Innovative Care Delivery Research Articles

Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room.

Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.

From Data to Insights: Priorities for Maturing Your Health Analytics Strategy.

Health care is ready for a transformation in how we leverage data, technology, and analytics to improve care. This requires starting off with a focus on establishing trusted data and setting clear paths within organizational cultures to accommodate and empower innovation in health care delivery with better insights from data and analytics.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

Spousal Caregivers Are Caregiving Alone In The Last Years Of Life.

Caregiving in the last years of life is associated with increased depression and negative health outcomes for surviving spouses, many of whom are themselves in poor health. Yet it is unclear how often spouses are caregiving alone, how they differ from supported spouses, and whether lack of support affects postbereavement outcomes. We hypothesized that spouses who were solo caregivers-that is, the only caregivers (paid or unpaid) who provided assistance with a spouse's self-care or household activities-would experience more depression after bereavement than supported spouses would. Using information from the Health and Retirement Study, we found that 55percent of the spouses of community-dwelling married people with disability were solo caregivers. Solo caregiving was even common among people who cared for spouses with dementia and those with adult children living close by. Bereavement outcomes did not differ between solo and supported caregiving spouses. Caregiving spouses are often isolated and may benefit from greater support, particularly during the final years before bereavement. While some state and federal policy proposals aim to systematically recognize and assess caregivers, further innovations in care delivery and reimbursement are needed to adequately support seriously ill older adults and their caregivers. Ultimately, the focus of serious illness care must be expanded from the patient to the family unit.

Predicting outcomes within an innovative post-acute rehabilitation model for older adults

BackgroundUnderstanding the provision of health services to community-dwelling older adults is of great importance due to regulatory changes within post-acute care. The aim of this study was to illustrate pathways by which older adults, within an innovative post-acute care delivery model, move to either independence or re-admission back into higher levels of care to maximize the value of rehabilitation delivery.MethodsClinical data specific to an episode of care (n = 30,001) provided to Medicare beneficiaries treated via a rehabilitation house-calls model of care in their homes and senior living communites were separated into training and test sets. Classification trees were fit on the training set’s administrative and clinical variables. Descriptive statistics were calculated for the overall sample, patient characteristics, clinical characteristics, and clinical outcomes.ResultsSubjects were 83.3 years on average, 69.4% were female, and 62.2% were seen in their own homes while 37.8% were in senior living. The key variables predictive of progressing to independence were total number of visits, the presence of the Patient Specific Functional Scale (PSFS), PSFS score at discharge and change in PSFS. Prediction accuracy of the classification tree on the test set was 82.4%.ConclusionsOlder adults progress to a higher degree of independence, instead of higher levels of care, via several distinct pathways within a rehabilitation house-calls model of care. A mix of service utilization and outcome variables are key predictors of each pathway and may be used to maximize the value of service delivery. Further examination of the predictors of outcome using administrative datasets drawn from different sub-sets of older adults across the post-acute care continuum is warranted.

Health care innovations across practice and academia: A theoretical framework

BackgroundAn innovation scholarly interest group used the Jobs to Be Done Theory from the business literature to provide insight into the solution-focused progress that nurses are trying to make in challenging situations. PurposeThis article presents a theoretical framework for understanding the progress nurses are trying to make through health care innovations across both practice and academic environments. MethodThis was a qualitative descriptive study using directed content analysis. We used the Jobs to Be Done Theory to guide the development of the semistructured questionnaire and the interpretation of findings. FindingsA theoretical framework of nursing innovations was derived to summarize and visually display the pathways and linkages of challenges, innovations, and impact domains of nursing innovations. Situations and opportunities arise within the context of interconnectedness and can lead to health care innovations in care delivery, patient care interventions, role transitions, research and translational methods, communication and collaboration, technology and data, teaching methods, and processes to improve care. DiscussionThis theoretical framework offers insight into the dynamic interactions of academic-practice partnerships for innovation. Workplace situations are interconnected and can result in needed innovations designed to impact care delivery.

Relationship of emergency department use pre- and post-cancer diagnosis in safety-net adults.

