Care Coordination Research Articles

Strategy for optimizing outpatient access for chronic patients in a health insurance company

ABSTRACT The last decades have been marked by significant population transformations in several nations. The demographic transition, resulting from the significant reduction in birth rates and the increase in life expectancy, has resulted in a further ageing population. Knowing how to prioritize and optimize the allocation of resources becomes, therefore, a prerequisite for managers decision-making. Strategies that reduce hospital costs while improving the quality of care are essential for the sector, mainly because they allow integrated processes and greater accessibility to users. Proximity and ease of access to health services are essential to ensure continuity of care and improve patient engagement with suggested treatment. The objective of this article is to demonstrate a viable solution for the allocation of chronic patients in the outpatient units of a Brazilian health insurance company in a regionalized manner and based on a set of criteria and restrictions. The study used Integer Programming, an optimization technique of Operations Research, to determine the outpatient units. As a result, it was possible to identify and suggest practical improvements in the care coordination process, offering a concrete contribution to the effectiveness and operational efficiency of the decision-making process.

The impact of a nurse's dual role on implementing an effectiveness study.

Reorganizing the Approach to Diabetes through the Application of Registries (RADAR) improved diabetes care and outcomes for First Nations people in Alberta, Canada. The nurse involved in the implementation of RADAR performed two roles in this model of care: research nurse and care coordinator. To describe the research nurse's dual role in the implementation and evaluation of RADAR. The research nurse not only documented and collected data in hard-to-reach communities as part of effective research, she also provided remote care coordination to support community healthcare providers using a culturally tailored registry to facilitate population-level care. This dual role required many qualities of nursing leadership and transformation. The research nurse's two roles contributed to the success of the intervention and were critical to the successful implementation of the model, creating valuable real-world evidence across diverse populations and settings. for practice Nurses are well placed to perform research duties alongside engagement and implementation activities. This can enhance the effectiveness and evaluation of healthcare interventions, particularly in community-based interventions within First Nations communities.

Reducing mental health emergency visits: population-level strategies from participatory modelling

BackgroundEmergency departments (EDs) are often the front door for urgent mental health care, especially when demand exceeds capacity. Long waits in EDs exert strain on hospital resources and worsen distress for individuals experiencing a mental health crisis. We used as a test case the Australian Capital Territory (ACT), with a population surge of over 27% across 2011–2021 and a lagging increase in mental health care capacity, to evaluate population-based approaches to reduce mental health-related ED presentations.MethodsWe developed a system dynamics model for the ACT region using a participatory approach involving local stakeholders, including health planners, health providers and young people with lived experience of mental health disorders. Outcomes were projected over 2023–2032 for youth (aged 15–24) and for the general population.ResultsImproving the overall mental health care system through strategies such as doubling the annual capacity growth rate of mental health services or leveraging digital technologies for triage and care coordination is projected to decrease youth mental health-related ED visits by 4.3% and 4.8% respectively. Implementation of mobile crisis response teams (consisting of a mental health nurse accompanying police or ambulance officers) is projected to reduce youth mental health-related ED visits by 10.2% by de-escalating some emergency situations and directly transferring selected individuals to community mental health centres. Other effective interventions include limiting re-presentations to ED by screening for suicide risk and following up with calls post-discharge (6.4% reduction), and limiting presentations of frequent users of ED by providing psychosocial education to families of people with schizophrenia (5.1% reduction). Finally, combining these five approaches is projected to reduce youth mental health-related ED presentations by 26.6% by the end of 2032.ConclusionsPolicies to decrease youth mental health-related ED presentations should not be limited to increasing mental health care capacity, but also include structural reforms.

Effects of physical and psychological multimorbidity on the risk of dementia: multinational prospective cohorts and a meta-analysis

BackgroundPrevious studies only considered the impact of a single physical or psychological disorder on dementia. Our study investigated the association of physical and psychological multimorbidity with dementia among older adults using two multinational prospective cohorts to supplement the limited joint evidence.MethodsWe utilized the Health and Retirement Study (HRS 2012 to 2018) in the United States (US) and the Survey of Health, Ageing and Retirement in Europe (SHARE 2012 to 2018). Physical disorder was defined as any one of seven self-reported physician-diagnosed conditions. Psychological disorder was assessed using the 8-item Center for Epidemiologic Research Depression (CES-D) scale or the EURO-D. Dementia was determined through a combination of self-reported physician diagnosis of dementia or Alzheimer’s disease, or the 27-point HRS cognitive scale. Competing risk models were utilized to estimate the hazard ratios (HRs) and 95% confidence intervals (95% CI). DerSimonian-Laird random-effects meta-analyses were conducted to obtain pooled estimates.ResultsThe prevalence of physical and psychological multimorbidity was 17.29% (1027/5939) in continental Europe and 15.52% (1326/8543) in the US. The incidence of dementia was 6.21 per 1000 person-years in continental Europe and 8.27 per 1000 person-years in the US, respectively. It was highest among participants with physical and psychological multimorbidity in continental Europe (10.46 per 1000 person-years) and the US (14.82 per 1000 person-years), compared with the other three groups. In the univariate model, participants who reported physical and psychological multimorbidity had a higher risk of dementia compared with those who reported no physical and psychological disorders in continental Europe (HR = 2.59; 95% CI: 1.55, 4.33) and the US (HR = 4.11; 95% CI: 2.44, 6.94). After adjusting all covariates, the risk of dementia among participants who reported physical and psychological multimorbidity increased by 86% in continental Europe (aHR = 1.86; 95% CI: 1.08, 3.21) and by 176% in the US (aHR = 2.76; 95% CI: 1.61, 4.72), respectively. After pooling the outcomes, the risk of dementia among participants who reported physical and psychological multimorbidity increased by 115% (aHR = 2.15; 95% CI: 1.27, 3.03).ConclusionsPhysical and psychological multimorbidity was prevalent among older adults in the US and continental Europe. Given the consistent associations with dementia, it is imperative to increase awareness of the links and recognize the limitations of single-disorder care. Specific attention should be given to providing care coordination.

Qualitative perspectives of Medicaid-insured patients on ambulatory care at an academic medical center: challenges and opportunities

BackgroundAmbulatory access to academic medical centers (AMCs) for patients insured with Medi-Cal (i.e., Medicaid in California) is understudied, particularly among the 85% of beneficiaries enrolled in managed care plans. As more AMCs develop partnerships with these plans, data on patient experiences of access to care and quality are needed to guide patient-centered improvements in care delivery.MethodsThe authors conducted semi-structured, qualitative interviews with Medi-Cal-insured patients with initial visits at a large, urban AMC during 2022. Participant recruitment was informed by a database of ambulatory Medi-Cal encounters. The interview guide covered Medi-Cal enrollment, scheduling, and visit experience. Interviews were transcribed and inductively coded, then organized into themes across four domains: access, affordability, patient-provider interactions, and continuity.ResultsTwenty participant interviews were completed (55% female, 85% English speaking, 80% self-identified minority or “other” race, and 30% Hispanic or Latino) with primary and/or specialty care visits. Within the access domain, participants reported delays with Medi-Cal enrollment and access to specialist care or testing, though appointment scheduling was reported to be easy. Affordability concerns included out-of-pocket medical and parking costs, and missed income when patients or families skipped work to facilitate care coordination. Participants considered clear, bilateral communication with providers fundamental to positive patient-provider interactions. Some participants perceived discrimination by providers based on their insurance status. Participants valued continuity, but experienced frustration arising from frequent and unexpected health plan changes that disrupted care with their established AMC providers.ConclusionsThe missions of AMCs typically focus on clinical care, education, research, and equity. However, reports from Medi-Cal insured patients receiving care at AMCs highlight their stress and confusion related to inconsistent provider access, uncompensated costs, variability in perceptions of quality, and fragmented care. Recommendations based upon patient-reported concerns suggest opportunities for AMC health system-level improvements that are compatible with AMC missions.

Exploring Innovative U.S. School Health Delivery Models: A Narrative Review.

School health services have been described as the "hidden healthcare" system because of their isolation within schools and from other healthcare providers. This isolation may inhibit innovations in school healthcare delivery. Hence, there is a need to identify and characterize various delivery models. This review examines models to identify innovative approaches and formulate suggestions for public health departments, local and state educational agencies, and policymakers. Toward this goal, published and gray literature were studied and synthesized, identifying three delivery models: the traditional model of school-based nursing and two alternative models: school-based health centers and community partnerships. Mechanisms of delivery included telehealth, mobile clinics, and system-level care. Although no innovative, comprehensive approaches to school health services models were found, innovation generally focused on improving equitable delivery to vulnerable populations. Policies must be formulated and funded to integrate such innovations into a comprehensive, preventative approach, including improved care coordination and data sharing.

Validation of the 40-Item and 24-Item Short Version of the Person-Centred Obesity Care Instrument for Patients Living with Obesity.

Person-centred care (PCC) may hold promise for improved healthcare experiences and outcomes among patients living with obesity. A validated instrument to assess the delivery of PCC to patients living with obesity is, however, currently lacking. This study aimed to validate such an instrument. In this article, we describe the development and psychometric testing of the 40-item and 24-item short version of the Person-Centred Obesity Care (PCOC) instrument. A total of 590 individuals living with obesity (BMI 33.4 ± 3.9) from a representative Dutch sample completed the 49-item PCOC instrument measuring the eight dimensions of PCC (patient preferences, physical comfort, coordination of care, emotional support, access to care, continuity and transition, information and education, and family and friends), and two measures of satisfaction with care. We performed confirmatory factor analyses to verify the factor structure of the instrument and examined its reliability and validity. Fit indicators of the first model with all 49 items showed that the model left room for improvement (comparative fit index [CFI] <0.90). A 40-item version was obtained with satisfactory-to-good fit (standardized root mean square residual [SRMR] = 0.05, root mean square error of approximation [RMSEA] = 0.06, CFI = 0.90). The instrument demonstrated good reliability, and the relationship between the PCOC and two indicators of satisfaction with care supported the validity of the scale. Shortening the instrument only further improved the fit indicators, resulting in the development of a 24-item short version (SRMR = 0.04, RMSEA = 0.05, CFI = 0.96), with similar results in terms of reliability and validity. The 40-item PCOC instrument and the 24-item short version showed to be reliable and valid instruments for the assessment of PCC among patients living with obesity. Based on the results, the 40 and 24-item PCOC are promising tools that can be used by clinicians and researchers to explore PCC delivery for patients living with obesity.

Beyond Boundaries: Elevating Continuity of Care in Student-Run Free Clinics

We discuss the challenge of continuity of care in Student-Run Free Clinics (SRFCs) across the nation due to barriers of transportation, variation in care teams, communication, coordination, and improper utilization of resources. Discussion at the 2023 Society of Student-Run Free Clinic’s Annual Conference “Bridging the Gap” session with various medical schools and respective SRFCs allowed us to identify after-care teams as a common and effective modality to improve continuity of care. Patient-centered care is at the heart of SRFCs, and we strongly believe that communicating outside of clinic hours allows for effective longitudinal patient care. Such initiatives allow for improvements in health status via motivational interviewing, discussing medications, and addressing socioeconomic issues. Each clinic we consulted during this session had its individualized program focused on the same ideology. By instituting an after-care team, SRFCs can improve continuity of care while fulfilling the Triple Aim outlined by the Institute of Healthcare Improvement (IHI). Our perspective article emphasizes the importance of after-care teams to improve continuity of care and patient value in relation to the Triple Aim.

Registered nurse case managers’ work experiences with a person-centered collaborative healthcare model: an interview study

BackgroundMultimorbidity is increasingly acknowledged as a significant health concern, particularly among older individuals. It is associated with a decline in quality of life and psychosocial well-being as well as an increased risk of being referred to multiple healthcare providers, including more frequent admissions to emergency departments. Person-centered care interventions tailored to individuals with multimorbidity have shown promising results in improving patient outcomes. Research is needed to explore how work practices within integrated care models are experienced from Registered Nurse Case Managers’ (RNCMs) perspective to identify areas of improvement. Therefore, the aim of this study was to describe RNCMs’ work experience with a person-centered collaborative healthcare model (PCCHCM).MethodsThis study used an inductive design. The data were collected through individual interviews with 11 RNCMs and analyzed using qualitative content analysis.ResultsData analysis resulted in four generic categories: ‘Being a detective, ‘Being a mediator’, ‘Being a partner’, and ‘Being a facilitator of development’ which formed the basis of the main category ‘Tailoring healthcare, and social services to safeguard the patient’s best.’ The findings showed that RNCMs strive to investigate, identify, and assess older persons’ needs for coordinated care. They worked closely with patients and their relatives to engage them in informed decision-making and to implement those decisions in a personalized agreement that served as the foundation for the care and social services provided. Additionally, the RNCMs acted as facilitators of the development of the PCCHCM, improving collaboration with other healthcare professionals and enhancing the possibility of securing the best care for the patient.ConclusionsThe results of this study demonstrated that RNCMs tailor healthcare and social services to provide care in various situations, adhering to person-centered care principles and continuity of care. The findings underline the importance of implementing integrated care models that consider the unique characteristics of each care context and adapt different case managers’ roles based on the patient’s individual needs as well as on the specific needs of the local setting. More research is needed from the patients’ and their relatives’ perspectives to deepen the understanding of the PCCHCM concerning its ability to provide involvement, security, and coordination of care.

Early diagnosis, effective treatment: modern approaches to the management of ectopic pregnancies

Purpose of research: The aim of this article is to provide an overview of the diagnosis and management of atypical ectopic pregnancy, with particular reference to pregnancy in the cesarean scar. The importance of early detection and medical intervention will be described, as well as the impact of advanced diagnostic techniques and modern treatments on the curability of patients.This article aims to provide valuable insights into the development of effective strategies for the diagnosis, treatment and prognosis of ectopic pregnancy. State of knowledge: Ectopic pregnancies account for 1-2% of all pregnancies, with the majority (90%) occurring in the fallopian tube. Less commonly, they present as ovarian, cervical or abdominal pregnancies. Advances in diagnosis and treatment have made it possible to identify rare forms such as cesarean scar pregnancy (0.15% of all pregnancies), interstitial pregnancy and recurrent ectopic pregnancy on tubal remnants. Techniques such as transvaginal ultrasound (TVS), MRI and laparoscopy have the potential to improve diagnostic accuracy and treatment outcomes. Modern interventions such as transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and methotrexate have shown promise in terms of safety and efficacy. Conclusions: Ectopic pregnancy and its complications have a significant impact on the psycho-physical health of patients, requiring ongoing research to improve diagnostic and therapeutic methods. Future studies should focus on long-term outcomes and the coordination of multidisciplinary medical care to further improve diagnosis and treatment.

Hospital‐physician integration and Medicare spending: Evidence from stable angina

AbstractObjectiveTo examine the association between hospital‐cardiologist integration and Medicare spending for stable angina patients.Data Sources and Study SettingThis study used Medicare Standard Analytic Files from 2013 to 2020 and the Centers for Medicare and Medicaid Services National Downloadable File for accompanying physician data.Study DesignThis was a retrospective cohort study of Medicare beneficiaries with a new diagnosis of stable angina between 2013 and 2020.Data Collection/Extraction MethodsPatients with a new diagnosis of stable angina were categorized by whether they received care from an independent or a hospital‐integrated cardiologist.Principal FindingsTotal spending for this sample was high: an average of $103,946 per patient over 12 months. Adjusted for covariates, patients of integrated cardiologists did not spend significantly more or less than clinically comparable patients of independent cardiologists (−$3856, 95% CI: −$8631 to 920, p = 0.11). This was true for overall inpatient (−$2622, 95% CI: −6069 to 825, p = 0.14) and outpatient (−1162, 95% CI: −$3510 to 1185, p = 0.33) spending as well as cardiology‐specific inpatient and outpatient spending. Among high‐risk patients, overall spending between the integrated and independent groups was comparable, though patients of integrated cardiologists incurred lower spending than those of their independent counterparts in inpatient care (−$13,589; 95% CI: −24,432 to −2746, p = 0.01). In a supplemental analysis, findings suggested that site‐neutral payments would have resulted in lower spending among patients of integrated physicians.ConclusionsSpecific clinical settings may lend themselves to efficiencies created by integration for certain complex patients, though we do not test a causal mechanism here. Adoption of site‐neutral payment policy may also lead to lower spending among patients of integrated physicians.What is known on this topic Hospital‐physician integration has increased significantly in the United States. Policymakers and health policy experts have expressed concerns that hospital‐physician integration leads to increased health spending and may threaten healthcare affordability. While some studies link integration to greater spending, many use incomplete measures of spending, do not consider the potential benefits of care coordination, or rely on outdated data. What this study adds Spending among patients with stable angina, a common cardiovascular condition, was nearly equal, on average, across patients of integrated and independent cardiologists. Inpatient spending on high‐risk patients was somewhat lower for those under the care of integrated cardiologists. Overall, patients of integrated cardiologists incurred largely comparable spending relative to patients of independent cardiologists, indicating that the impact of hospital‐physician integration may depend on the clinical context.

Abstract C034: Impact of survivorship care plans on self-reported health and functional well-being

Abstract Introduction: Cancer survivors have varying physical, psychosocial, and informational needs. Organizations such as American Society of Clinical Oncology have developed survivorship care plans (SCP) for cancer screening, treatment side effect management, and care coordination. There is a need to better understand SCP utilization among underserved and diverse patient communities. Methods: Adults ages 18+ years with breast or colorectal cancer diagnosed between 2019 and 2021 were recruited from the Greater Bay Area Cancer Registry. Participants completed a 30-minute survey about their survivorship plans, quality of life, health behaviors, and social support. Analysis: Overall comparisons between groups were evaluated with chi-square tests. Associations between demographic characteristics and receipt of any type of survivorship plan were evaluated with univariate binomial logistic regression models, and associations between receipt of any type of survivorship plan and health/well-being outcomes were assessed using univariate ordinal regression models. Multivariable models will be built using relevant variables. Results: Participants (n=872) were on average 59 years (range=24-95) and mostly female (70.2%). Participants had either breast (41.3%) or colorectal cancer (58.7%). Participants were American Indian/Alaska Native (AIAN) (1.0%), Asian American (18.2%), NH Black (12.8%), NH White (38.0%), LatinX (29.0%), and Native Hawaiian or Pacific Islander (0.8%). Receipt of a SCP was reported by 258 (29.6%) participants, 328 (37.6%) had another type of post-treatment guide provided to them, and 224 (25.7%) were not offered any kind of survivorship plan. There were no differences in race/ethnicity, nativity status, non-English language spoken at home, marital status, or educational attainment between those who received any kind of survivorship plan vs. no plan. Being female was associated with 40% lower odds of receiving any kind of survivorship plan (OR=0.60, 95%CI=0.42-0.87). Being on public insurance was also associated with lower odds of receiving a survivorship plan than being on private insurance (OR=0.59, 95%CI=0.43-0.81). Receipt of a survivorship plan was associated with 52% higher odds of reporting a higher level of overall current health (OR=1.52, 95%CI=1.14-2.02) compared to those who did not receive any plan. Receiving a survivorship plan was also associated with higher odds of reporting a higher level of ability to work (OR=1.58, 95%CI=1.18-2.11), more fulfilling work (OR=1.69, 95%CI=1.27-2.23), ability to enjoy life (OR=1.55, 95%CI=1.17-2.06), ability to sleep well (OR=1.35, 95%CI=1.03-1.79), and contentment with their current quality of life (OR=1.51, 95%CI=1.14-1.99). Conclusion: Receipt of any survivorship plan was associated with higher levels of self-reported current overall health and measures of functional well-being. Women, as well as people on public insurance, are less likely to receive a survivorship plan, highlighting disparities in survivorship care planning for these populations. Citation Format: Aly M. Cortella, Katarina Wang, Debby Oh, Niharika Dixit, Zinnia Loya, Kathie Lau, Michelle Wadhwa, Chris Duffy, Salma Shariff-Marco, Kristan Olazo, Vlad Honcharov, Marika Dy, Urmimala Sarkar, Scarlett Lin Gomez. Impact of survivorship care plans on self-reported health and functional well-being [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C034.

Abstract B148: Prevalence of Multimorbidity Among Patients with Newly Diagnosed Cancer at a Safety-Net Health System

Abstract Background: Multimorbidity (MM) presents challenges for cancer care and may require coordination between oncologists and primary or specialty care providers. Nevertheless, U.S.-based studies of MM among cancer patients have mostly been conducted in non-Hispanic White and insured populations, which limits understanding of strategic care planning and resource allocation among more diverse populations. Therefore, we aimed to assess the prevalence of MM among adults with newly diagnosed cancer at a large, racial/ethnically diverse safety-net health system. Methods: We used electronic health record and cancer registry data from JPS Health Network, an urban safety-net health system in North Texas. Our eligible population included patients ≥18 years of age diagnosed with first primary cancer in 2016 – 2020 (excluding in situ cases), whose diagnosis or first-course cancer treatment was received at JPS. Our outcomes of interest were MM (≥2 chronic conditions) and severe MM (≥3 chronic conditions) based on 30 chronic conditions defined by the Centers for Medicare & Medicaid Services with up to a 2-year lookback period before cancer diagnosis. We assessed overall and sub-group specific (age group, sex, and race/ethnicity) prevalence of MM and severe MM. We estimated prevalence differences (PD) and 95% confidence intervals between groups using pairwise comparisons with Bonferroni correction. Results: Our study population comprised 5,019 newly diagnosed adult cancer patients. The median age was 58 years and the majority were females (51%), racial/ethnic minorities (59%), uninsured (51%), and overweight or obese (69%). The most common cancer types were breast (13%), lung (12%), and colorectal (11%). Nearly half (45%) were diagnosed with advanced stage cancer. A high proportion of cancer patients had MM (79%) and severe MM (62%). The most common conditions were hypertension (55%), anemia (36%), hyperlipidemia (31%), diabetes (27%), and depressive mood disorders (22%). MM increased by age: 56% among patients aged 18 – 39 years, 78% among patients aged 40 – 64 years, and 91% among patients aged ≥65 years. A higher proportion of males had MM (PD: 6.0% [95% CI: 3.8%, 8.3%]) and severe MM (PD: 7.5% [95% CI: 4.9%, 10%]) compared with females. By race/ethnicity, Non-Hispanic Black patients had the highest prevalence of MM (PD: 8.1% [95% CI: 4.3%, 12%]) and severe MM (PD: 11% [95% CI: 6.7%, 16%]) compared with the lowest prevalences among Hispanic patients. Conclusions: We observed a high prevalence of MM and severe MM among adult cancer patients, particularly among patients aged ≥45 years and non-Hispanic Black patients. Our estimates were >15% higher than prior studies that included mostly non-Hispanic White adult cancer survivors with higher socioeconomic status. Our findings provide insight about the burden of MM among racially diverse cancer patients with low socioeconomic status, which may inform resource allocation and care coordination initiatives to manage MM. Citation Format: Anand B. Singh, Yan Lu, Aaron W Gehr, Kalyani Narra, Bhavna Tanna, Jolonda Bullock, Rachel J. Meadows. Prevalence of Multimorbidity Among Patients with Newly Diagnosed Cancer at a Safety-Net Health System [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B148.

Towards Health 4.0: Blockchain-Based Electronic Health Record for Care Coordination

Inter-organizational data sharing in healthcare is fraught with challenges, including diverse healthcare terminologies, incompatible data structures, and issues with data consistency and security. Establishing a unified patient record across a data-sharing network is problematic, and centralized data stores and authority providers are prime targets for cyberattacks. This study proposes a blockchain-based patient data-sharing strategy that relies on network consensus rather than a single, centralized source of trust. The consensus is based on evidence of both structural and semantic interoperability. The primary objective is to develop secure and controlled data-sharing mechanisms that enhance care coordination. The research utilized Kanban as the software development methodology to manage the project effectively. The study found that blockchain-based electronic health record (EHR) systems significantly enhance care coordination by enabling seamless data transfer and fostering trust and collaboration among healthcare providers. Key findings include improved data consistency, enhanced security, and increased interoperability across diverse healthcare systems. These results suggest that blockchain technology can play a crucial role in transforming healthcare delivery and improving patient outcomes in the context of Health 4.0. This work contributes to the ongoing discussion on leveraging blockchain technology to revolutionize healthcare systems, offering a robust framework for secure and efficient data sharing that can lead to better healthcare delivery and patient care outcomes.

Trends in Adverse Pregnancy Events Among Veterans: Racial Disparities and Care Coordination

Trends in Adverse Pregnancy Events Among Veterans: Racial Disparities and Care Coordination

Predicting extended hospital stay following revision total hip arthroplasty: a machine learning model analysis based on the ACS-NSQIP database.

Prolonged length of stay (LOS) following revision total hip arthroplasty (THA) can lead to increased healthcare costs, higher rates of readmission, and lower patient satisfaction. In this study, we investigated the predictive power of machine learning (ML) models for prolonged LOS after revision THA using patient data from a national-scale patient repository. We identified 11,737 revision THA cases from the American College of Surgeons National Surgical Quality Improvement Program database from 2013 to 2020. Prolonged LOS was defined as exceeding the 75th value of all LOSs in the study cohort. We developed four ML models: artificial neural network (ANN), random forest, histogram-based gradient boosting, and k-nearest neighbor, to predict prolonged LOS after revision THA. Each model's performance was assessed during training and testing sessions in terms of discrimination, calibration, and clinical utility. The ANN model was the most accurate with an AUC of 0.82, calibration slope of 0.90, calibration intercept of 0.02, and Brier score of 0.140 during testing, indicating the model's competency in distinguishing patients subject to prolonged LOS with minimal prediction error. All models showed clinical utility by producing net benefits in the decision curve analyses. The most significant predictors of prolonged LOS were preoperative blood tests (hematocrit, platelet count, and leukocyte count), preoperative transfusion, operation time, indications for revision THA (infection), and age. Our study demonstrated that the ML model accurately predicted prolonged LOS after revision THA. The results highlighted the importance of the indications for revision surgery in determining the risk of prolonged LOS. With the model's aid, clinicians can stratify individual patients based on key factors, improve care coordination and discharge planning for those at risk of prolonged LOS, and increase cost efficiency.

Hospital discharge processes: Insights from patients, caregivers, and staff in an Australian healthcare setting

Hospital discharge is a pivotal point in healthcare delivery, impacting patient outcomes and resource utilisation. Ineffective discharge processes contribute to unplanned hospital readmissions. This study explored hospital discharge process from the perspectives of patients, caregivers, and healthcare staff. Qualitative data were collected through semi-structured interviews with adult patients being discharged home from a medical ward, their caregivers, and healthcare staff at an Australian hospital. Thematic analysis followed established guidelines for qualitative research. A total of 65 interviews and 21 structured observations were completed. There were three themes: i) Communication, ii) System Pressure, and iii) Continuing Care. The theme ‘Communication’ highlighted challenges and inconsistencies in notifying patients, caregivers, and staff about discharge plans, leading to patient stress and frustration. Information overload during discharge hindered patient comprehension and satisfaction. Staff identified communication gaps between teams, resulting in uncertainty regarding discharge logistics. The theme ‘System Pressure’ referred to pressure to discharge patients quickly to free hospital capacity occasionally, even in the face of inadequate service provision on weekends and out-of-hours. The ‘Continuing Care’ theme drew attention to gaps in patient understanding of follow-up appointments, underscoring the need for clearer post-discharge instructions. The lack of structured systems for tracking referrals and post-discharge care coordination was also highlighted, potentially leading to fragmented care. The findings resonate with international literature and the current emphasis in Australia on improving communication during care transitions. Furthermore, the study highlights the tension between patient-centred care and health service pressure for bed availability, resulting in perceptions of premature discharges and unplanned readmissions. It underscores the need for strengthening community-based support and systems for tracking referrals to improve care continuity. These findings have implications for patient experience and safety and suggest the need for targeted interventions to optimise the discharge process.

The Digitally Enabled Care Framework: Leveraging Technology to Enhance the Physician–Patient Relationship

Clinical medicine is transitioning from in-person care to digitally enabled care (DEC), a framework in which consumer-behavior research and technology are used to fully support patients in their care journey. The Covid-19 pandemic saw a rapid transformation from in-person to virtual care models, including televisiting and email messaging, but the urgency of the pandemic response limited the full development of these care models. The result has been a workflow crisis for physicians, who are juggling packed schedules with increased electronic documentation and an abundance of messages from patients in their inboxes. In this paper, the authors describe the features necessary for the successful implementation of a fully realized DEC framework. This framework has the potential to improve the value of health services for patients through DEC and extends beyond virtual visits, envisioning a comprehensive set of patient-directed services that are enabled by technology. The DEC framework considers the previsit, visit, and postvisit periods as having discrete sets of objectives and opportunities for the development and integration of new digital tools and strategies to help patients achieve their goals. In the previsit period, there are opportunities to foster active preparation, to improve condition-specific health literacy, and to reduce stress. During visits, there are opportunities to build engagement, reach agreement on care plans, and coordinate care in partnership with the patient. In the postvisit period, there are opportunities to reinforce the decisions reached during a visit, build patient engagement and activation, and facilitate the logistics of care. The authors discuss how the payment model for clinical services must evolve to support this new care paradigm.

Patient navigation in reproductive healthcare.

This review summarizes evidence about barriers to abortion care pre-Dobbs and post-Dobbs, inequities in abortion access, and approaches to improving access to abortion care with use of patient navigators. The Dobbs decision and resulting state-level restrictions exacerbated economic, knowledge, and logistic barriers to abortion care. Abortion funds and emotional support are two main resources to help address these barriers; however, only with coordination can patients and clinics fully benefit from the resources. Patient navigation provides that coordination. Evidence shows it improves reproductive outcomes, is acceptable to patients and providers, and engages community health workers and community-based organizations. Increasing legal restrictions and barriers to abortion care have motivated advocates to identify effective interventions to facilitate patient-centered and culturally competent care. Navigators have improved postpartum care by increasing attendance, education and helping coordinate overall care. They have improved referrals and access to abortion care in statewide programs.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients Under Guardianships.

Palliative care clinicians often help facilitate coordination of care, complex serious illness, and end-of-life medical decision-making. However, the clinical and legal issues related to guardianship can complicate the decision-making process, care delivery, outcomes, and the role of the palliative care clinician. Adult patients who have a guardian have been found by a court to be unable to make some or all decisions for themselves. Providing care for patients under guardianship is where medicine overlaps with legal rights. It is crucial to be familiar with the patients' rights and the guardians' responsibilities to clarify medical decision-making processes and identify necessary authorities. This article uses an interprofessional approach to leverage the expertise of physicians, nurses, lawyers, and guardians and to guide palliative care clinicians to optimally support patients under guardianship.