Individualized Care Plans Research Articles

Selected aspects of nursing care for a patient after ischemic stroke in a care and treatment facility - a case study

Cerebrovascular diseases (including strokes) are currently the second leading cause of death in the world [1,2]. In Poland, statistical data are quite diverse, depending on their source. Stroke patients are often at risk of chronic disability. A significant number of them are doomed to lose their independence and self-care for the rest of their lives. The aim of the study is to present selected nursing problems and ways to solve them in a patient after ischemic stroke who requires round-the-clock care in the field of nursing and care services as part of inpatient long-term care. The subject of the study is the process of nursing a patient diagnosed with ischemic stroke who requires round-the-clock care in the field of nursing and care services as part of long-term care. The study uses a research method - a case study, supported by individual observation, measurements, interview and analysis of medical records. Two scales were used to assess the patient's condition: Barthel and Norton. Conclusions: The individual care plan takes into account the most important problems arising from the specificity of the disease entity, needs and individual situation of the patient. The patient's care problems after a stroke are presented and proposed an effective solution to ensure the best possible care. Nursing and care difficulties have been properly recognized, which has enabled appropriate nursing interventions. Due to systematic prophylactic measures, the patient did not suffer from complications. A detailed interview and careful observation made it possible to plan and implementation of interventions (not only nursing) to provide comprehensive care. The urgent procedure of admitting the patient to the care and treatment facility contributed to the improvement of the quality and availability of health care services, which translated into an improvement in the patient's general condition.

Designing an Implementable Clinical Prediction Model for Near-Term Mortality and Long-Term Survival in Patients on Maintenance Hemodialysis

The life expectancy of patients treated with maintenance hemodialysis (MHD) is heterogeneous. Knowledge of life-expectancy may focus care decisions on near-term versus long-term goals. The current tools are limited and focus on near-term mortality. Here, we develop and assess potential utility for predicting near-term mortality and long-term survival on MHD. Predictive modeling study. 42,351 patients contributing 997,381 patient months over 11 years, abstracted from the electronic health record (EHR) system of midsize, nonprofit dialysis providers. Demographics, laboratory results, vital signs, and service utilization data available within dialysis EHR. For each patient month, we ascertained death within the next 6 months (ie, near-term mortality) and survival over more than 5 years during receipt of MHD or after kidney transplantation (ie, long-term survival). We used least absolute shrinkage and selection operator logistic regression and gradient-boosting machines to predict each outcome. We compared these to time-to-event models spanning both time horizons. We explored the performance of decision rules at different cut points. All models achieved an area under the receiver operator characteristic curve of≥0.80 and optimal calibration metrics in the test set. The long-term survival models had significantly better performance than the near-term mortality models. The time-to-event models performed similarly to binary models. Applying different cut points spanning from the 1st to 90th percentile of the predictions, a positive predictive value (PPV) of 54% could be achieved for near-term mortality, but with poor sensitivity of 6%. A PPV of 71% could be achieved for long-term survival with a sensitivity of 67%. The retrospective models would need to be prospectively validated before they could be appropriately used as clinical decision aids. A model built with readily available clinical variables to support easy implementation can predict clinically important life expectancy thresholds and shows promise as a clinical decision support tool for patients on MHD. Predicting long-term survival has better decision rule performance than predicting near-term mortality. Clinical prediction models (CPMs) are not widely used for patients undergoing maintenance hemodialysis (MHD). Although a variety of CPMs have been reported in the literature, many of these were not well-designed to be easily implementable. We consider the performance of an implementable CPM for both near-term mortality and long-term survival for patients undergoing MHD. Both near-term and long-term models have similar predictive performance, but the long-term models have greater clinical utility. We further consider how the differential performance of predicting over different time horizons may be used to impact clinical decision making. Although predictive modeling is not regularly used for MHD patients, such tools may help promote individualized care planning and foster shared decision making.

Digitally Recording Comfort Observations in the Last Days of Life.

Background: 37.5% of deaths in our area occur in hospital. There are known high unmet needs of adult patients dying in hospital, this unmet need can be reduced by using an individualised care plan and specialist palliative care review. Intervention: In 2022 UHSussex developed an electronic comfort observation chart and individualised care plan, with a centralised dashboard allowing Palliative Care Teams (SPCT) to view trends, target interventions, and a rolling prospective audit. Results: 3000 patients have had their care supported with electronic comfort observations (e-comfort obs). Over 72% of all deaths in the Trust in the last 3months have been on e-comfort obs, with 2/3 of all deaths in the first 12months on e-comfort obs. The average length of time on e-comfort obs is 4days resulting in 70,000 sets of e-comfort obs recorded since launch. Seven percent of e-comfort obs record moderate or severe symptoms. We have identified benefits to people who are dying, those important to them, ward staff, SPCT and on a systems level. Conclusion: E-comfort obs can be successfully embedded in a large acute Trust. This development should improve quality of end of life care in our hospitals both for individuals and for future patients, through on-going targeted education and intervention. Further work is needed to develop the system further including integrating data from electronic prescribing.

Monthly engagement with EIP keyworkers was associated with a five-fold increase in the odds of engagement with psychosocial interventions.

Early intervention in psychosis (EIP) supports people who are experiencing their first episode of psychosis (FEP). A new Model of Care (MoC) for EIP services was launched in Ireland in 2019. Three EIP demonstration sites were chosen to test this MoC through a 'hub and spoke' approach. These services were a new way of organising care for people experiencing FEP, based upon a recovery model of care, and which sought to standardise care, improve access by clinically led multidisciplinary teams. This included newly created EIP keyworker roles whereby keyworkers assumed responsibilities regarding assessment, comprehensive individual care planning and coordination of care. A mixed methods design utilising the UK Medical Research Council's process evaluation framework. Purposive sampling techniques were utilised. Descriptive analyses and logistic regression were performed to examine how increased keyworker engagement influenced the use of other psychosocial interventions within the EIP demonstration sites. Thematic analyses was used for qualitative data. There was a strong positive relationship between keyworker contacts and psychosocial interventions offered. Specifically, the odds of achieving at least monthly engagement with cognitive behavioural therapy for psychosis (CBTp; (5.76 (2.43-13.64), p < 0.001), and behavioural family therapy (BFT; (5.52(1.63-18.69, p < 0.006)) increased by fivefold with each additional monthly keyworker contact. For individual placement support (IPS) each additional monthly keyworker contact was associated with a three-fold increase in the odds of achieving monthly attendance with IPS (3.73 (1.64-8.48), p < 0.002). Qualitative results found that the EIP keyworker role as viewed by both service users and staff as a valuable nodal point, with a particular emphasis on care coordination and effective communication. This study advances the understanding of keyworker effects through qualitative evidence of keyworkers functioning as a "linchpin" to the service, while the positive response association between keyworker contacts and engagement with other services provides quantitative support for keyworkers reducing the organisational or structural barriers to service access. Given the importance of these positions, health systems should ensure that EIP programmes identify qualified and experienced staff to fill these roles, as well as allocate the appropriate funding and protected time to support keyworker engagement and impact.

The Patient Journey in Facial Aesthetics: Findings from a European Consensus Meeting on Improving the Quality of Life for Patients Receiving Botulinum Toxin Injections.

Successful treatment of facial lines with botulinum toxin is largely dependent on patient satisfaction; thus, a structured treatment journey that uses patient-reported outcomes (PROs) is helpful for maximizing botulinum toxin results. To develop a patient-centric approach for botulinum toxin injections in facial aesthetics, a group of clinicians met to provide opinions on an optimal treatment journey that uses PROs to quantify treatment benefits on patient quality of life. A multidisciplinary panel of 9 clinicians with expertise in facial aesthetic procedures convened for an advisory board that was preceded by and followed up with a structured, multistep consensus discussion. Based on current literature, the panel's expertise, structured questions, and group discussion, panelists assessed, reconciled, and agreed upon on a patient journey for botulinum toxin treatment in facial aesthetics. Panelists agreed that an optimal patient journey includes screening, assessment, treatment, posttreatment, and follow-up visits. A compact, easy-to-complete, and digital PRO questionnaire should be provided before the visit. During screening, thorough assessments are integral for a successful patient journey because they provide an opportunity to understand treatment goals, address patient concerns, discuss risks and benefits, obtain medication lists/medical history, and take pretreatment photographs. Treatment strategies should include discussing and educating on the approach/choice of botulinum toxin and ensuring patients are comfortable. Posttreatment, clinicians should request intense muscle movements to enhance product uptake and be available to address patient concerns. Finally, during follow-up, PRO questionnaires can be provided to gauge patient satisfaction with treatment, and pretreatment photographs can be provided to allow patients to track their progression. Follow-ups should be scheduled with new patients or those reporting low satisfaction. Establishing a relationship, being aware of the patient's goals, and developing an individualized care plan allows for a structured, patient-centered treatment journey that promotes positive aesthetic outcomes.

Development and preliminary validation of a PROS scale for Chinese bladder cancer patients with abdominal stoma

Bladder cancer is a common malignant tumor, and patients who have undergone radical cystectomy and urinary diversion require a lifelong abdominal stoma. This greatly affects their physiological, psychological, and social well-being. However, there is currently a lack of a self-assessment outcome scale specifically designed for bladder cancer patients with abdominal stomas. Therefore, we developed and validated a self-assessment outcome scale (PROS-BCAS) for Chinese bladder cancer patients with abdominal stomas. The scale was initially developed through literature research and expert consultation, and it comprised four dimensions: physiological, psychological, social, and treatment, with a total of 66 items. After item analysis, 44 items were retained. We collected scale data from 382 patients to examine its validity and reliability. The results showed that the PROS-BCAS scale had good content validity (S-CVI/Ave = 0.992), construct validity (KMO > 0.6), and discriminant validity (correlation coefficient 0.404–0.870). The Cronbach's alpha coefficients (0.801–0.954), test–retest reliability (0.778–0.956), and split-half reliability (0.896–0.977) all demonstrated good internal consistency for each dimension and the overall scale. The study demonstrated that the PROS-BCAS scale is a reliable and valid tool for accurately assessing the health-related quality of life of bladder cancer patients with abdominal stomas, providing reference for developing individualized clinical care plans.

Integrated Care Models for Older Adults with Depression and Physical Comorbidity: A Scoping Review.

Multimorbidity is a growing challenge in the care for older people with mental illness. To address both physical and mental illnesses, integrated care management is required. The purpose of this scoping review is to identify core components of integrated care models for older adults with depression and physical comorbidity, and map reported outcomes and implementation strategies. PubMed, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers for studies concerning integrated care interventions for older adults with depression and physical comorbidity. We used the SELFIE framework to map core components of integrated care models. Clinical and organisational outcomes were mapped. Thirty-eight studies describing thirteen care models were included. In all care models, a multidisciplinary team was involved. The following core components were mainly described: continuity, person-centredness, tailored holistic assessment, pro-activeness, treatment interaction, individualized care planning, and coordination tailored to complexity of care needs. Twenty-seven different outcomes were evaluated, with more attention given to clinical than to organisational outcomes. The core components that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g., the cost of the intervention for the healthcare user, more transparently.

Human lifespan and sex-specific patterns of resilience to disease: a retrospective population-wide cohort study

BackgroundSlower paces of aging are related to lower risk of developing diseases and premature death. Therefore, the greatest challenge of modern societies is to ensure that the increase in lifespan is accompanied by an increase in health span. To better understand the differences in human lifespan, new insight concerning the relationship between lifespan and the age of onset of diseases, and the ability to avoid them is needed. We aimed to comprehensively study, at a population-wide level, the sex-specific disease patterns associated with human lifespan.MethodsObservational data from the SIDIAP database of a cohort of 482,058 individuals that died in Catalonia (Spain) at ages over 50 years old between the 1st of January 2006 and the 30th of June 2022 were included. The time to the onset of the first disease in multiple organ systems, the prevalence of escapers, the percentage of life free of disease, and their relationship with lifespan were evaluated considering sex-specific traits.ResultsIn the study cohort, 50.4% of the participants were women and the mean lifespan was 83 years. The results show novel relationships between the age of onset of disease, health span, and lifespan. The key findings include: Firstly, the onset of both single and multisystem diseases is progressively delayed as lifespan increases. Secondly, the prevalence of escapers is lower in lifespans around life expectancy. Thirdly, the number of disease-free systems decreases until individuals reach lifespans around 87–88 years old, at which point it starts to increase. Furthermore, long-lived women are less susceptible to multisystem diseases. The associations between health span and lifespan are system-dependent, and disease onset and the percentage of life spent free of disease at the time of death contribute to explaining lifespan variability. Lastly, the study highlights significant system-specific disparities between women and men.ConclusionsHealth interventions focused on delaying aging and age-related diseases should be the most effective in increasing not only lifespan but also health span. The findings of this research highlight the relevance of Electronic Health Records in studying the aging process and open up new possibilities in age-related disease prevention that should assist primary care professionals in devising individualized care and treatment plans.

Parents' and healthcare professionals' experiences with the content of an individual care plan for pediatric palliative care: a mixed-method study.

The Individual Care Plan (ICP) for pediatric palliative care translates the general guideline recommendations into a personalized plan for the child. Various documents exist in pediatrics globally, aimed at facilitating anticipatory care or coordinating end-of-life care. The ICP aims both, but user experiences have not been studied post-development. The overall aim is to enhance knowledge and understanding of the content of the ICP from the perspectives of parents and healthcare professionals (HCPs). We conducted a mixed-method study using a convergent parallel design consisting of questionnaires and individual and focus group interviews among parents and HCPs having user experience with the ICP. The questionnaire and interview data were analyzed separately. Quantitative data were descriptively analyzed using mean, ±SD, and median. Qualitative data were thematically analyzed. A narrative approach and joint display were used to describe the results. In total, 27 parents and 161 HCPs participated. Overall, the content of the ICP was seen as important and complete, but changes and additions were called for on language, structure, and content. The chapter on the needs and wishes of child and parents was considered most important. HCPs would like to see this chapter expanded to incorporate more advance care planning outcomes, and parents wished for this chapter to reflect better who their child is. HCPs mentioned missing a chapter for palliative sedation, mainly to guide other HCPs. The ICP was appraised as not user-friendly and might possibly improve by making the ICP available in a secure digital environment. To meet the needs of parents and HCPs considering importance and completeness of the content of the ICP and its user-friendliness, changes are necessary in the content of the ICP, and preferably the ICP should be made digitally available. Although various documents exist globally to facilitate anticipatory care or coordinating end-of-life care, it appears that the combination of describing the values and preferences of the child and parents, along with medical decisions and life-sustaining treatments, makes the ICP a unique and comprehensive care plan.

Shared decision-making in pediatric palliative care in the Netherlands

Shared decision-making (SDM) is a process in which health care professionals (HCPs) involve parents and children - when appropriate- to decide together on future treatment. These decisions are based on values that are important for the family, goals of care and preferences for future care and treatment. Elucidation of these values and preferences is preferably done early in the disease trajectory via so-called Advance Care Planning (ACP) conversations.In the Netherlands, ACP and SDM are being adopted by most health care professionals. This has happened only recently. Ten years ago, ACP and SDM were unknown concepts for the vast majority of Dutch HCPs. Today, interest in these conversational approaches is booming in both daily practice and in research.This rise has been reinforced by two recent major advancements in Dutch pediatric palliative care: the Individual Care Plan (ICP) and the Dutch Evidence-Based Guideline on Pediatric Palliative Care (DGPPC).Despite this positive evolution, a lot of work is still ahead. ACP and SDM demand a change in mindset from the traditional paternalistic approach by which the HCP ‘knows what is best for this child’ to a more humble and open approach in which (non-medical) factors that are important to the child and family and may influence the final treatment decision. Such changes in mindset don't happen overnight.In this article we describe the situation of pediatric palliative care in the Netherlands, with focus on the recent evolution of ACP and SDM.

Perceptions and experiences of living with and providing care for multimorbidity: A qualitative interview study.

Experiences of living with and seeking care for multimorbidity is a relatively under-researched field. By analysing experiences of people with multimorbidity, caregivers and care professionals, we can better understand the complex care needs of those with multimorbidity and identify improvements to care management. This paper reports findings from research that elicited the views of key stakeholders to inform future care practice and policy. To elicit care recipient and care provider views to understand the care needs of those living with and seeking care for multimorbidity. A qualitative interview study using purposive sampling of those living with and providing care in multimorbidity. Increased support to those with multimorbidity and caregivers to navigate care systems was advocated. Establishing trusting care relationships featured prominently in participants accounts. Fragmented care, inadequate coordination and poor communication between care providers, were identified as system-wide challenges. There was agreement that integrated care models were needed, which delivered personalised care, such as shared decision-making, choice in care options and accessing services, and individualised care plans. We found significant agreement among stakeholders on care need and management in multimorbidity. Understanding the experiences of those with multimorbidity, caregivers and care professionals, can inform future improvements in care management.

Living, Caring, Learning – Setting boundaries for the wellbeing of everyone in bleeding disorders care

Abstract Cathy, a haemophilia nurse specialist in the UK, reflects on a challenging patient with a rare inherited platelet disorder. The patient did not attend regular clinic appointments, and when presenting at clinic due to severe bleeding or feeling unwell was often aggressive and abusive towards staff. The care team were concerned that he was putting his health at risk and followed protocols for vulnerable adults to try and ensure he was accessing the care he needed. This involved bringing in expertise outside of the multidisciplinary team (MDT), including non-medical services. Steps were also taken to ensure staff safety and wellbeing through in-house psychological support and the agreement of strategies for dealing with difficult behaviour. Ultimately, it was necessary to find an alternative care pathway for the patient. While acknowledging her disappointment in this outcome, Cathy reflects on how the processes followed have reinforced the development of individualised care plans for all patients with complex needs, and the importance of access to specialist services beyond the MDT. She also highlights considerations around the safety and wellbeing of the care team, the role of discussion and ‘debriefing’, and the value of staff access to psychological support.

The effectiveness of virtual passport, an app-based intervention, for dementia care.

This study aimed to confirm the effectiveness of the virtual passport for dementia care. The virtual passport is an application (app) tool connecting healthcare professionals, dementia care sites, and people living with dementia (PLWD) and their family caregivers. This tool assists case managers in hospitals by providing individualized care plans and health education to PLWD and their caregivers. The dementia quality indicator achievement rates, care needs investigation and fulfillment, severity of behavioral and psychological symptoms of dementia (BPSD), and changes in caregiver burden and depression are measured at the initial interview and 6 and 12 months after the intervention. We enrolled 57 and 54 patients and their caregivers in the virtual passport and routine care groups, respectively. Compared to the control group, six quality indicators in the passport group showed significantly higher achievement at 6 months after using the virtual passport. Case managers addressed more care needs at 6 months (1.37 vs 0, p < 0.001) and 12 months (1.32 vs 0, p < 0.001). Improvement in severity of neuropsychiatric symptoms (neuropsychiatric inventory (NPI) irritability/lability difference: -0.58 vs 0.22, p = 0.044; NPI agitation/aggression difference =-0.78 vs 0.00, p = 0.042) were also observed. No obvious influence was found in caregiver burden and depression after using the virtual passport. The virtual passport is an effective information technology tool in improving the quality of dementia care, assisting case management in identifying more care needs, and reducing the severity of BPSD.

Rehabilitation needs of critically Ill patient’s at General Hospital -Kafr- ELsheikh Governorate

Background Assessing rehabilitation needs is an essential part of the care provided to critically ill patients and is used to identify areas of need to develop an individualized care plan for each patient. Aim To explore rehabilitation needs of critically ill patients during the acute stage of illness. Research question What are the different rehabilitation needs of critically ill patients at a general hospital- Kafr- El sheikh Governorate over a period of 6 months? Design descriptive exploratory research design was used. Sample Purposive sample consist of 100 conscious adult male and female patients, aged from 18- 60 years within period of 6 months was included. Setting Four intensive care units affiliated to General Hospital- Kafr Elsheikh Governorate. Tools Two tools were utilized (A) Rehabilitation needs of critically ill patient assessment tool, (B) Patient Categorization Assessment Tool (PCAT). Result More than half (52%) of patients were the age group 51-60 years old, more than half (54%) of them were females. More than half (55%) of patients stayed 4-6 days at the hospital, all of them were fully conscious. More than one quarters (37%) of the studied patients had a cardiac disease. There were statistical significant difference (χ 2=25.28, P=0.00) with deterioration in chest sound 42% of patient (n=100)had abnormal chest sound in first day elevated to 70% of them(n=10) at the last day of their hospitalization. there were significant statistical differences (p≤0.05) in daily living activity between the hospitalization days among critically ill patients. there were significant statistical differences (p≤0.05) in mobility between the hospitalization days among critically ill patients. the cognitive aspect needs were the same at the hospitalization days. There were statistical significant difference (χ 2=94.5, P=0.03) with deterioration in psychological stressors presence 71% of them had psychological stressors in first day increased to all of them at the last day of their hospitalization. Conclusion Critically ill patients have variable rehabilitation needs that change throughout acute stage of their illness. Recommendation Putting into practice the rehabilitation needs assessment for critically ill patients, which is regarded as the initial stage in creating rehabilitation programs. Replication of this study on a larger probability sample from different geographical locations in Egypt is recommended.

Integrated care models for older adults with depression and physical multimorbidity: a scoping review

Objective: Multimorbidity, the coexistence of multiple chronic conditions occurring in one person at the same time, where one is not a known complication of the other, is a growing challenge in the care for older people with mental illness. In order to address both physical and mental illnesses in older people, integrated care management is required. The purpose of this scoping review was to provide a comprehensive overview of integrated care models for older adults (60+) with depression and physical multimorbidity. We identified the core components of the examined integrated care models and mapped the reported outcomes and implementation strategies.&#x0D; Methods and analysis: We followed the methodology of Arksey and O’Malley’s. MEDLINE, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers from inception to May 2022. Studies composed in English or Dutch concerning integrated care interventions for older adults with major depression and physical multimorbidity were included. We used the micro-level SELFIE framework to map the core concepts of integrated care models. Outcomes were divided in person-centered and service themes.&#x0D; Results: After title and abstract and subsequent full-text screening, 38 studies were included describing 13 different care models. The majority (n=21) were randomized controlled trials, followed by observational studies (n=6), study protocols (n=5), qualitative studies (n=4), and feasibility studies (n=2). Studies were conducted in the North-America (n=28), Europe (n=6), Asia (n=3) and Australia (n=1). In all care models, a multidisciplinary team with a care coordinator was involved. Also treatment interaction, continuity of care, individualized care planning, tailored holistic assessment and self-management support were elements of all care models. Informal care giver involvement and shared decision making were less often described as core elements. Discrepancy was detected in the information systems and technology that different care models used. Only seven care models reported on financial aspects of the intervention, e.g. the reimbursement on participation or the provision of financial incentives.&#x0D; A total of 32 different outcomes were evaluated in the primary studies. Patient outcomes, e.g. functional status and depression symptoms, are well described by all care models. In contrast, little attention is paid to service outcomes such as emergency department visits or therapy attendance. Only two studies briefly described the implementation strategies used in the study.&#x0D; Conclusion: The core elements that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g. the cost of the intervention for the healthcare user, more transparently.&#x0D; Key words: Collaborative care, integrated care, psychosomatic medicine, geriatric psychiatry, care models

'Integrated antenatal care pathway':&amp;nbsp; a regional experience in Belgium (Flanders).

In a 2019 publication, the KCE (the Federal Knowledge Center, an independent research institution providing scientific advice on health care as requested by the Belgian government) proposes to monitor all pregnant women in Belgium through an “Integrated Antenatal Care pathway”. The baseline care needs to be expanded in case of high medical risk or psychosocial vulnerability.&#x0D; This advice addressed some new aspects: the extension of the classic clinical (medical) follow-up with Individual Counseling Consultation (ICC) sessions, sessions for Birth Preparation and Parenthood Education (BPPE). The pregnant woman chooses one health care provider as coordinator. The coordinator draws up an individual care plan and, if necessary, extends the standard counseling (general practitioner, gynecologist, midwife, physiotherapist and regional child guidance services) to a social worker, mental health care professionals and other specialists. The coordinator organizes Multidisciplinary Antenatal Consultation (MAO) if needed. Holistic view on patientcare and shared decision making are keypoints.&#x0D; In the East Flemish Brabant region, the execution of such an integrated care pathway was started following this advice and has been implemented since late 2021 under coordination of vzw De Bakermat, a center of expertise in Maternity care.&#x0D; The Bakermat previously also set up a pilot project called 'Kort in Kraamkliniek' (KIK), a postnatal care pathway, to reduce the length of postnatal hospital stays in the region, also upon request by the government. Similarly, seamless transition of the transmural care was crucial for the patient.&#x0D; The development of the integrated antenatal care pathway was a challenging, complex process of co-creation, involving a large number of partners in the region from the start. The region spanned across the entire ""Plexus"" hospital network covering 585,000 inhabitants, consisting of three regional and one supra-regional (university) hospital. Collaboration occurred across lines and trans-disciplinary. Existing organizations with local initiatives of integrated care and well-being were involved, in light of their shared vision and expertise. Therefore, the project did not only create a care pathway but also a strong interconnectedness between all partners involved!&#x0D; The project resulted in uniformity and greater clarity for caregiver and care recipient. One follow-up schedule was created and all patient info was centralized. At the beginning of each pregnancy, there is a screening for psychosocial vulnerability, through a scientifically validated tool (Born In Belgium, antenatal screening of vulnerability). Red flags for referral from primary to secondary care were listed to maximize the use of additional expertise.&#x0D; Electronic data sharing in a joint patient file is complex and will be further developed.&#x0D; The quality of the project is continuously monitored through a set of indicators coordinated by the Academic Center for General Practice of the KULeuven. Regular training sessions are organized by and for all project partners. Meanwhile, the regional coordination and adjustment of the project in the future is embedded in and provided by the center of expertise for maternity care.&#x0D; &#x0D;

Interviewing persons-supported in an evaluation of individual person-centred care plan development for community-care services: practical methodological considerations

Background: Person-centred care plans (PCPs) have been identified as a promising upstream intervention to address health inequities in the community-care population. Studies in primary care and long-term care have shown that a person-centred approach has the potential to reduce costly and preventable health service utilization, improve health outcomes, and improve person-supported and provider experiences. PHSS Medical and Complex Care in Community (hereafter PHSS) uses an individualized, person-centred, participatory model of care. PHSS creates PCPs through a series of discussions with the person-supported, and with input from family members, friends, staff, and community members. PCPs incorporate personal goals and support participation in activities that are meaningful to each person-supported. PCPs are annually reviewed and updated, and provide a road map to services and supports, with options tailored to individual needs and capacities. PHSS is a partner in the research project and has been involved in team meetings and all project decisions.&#x0D; Objectives: As part of a larger project evaluating PCPs, we conducted interviews with person-supported by PHSS which includes individuals with physical and developmental disabilities and complex medical conditions that may pose challenges to conducting traditional qualitative interviews. We describe experiences of conducting interviews with persons-supported, and outline practical steps in gathering data from this population. &#x0D; Methods: Using a descriptive qualitative design, we conducted semi-structured interviews with 13 persons-supported. PHSS staff acted as an intermediary to help recruit and consent participants and conduct interviews. Participants chose where interviews took place and whether or not staff was present. Interviews were conducted in person, took up to 30 minutes, were recorded, and transcribed verbatim for analysis. In each interview, we asked about: the process used to create PCPs; examples of how PCPs were tailored to the person-supported’s goals; perceived benefits and challenges of carrying out the PCP on persons-supported, their families, and on staff; and supports/barriers that facilitate/hinder the individualized participatory process. We also gathered relevant demographic data to describe participants. Using correspondence from the research ethics board, field notes (including notes from reflection journals), we outline practical steps in conducting interviews with vulnerable, often non-verbal participants.&#x0D; Results: We outline five overarching themes. Interviews with persons-supported were aided by: 1) negotiation with research ethics officers to allow recruitment and consenting by an intermediary (i.e. PHSS); 2) using copies of the PCP in the interview as a common point of reference; 3) the presence of staff who facilitated communication; 4) organizational support in recruiting participants and scheduling interviews; and 5) having a trained interviewer with experience working with persons-supported and knowledge of adapted processes for individual capacity and circumstances.&#x0D; Discussion: Conducting interviews with persons-supported is consistent with a “nothing about us without us” approach, but requires attention to ensure ethics requirements are satisfied and individual and practical considerations are incorporated into the research plan. An integrated knowledge translation approach, wherein researchers and providers work closely together to develop the research plan, is integral to facilitating participation of persons-supported in research. &#x0D; Conclusion: Creative and flexible approaches are needed to include persons-supported in research.

Integrated neighborhood teams in the chronic care project 'Leuven Cares' (Zorgzaam Leuven)

In the city of Leuven, ‘integrated neighborhood teams’, as the smallest building blocks of primary care networks, work together facilitated by ‘Leuven Cares’ and driven by population health management and clinical guidelines for the most common chronic diseases.&#x0D; Primary caregivers from different professional backgrounds and working in the same neighborhood cooperate to provide structured and coordinated care.&#x0D; The targeted patient groups are their shared most vulnerable population with complex needs.&#x0D; In 2018 Leuven Cares started founding neighborhood teams. Via a bottom up approach, primary care providers were stimulated to unite in neighborhood oriented networks. Frameworks and local actions for integrated care are elaborated by the neighborhood teams, who act on the level of the neighborhood, while individual teams at patient level do apply them. To start with, risk stratification based on queries in the electronic records helps the teams to indicate what population(s) to focus most on. Than agreements are made for disease management in patients with chronic diseases and care protocols for patients with increased care needs. Stratification helps to see parallelism and complementarity in existing interventions and actions. It also points out where gaps exist that are not covered with usual care. Proactive care, profound coordination of care for complex needs, care planning, empowerment of patients to control their own care process are items that are focused on in the local teams.&#x0D; More specific, those frameworks make sure that every patient has access to a care plan that is spoken trough and clear. Items of this care plan are medical follow up and coordination of care, medication coordination, healthy lifestyle, mental wellbeing, prevention etc…&#x0D; An individual care plan structures the fragmented care and supports communication between the individual caregivers. An even more important goal of this plan is the possibility for the individual patient to take control over his own care process. For people who are not capable to coordinate their own care, support can be given by the local network. One team member, with a specific focus takes on a coaching role in care coordination This team member can supervise the individual care process for those who cannot do it alone, or can even take over coordination if needed.&#x0D; General team processes are supported by the team coach, acting as an operational manager, who assists the team in focusing on the long-term vision, in the implementation of the framework, in gathering data of what happens in the local actions etc.&#x0D; &#x0D; This results in eight multidisciplinary primary care teams that are progressively engaged to provide integrated care to their shared, most vulnerable population. In these teams up to 60% of the primary caregivers are involved to support the needs of 4000 included patients (October 2022).&#x0D; Leuven has been our testing ground to develop these co-acting teams. The overall population of this city is already very divers. On the other hand, our model is not tested for smaller less divers cities, and more rural neighborhoods.&#x0D; Next steps are to find out whether our model is implacable for other environments. &#x0D; &#x0D; &#x0D; &#x0D; "

The ADEM project: implementation of ‘Good medicines use conversation’ for COPD-patients, embedded in multidisciplinary context.

COPD is a chronic, progressive disease, for which a multidisciplinary approach is crucial. Appropriate follow-up is crucial to improve the quality of life of COPD-patients and reduce associated healthcare costs. &#x0D; A ‘Good medicines use conversation’ COPD is a pharmaceutical care intervention, conducted by the community pharmacist, consisting of a tailored-made education of the COPD-patient on the disease and its treatment. Scientific research (PHARMACOP-trial) has shown that this intervention significantly improves therapy adherence and inhalation technique and reduces exacerbation rates and associated hospitalizations. &#x0D; The aim of the ADEM implementation project was to investigate the needs for a sustainable implementation of this intervention.&#x0D; The ADEM project was conducted in Flemish-Brabant (Belgium), with the integrated care region ‘Leuven Cares’ as a separate entity. &#x0D; All participating pharmacies (9 in region Flemish-Brabant and 8 in region ‘Leuven Cares’) received a support package consisting of: 1) a three-part online training about COPD and a visual COPD-atlas; 2) a population management-tool (a query to identify COPD-patients in the pharmacy, resulting in a list of COPD-patients with a ‘score’ per patient as an initial proxy for patient prioritization); and 3) local interdisciplinary meetings (LIM) to discuss and promote the intervention. Pharmacist of the region Caring Leuven additionally received individual care plans, providing an overview of the healthcare status of each COPD-patient, and an individual coaching session.&#x0D; Semi-structured interviews were conducted with 8 participating pharmacists (4 region Flemish-Brabant, 4 region ‘Leuven Cares’). Thematic analysis was performed.&#x0D; &#x0D; All elements of the support package were positively evaluated by the participating pharmacists. The population management tool seemed to support pharmacists in planning, interpreting and prioritizing care for COPD-patients. A follow-up study is needed to further investigate the tool and to what extent population management contributes to a more qualitative and effective pharmaceutical care. &#x0D; COVID-19, lack of personnel, lack of reimbursement and lack of time were identified as limiting factors for the implementation of the protocol-based COPD-intervention. Cooperation with the GP was indicated by the majority as minimal and insufficient. Therefore, LIM’s were evaluated as very important to inform GP’s about the pharmaceutical intervention and make local agreements about the multidisciplinary approach of COPD.&#x0D; The findings of this study are in line with the available evidence on the implementation of new services in pharmacies. Many pharmacists have the intrinsic motivation to offer extended pharmaceutical care, but current practices often do not allow this. Population management appeared to be a major factor that can be used to facilitate the implementation. By considering the needs of the local population, pharmacists can work in a more targeted way and prioritize the pharmaceutical services they offer. Given the group of chronically ill people in Belgium is expected to grow in the coming years due to the increasing ageing of the population, there will be an increasing demand for specialized interventions and advice from the pharmacist. It is therefore necessary to provide a sufficient framework for these services, bearing in mind the needs of the local population and the requirement for a pragmatic approach in the pharmacy. &#x0D;

Seamless Discharge Planning and Care Transition in a Tertiary Hospital

Background: As Singapore's health care landscape evolves to cope with the rapidly ageing society, growing burden of chronic disease and rising health care cost, there is an impetus need to review the hospital's discharge planning process, so as to facilitate timely discharge and safe care transition from hospital to community. In SGH, the role of the Patient Navigator (PN) is to facilitate care coordination, discharge planning and care transition from hospital to community. However, in order to meet the increasing demand and workload, there is a need to look into capability building and empowering all nurses on the essential skills to perform a comprehensive discharge planning. Nurses play a pivotal role in patient/ caregiver's care needs assessment. Having the insight and knowledge will help them facilitate safe, smooth and timely discharge. Patient's discharge planning process is a critical point in care continuity, but it is often complex and challenging. A successful discharge planning involves the proactive identification of care needs and development of individualized care plans.&#x0D; Methods: A pre-survey was done to understand the nurses' knowledge on discharge planning and care transition. 463 nurses responded to this survey. 56% of the nurses rated their knowledge on discharge planning as fair (4 to 7) from a Likert scale of 0 (no knowledge) to 10 (very knowledgeable) (9% rated as poor and 34% rated as good).&#x0D; Hence, this study aims to increase the nurses' knowledge on discharge planning and care coordination, from baseline 34% (good) to 54% (20% improvement) within 6 months.&#x0D; The team used various Quality Improvement tools and techniques, such as the 5-Why diagram to identify the root cause/s to the problem. The final root cause identified was “nurses lack the information and skills” to initiate a comprehensive discharge planning.&#x0D; Intervention: The team then conducted a survey to gather the nurses (stakeholder) feedback on what areas/topics they would like to learn. From the survey results, the team then brainstormed on the delivery mode. Due to the Covid-19 restrictions, the team opted for online e-learning via Wizlearn. The e-learning invitation was then emailed to all Registered Nurses (RNs) in SGH to complete and their feedback was gathered for continued improvement. &#x0D; Results: Post e-learning, the nurses would rate their knowledge gained using a Likert Scale of 0 to 10 (with 0 being no knowledge gained). As of 16 Dec 2021, 504 nurses completed the wizlearn and post-survey. From the pre-post results, there was an increase in ‘Good’ by 27%.&#x0D; P value was statistically significant for “Fair” and “Good” outcomes, p=0.011117. Intangible results include the good feedback received from the nurses in wizlearn stating their appreciation for the information (staff satisfaction). &#x0D; Sustainability plans: The e-learning module is incorporated into the Singhealth e-learning portal and is made available to all staff. New nurses are encouraged to register for this course. The next phase of the project’s sustainability plans includes measuring how the knowledge translates to actual clinical outcome, such as patient’s discharge care plan are documented timely as part of the nurse's assessment.