6626 Background: Safety-net adults generate a high rate of emergency department (ED) visits within the 180 days after a new cancer diagnosis, many of which could be alternatively triaged to an urgent care clinic. It is unclear how much of this ED use is attributable to the cancer and treatment vs. ED-seeking behavior. To identify patients at risk of frequent ED use, we explored whether a patient’s pre-cancer ED visit use predicted ED use after diagnosis. Methods: We identifiably linked adults from the tumor registry in the Dallas County safety-net health system to a regional hospital database with claims-like data for all patients from 98% of non-federal hospitals in North Texas. We applied a mixed-effects multivariate logit model, using frequent ED use (≥4 visits) in the 6-12 months or 12-18 months before diagnosis to predict frequent ED use after diagnosis, adjusting for demographics, comorbidities; cancer type, stage, initial treatment modalities; and grouping visits at the patient level. Results: Of 8,610 adults diagnosed from 2012-2016, 76.2% had Medicaid or were uninsured, 30.9% had lung, breast, or colorectal cancer, and 25.9% had advanced-stage cancer at diagnosis. In the 180 days after diagnosis, 42.5% of patients had zero ED visits, 45.7% had 1-3 visits, and 11.8% were frequent ED users (≥4). In multivariate analysis, patients with frequent ED use in the 6-12 months before a cancer diagnosis had 6.7 higher odds (95% CI: 4.8, 9.3) of having frequent ED use after diagnosis, compared to patients who had zero ED visits prior to diagnosis. This compared to 1.3 higher odds (95% CI: 1.1, 1.5) of frequent ED use if the patient had advanced-stage cancer, and 2.1 higher odds (95% CI: 1.8, 2.4) if chemotherapy was part of initial treatment. Although most post-diagnosis frequent ED users generated zero visits (62.2%) or 1-3 visits (30.7%) in the 6-12 months prior to diagnosis, 38% of patients with frequent ED use pre-diagnosis continued frequent ED visits after diagnosis. Results were similar for ED use 12-18 months prior to diagnosis. Conclusions: Among safety-net adults, prior ED-seeking behavior strongly predicted ED use after a new cancer diagnosis. This may represent a high-risk group that might benefit from care delivery innovation.

Implementation of a brief screening tool to identify needs of cancer survivors.

e23075 Background: Innovation in health care delivery is needed to improve care for cancer survivors. We report a pragmatic study intended to evaluate our experience with adopting screening guidelines from the National Comprehensive Cancer Network (NCCN) to the routine care of breast cancer survivors in primary care and oncology follow up. Methods: We adapted the NCCN recommended screening questions into a plain language self-administered 1 page intake questionnaire. The tool was administered to a convenience sample of female breast cancer survivors in routine follow-up at an oncology or primary care clinic from September through December 2018. Domains included symptoms, lifestyle concerns, and financial issues. Frequency of concerns was assessed as “never”, “rarely”, “sometimes”, “very frequently” and “always”. We dichotomized results and evaluated feasibility of administration, prevalence of reported symptoms and qualitative assessment of burden as well as utility of the tool among participating clinicians. Results: 165 out of 169 patients offered the questionnaire participated (98%). Office staff provided the questionnaire at routine visits without notable impact on clinic flow. Most commonly endorsed concerns (sometimes or more) were: desire to improve fitness or nutrition (80%), worry about cancer recurrence (72%), and problems with sleep (57%). A majority also reported feeling nervous or worried (55%) and aches or pains in limbs or joints (55%). Several issues known to be underreported in clinic visits were endorsed including lack of satisfaction with sexual function (30% sometimes or more, 12% very often or always) and difficulty remembering things (47% sometimes or more, 13% very often or always). Among 7 participating clinicians, the tool was deemed useful and not burdensome. Several noted that it led to discussing issues that may not otherwise have been addressed. Suggestions included systematically identifying resources and strategies to address common issues and incorporating the tool into the electronic health record to increase utility. Conclusions: Screening for individual needs among survivors is feasible and efficient and may identify prevalent issues that otherwise can be missed in routine survivorship care.

Does the innovative 4R Cancer Care Delivery Model improve patient self-management in safety net and non-safety net centers?

6601 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R (Right Info / Care / Patient / Time) enables patient (pt) and care team to manage complex care continuum with an innovative multimodality 4R Care Project Plan. 4R includes a novel “project” feature – a graphical description of care interdependencies. 4R was previously piloted at 3 Chicago centers (Trosman ASCO ‘18). Methods: In this new study, we improved and tested 4R for impact on pSM at 4 safety net and 3 non safety net centers across the US. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18 (4R cohort). We surveyed the 4R cohort and a historical control cohort of pts who received care at same centers pre-4R, Jan - Dec ’17. Results: Survey response rates: 65%, 105/162 (4R cohort); 44%, 190/432 (control). 4R markedly improved 4 of 5 pSM metrics vs control (Table). Additional analyses showed that safety net pts had a significant increase in 4R vs control cohort in “seldom overwhelmed” (84%, 49/58 vs 64%, 67/104 respectively, p = .007), while non safety net pts had nonsignificant increase. Other metrics improved to a similar extent for safety net vs non safety net pts. Within the 4R cohort, 85% found 4R useful in organizing their care and 73% found 4R’s novel “project” feature useful in understanding care interdependencies. Safety net pts reported similar usefulness of 4R in organizing their care as non safety net pts (88%, 51/58 vs 81%, 38/47, NS) and similar usefulness of the “project’ feature in understanding care interdependencies as non safety net pts (74% vs. 72%, NS). Conclusions: 4R significantly improved patient self-management, but further efforts are needed to expand the benefit to as close to a 100% of pts as feasible. Safety net pts benefited from 4R at similar or higher rates than non safety net pts, indicating that 4R may reduce care disparities. An expansion of 4R across the US continues this work. [Table: see text]

Does the innovative 4R Care Delivery Model improve timing and sequencing of guideline recommended breast cancer care in safety net and non-safety net centers?

562 Background: Under the NCI ASCO Teams Project, we proposed a 4R Model which enables patient (pt) and care team to manage timing and sequencing of interdependent care with a novel multimodality 4R Care Project Plan (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) was previously piloted at 3 Chicago centers (Weldon ASCO ‘18). Methods: A new study tested impact of 4R on timing and sequencing of guideline recommended care at 4 safety net and 3 non safety net US centers. 4R Plans were provided to stage 0-III breast cancer pts Jan-Nov’18, 4R cohort. Clinical and pt reported data analyses compared 4R cohort (N=105) to a historical control cohort of pts who received care pre-4R, Jan - Dec ’17 (N=190). Results: We significantly improved 3 referral metrics and 4 referral completion metrics - receipt of care by pts who were referred (Table). After referrals, safety net pts had a significant increase in 4R vs control cohort in receiving genetic consult (72%, 21/29 vs. 42%, 18/43, p=.02) and dental visit (100%, 6/6 vs. 20%, 1/5, p=.02). They had lower increases in flu shot referrals (41%, 24/58, vs 36%, 37/104, NS) and dental referrals (10%, 6/58, vs 5%, 5/104, NS) than non safety net pts who had significant increases. Other metrics improved at a similar rate for safety net and non safety net pts. Conclusions: 4R markedly improved referral and receipt of interdependent guideline recommended breast cancer care. For most metrics safety net pts benefited from 4R at a similar or higher rate than non safety net pts, indicating that 4R may reduce care disparities. Low increases in referrals for safety net pts and in trial referral/enrollment for all pts must be addressed. An expansion of 4R across the US continues this work. [Table: see text]

Satisfaction survey from an innovative cancer care delivery model (Pendharkar model), creating access at scale: An outcome research.

e18002 Background: With the aim of empowering alternate oncology workforce, to resolve the issue of access, a unique cancer care delivery model (Pendharkar model) was launched in 4 states of India, spread across 125 districts with population coverage of around 210 million. The model has established nodal cancer units in every government run district hospital and created a point of contact for cancer- a physician-medical officer. Hundreds of patients have been seen by these hospital in last four years. The aim of this analysis was to survey the patient population attending and their satisfaction level. Methods: An elaborate survey was conducted amongst patients coming to district hospital. It sought information on satisfaction, choices. The written responses were sought, and data analysed. