial portion of Thrive participants live with serious mental illness (SMI), yet Thrive's efficacy has not been tested among these patients. To compare 30-day postdischarge outcomes between Thrive participants with and without SMI and explore Thrive's appropriateness and acceptability among participants with SMI. We conducted a sequential explanatory mixed-methods study of 252 (62 with SMI) Thrive participants discharged from an academic medical center from February 2021 to August 2023. Interviews of participants with SMI were analyzed using rapid qualitative analysis. Participants with and without SMI experienced similar rates of 30-day readmissions, emergency room visits, and postdischarge follow-up visits, with these differences being nonsignificant. Participants with SMI were highly satisfied with Thrive's care coordination and attention to social needs, yet participants suggested stronger connections to behavioral health care. Participants with and without SMI benefit equitably from Thrive.

Identification of interventions to improve patient experienced quality of care in transitions between healthcare settings: a scoping review

BackgroundTransitions in healthcare settings can be a challenge for patients and they express a need for guidance and support to cope with these transitions. The aim of this scoping review was to investigate if interventions can improve patients’ experiences when transitioning between healthcare settings.MethodsThis review was conducted following the Johanna Briggs Institute’s methods and reported according to the PRISMA-ScR Checklist. Included articles were published and peer-reviewed, and reported qualitative and quantitative findings on patient experiences with interventions when transitioning between healthcare settings. The search was conducted in May 2024 in Medline Ovid, Embase Ovid, and Cinahl.ResultsTwenty-three studies were included. Factors extracted from the studies were: author(s), year of publication, country of origin, study design, theoretical methods, population description, intervention, phenomena of interest(s), and key findings. There has been an increase in published studies on the subject in the last few years, and most of the included studies originated from Western countries. Most studies were quantitative, primarily RCTs, and the theoretical methods were thus mainly statistical analysis. The study populations were found to be heterogeneous. The interventions were categorized: care coordinator, program, integrated care, online communication platform, coaching, discharge care plan, and miscellaneous interventions.ConclusionsOverall, interventions were found to improve the patient experience. Centralization of healthcare has increased the number of transitions, and patients express that the coordination of healthcare transitions can be improved. This review’s findings should be used alongside other research on interventions’ effect on factors like hospital readmissions and mortality to determine the optimal intervention to implement.

A Proactive Telephonic Outreach Program to Address Unmet Social Needs of Children in Immigrant and Refugee Families at a Federally Qualified Health Center.

We developed a telephonic outreach and care coordination program for children in immigrant and refugee families (CIRF) at a federally qualified health center (FQHC) in North Carolina to address unmet health-related social needs (HRSN). Participants were recruited between December 2020 and October 2021. Eligible children were ages 0-5, non-English speaking, and were seen at the FQHC in the 2years prior. A bicultural/bilingual case manager completed telephonic outreach to caregivers of participants with HRSN screening. Bilingual patient navigators made follow-up calls to assess connection to resources and to develop strategies for addressing unmet needs. Three hundred forty-two families received outreach; 212 (62.0%) completed the baseline questionnaire. The majority (N = 160, 75.5%) completed at least one follow-up. The majority (N = 186, 88.1%) were Spanish-speaking, and over two-thirds (N = 149, 70.3%) were uninsured. Most participants had between 3-5 HRSNs identified (N = 121, 57.1%); "employment" (n = 158, 74.5%) and "food" (n = 138, 65.1%) were the most common. Despite repeated assistance, the majority of participants struggled to link to a community resource for their highest priority need (N = 123, 78.3%). Proactive phone-based HRSN screening may be a feasible and effective intervention to facilitate the identification of social needs for CIRF. The delivery of the intervention in languages other than English may have further contributed to program acceptability. Despite program feasibility and acceptability, community-level barriers to the resolution of HRSNs persist. While similar care coordination models can be considered to identify the high burden of unmet HRSN among CIRF, addressing the limited capacity of community-based resources for this population will be a critical component to ensuring the sustainability of such programs.

Managing Patients With COVID-19 in Armenia Using a Remote Monitoring System: Descriptive Study.

The COVID-19 pandemic has imposed immense stress on global health care systems, especially in low- and middle-income countries (LMICs). Armenia, a middle-income country in the Caucasus region, contended with the pandemic and a concurrent war, resulting in significant demand on its already strained health care infrastructure. The COVID@home program was a multi-institution, international collaboration to address critical hospital bed shortages by implementing a home-based oxygen therapy and remote monitoring program. The objective of this study was to describe the program protocol and clinical outcomes of implementing an early discharge program in Armenia through a collaboration of partner institutions, which can inform the future implementation of COVID-19 remote home monitoring programs, particularly in LMICs or low-resource settings. Seven hospitals in Yerevan participated in the COVID@home program. A web app based on OpenMRS was developed to facilitate data capture and care coordination. Patients meeting eligibility criteria were enrolled during hospitalization and monitored daily while on oxygen at home. Program evaluation relied on data extraction from (1) eligibility and enrollment forms, (2) daily monitoring forms, and (3) discharge forms. Over 11 months, 439 patients were screened, and 221 patients were managed and discharged. Around 94% (n=208) of participants safely discontinued oxygen therapy at home, with a median home monitoring duration of 26 (IQR 15-45 days; mean 32.33, SD 25.29) days. Women (median 28.5, mean 35.25 days) had similar length of stay to men (median 26, mean 32.21 days; P=.75). Despite challenges in data collection and entry, the program demonstrated feasibility and safety, with a mortality rate below 1% and low re-admission rate. Opportunities for operational and data quality improvements were identified. This study contributes practical evidence on the implementation and outcomes of a remote monitoring program in Armenia, offering insights into managing patients with COVID-19 in resource-constrained settings. The COVID@home program's success provides a model for remote patient care, potentially alleviating strain on health care resources in LMICs. Policymakers can draw from these findings to inform the development of adaptable health care solutions during public health crises, emphasizing the need for innovative approaches in resource-limited environments.

Barriers to identifying and addressing health-related social needs in cancer care: Patient and patient navigator perspectives

BackgroundThe study aimed to gain insight into the experiences of patients with cancer and survivors regarding the integration of social needs assessment into their care, while also gathering perspectives from patient navigators on the barriers to obtaining and utilizing social needs information during cancer care, which taken together may influence cancer care policies. By comparing the perspectives of patients and navigators, the study sought to inform best practices for integrating, identifying, and addressing social needs to improve patient experiences and outcomes. MethodsWe conducted qualitative interviews and self-report surveys involving patients with cancer, providers, and patient navigators or care coordinators, seeking their insights and firsthand experiences related to health-related social needs in cancer care. Interviews were transcribed, separated into memos of main themes based on deductive coding, and further analyzed for new emergent themes using inductive coding. ResultsThe present analysis focuses solely on the perspectives of 20 patient navigators and 21 patients. Qualitative analyses revealed two overarching themes: Theme 1: Personal and health system-related factors may create barriers for patients to disclose health-related social needs information during cancer care; and Theme 2: When social needs are identified, it is best practice to acknowledge and address social needs through referrals, resources, timely follow-up, and continued care coordination. Key barriers include individual beliefs and attitudes, concerns regarding privacy and sensitivity of questions, uncertainties about the outcomes of disclosing information, and patient-provider relationships and trust. ConclusionDrawing upon the perspectives of patients and patient navigators provided valuable insight into the challenges associated with acquiring information on social needs. Their viewpoints presented feasible solutions to overcome barriers through early acknowledgment of patient needs, timely resource provision, and maintaining consistent follow-up actions. Additionally, it enhanced understanding of the pivotal role patient navigators play in oncology, serving as crucial links between screening for health-related social needs and addressing individual patient requirements. Policy SummaryThe policies and policy improvements our paper seeks to impact include: inequalities in cancer care and health-related social needs of cancer.

Amplifying Influence: Unveiling the Dynamic Role of Speech and Language Therapists within ICPOP Specialist Community Teams across Ireland

Abstract Background Integrated Care Programme for Older People (ICPOP) provide services for people with complex needs requiring specialist community multidisciplinary assessment and intervention. This national programme aims to shift care from hospitals, toward communities. As of October 2023, 23 of 30 planned ICPOP teams have been established (Butler, 2023). The Irish Association for Speech and Language Therapists, recommend speech and language therapists (SLT) be included on all frailty intervention teams across all service areas, ensuring equal access regardless of geographical area. Currently 10 ICPOP teams have an SLT in post. The contribution of SLT within these teams remains unstudied. Understanding the role of SLTs within ICPOP, exploring similarities and differences, is essential for informing professional clinical guidelines and practice. Methods This study utilised an anonymous, non-experimental, cross-sectional survey design. The survey design incorporated the Tailored Research Method to enhance response rates. Survey Monkey (http://www.surveymonkey. com) was used to create and disseminate the open survey. All SLTs working on ICPOP teams were invited to participate. Results Findings highlight the diverse roles and responsibilities of SLTs within ICPOP. While some commonalities were observed in services provided by SLTs, such as dysphagia assessment and communication support, variations existed based on team location, setting, and individual professional experience. The majority of SLTs participated in non SLT specific activities such as triaging, conducting assessments and administrative duties. Rural SLTs faced challenges related to resources and coordination of care. Urban SLTs had greater access to specialist instrumental assessments. Conclusion This study underscores the importance of recognising and addressing the varied roles of SLTs within ICPOP teams to guide professional guidelines and promote consistency. By understanding the unique challenges and opportunities faced by SLTs in different geographical and organisational contexts, policymakers and healthcare leaders can better support professionals to meet the diverse needs of older individuals across Ireland.

Challenges and Benefits of Developing Case Management in an ICPOP Hub

Abstract Background Case management is a collaborative procedure involving assessment, planning, facilitation, care coordination, evaluation, and advocacy. Its aim is to address the comprehensive health needs of individuals and families by utilising communication and existing resources to achieve high-quality and cost-effective results. The Integrated Care Program for Older Persons (ICPOP) aims to improve life for older people by providing access to tailored interventions supporting them to live well in their own homes. (ICPOP, 2017). The goal of nurse-led case management interventions within the ICPOP Hub, is to provide continuous, patient-centred, comprehensive care for older adults with complex care needs. Methods The Nursing team, comprising Clinical Nurse Specialists, Candidate Advanced Nurse Practitioner, undertook case management of 40 patients with complex care needs, over a six-month period. Diagnoses included Delirium, Dementia, Parkinson’s disease, frailty syndromes. Particular attention was given to patients who, through case management, were able to be discharged earlier from the acute hospital, aligning with the goals of the Integrated Care Model. Quality Improvement methodologies were used aiming to improve service delivery, efficiency, patient outcomes. Results (Required) Benefits Challenges Conclusion Case management enables older adults to continue living independently at home but requires integration into a broader system prioritising seamless delivery utilising a collaborative, multidisciplinary approach to health and social care.

Redesigning Community Dwelling Geriatric Integrated Care Program for Better Care Co-Ordination and Health Outcomes

Abstract Background Existing health services and care models need to adapt to the increasing ageing population, multimorbidity, and frailty. Thus, diverse healthcare providers and caregivers are demanded to continue living at home. An Integrated Care Program, involving a multidisciplinary team with a patient-centred focus, is being promoted as an alternative model of care. However, uncoordinated existing services put them at risk of fragmented care, leading to adverse outcomes. This study aimed to fill gaps in previous ICP research by introducing a change roadmap into the implementation phase of the program. In addition, the study proposed evaluating the effectiveness and implementation of the pilot project together with the process evaluation. Methods The study conducted a systematised literature review to examine the outcomes and different structures of the ICP. Implementation Science was utilised to define, design, and deliver the model of change. Results A systematised literature review showed that most ICPs were led by an Advanced Nurse Practitioner with positive outcomes. SWOT analysis, stakeholders’ involvement, existing community service providers, and a population survey provide an in-depth perspective of the target population and set up contextually adapted implementation strategies. An ANP-led MDT was proposed to co-ordinate the ICP. A process evaluation to assess the care model together with health outcomes was outlined. Conclusion The study showed that ANP-led MDT, person-centred, co-ordinated care provides the best ICP implementation strategy. The study will further understand the ICP implementation process among frail older people in the community.

What Are the Perspectives and Experiences of Older Adults of Existing Integrated Care Services in the Mid-West Region of Ireland?

Abstract Background Substantial investment has been provided by the HSE in the form of The Integrated Care Programme for Older People (ICPOP) Community Specialist Teams (CSTs) for older people. These teams aim to provide timely specialist multi-disciplinary assessment and intervention to help maintain older adults’ independence and ability to live well at home. Little is known about older adult’s views or experiences of this service. This study aimed to resolve this research gap by exploring older adults’ experiences of CSTs within the Irish Healthcare context. Methods A qualitative descriptive research design was employed to explore this research area and a semi structured topic guide was developed. Purposive non-probability sampling was used to recruit 13 older adults who had completed intervention with the CSTs. Individual semi-structured interviews were completed with each participant and were transcribed verbatim. A reflexive approach to thematic analysis was used to guide analysis of the generated data. Results Four themes were identified, older people had limited knowledge of the service and experienced accessibility issues in attending CST within a HUB setting (Theme 1). Older people experienced positive and co-ordinated care by CST (Theme 2). Older people described that they valued the self-management education and support from attending CST that enabled to manage their long-term conditions effectively and maintain their independence (Theme 3). Once discharged from CST older people described positive emotional and physiological impact of CST that enabled them to be more confident to manage daily life at home (Theme 4). Conclusion It was evident from the data that CST had a positive impact on supporting older people to remain independent at home and increased their confidence in self- management of their long-term conditions. Further research would be beneficial to address ways to improve the delivery of care for the complex needs older persons within CSTs as they describe accessibility issues in attending the service.

Integrated Care in Action: A Case Study of Collaborative Multidisciplinary Approach for Older Adults in Ireland

Abstract Background In Ireland, the healthcare landscape is evolving with frameworks which emphasize community-based care, such as Enhanced Community Care and the National Integrated Care Programme for Older Persons. Our Integrated Care Team for Older Persons (ICPOP) service exemplifies this shift by providing intensive, immediate multidisciplinary care to frail adults, aiming to maintain their independence in their homes and communities. Methods In the case study we describe service users journey with ICPOP. The case study illustrates the transition from fragmented care to a collaborative, patient-centred approach. ICPOP employs a structured process involving comprehensive assessment, goal setting, weekly multidisciplinary team meetings, stakeholder liaison, and detailed discharge reports. This approach focuses on early supported discharge and close coordination with local MDT teams, fostering effective communication and shared decision-making. Results This case study demonstrates the effectiveness of ICPOP's multidisciplinary model. Key factors contributing to this success include physical co-location, shared goals and vision, mutual trust, and established relationships among professionals. Furthermore, the integration of Allied Health Professionals (AHPs) within community teams enriches the care continuum and enhances outcomes for older adults. Conclusion To further enhance integrated care delivery, digital solutions are crucial. Implementing shared electronic health records and facilitating access to medical findings can streamline communication and improve care coordination. Additionally, prioritizing written discharge summaries for clients can ensure continuity of care and empower patients and their families in the post-discharge phase. This patient journey underscores the importance of collaborative, patient-centred care models in achieving the objectives of Sláintecare leading to better outcomes for older adults in Ireland.

Bridging the gap — Establishing a dental-oncology service in a cancer centre

Dental disease remains the most common non-communicable disease worldwide. It predisposes patients to significant morbidities following bone modifying agents or radiation therapy to the head and neck. Preventative dental regimes effectively reduce the risk of both medication-related osteonecrosis of the jaw (MRONJ) and osteoradionecrosis (ORN) in these patients. Co-ordination of routine dental care as a component of mainstream oncology treatment optimises long term outcomes for oncology patients. This case series offers insights into patient, institutional and social difficulties that challenge the dental-oncology interface. These obstacles and subsequent resolutions experienced whilst establishing a dental-oncology service in a cancer centre highlight the importance of effective multidisciplinary lead care for oncology patients. It reinforces the need for structured, supported dental pathways for these oncology patients.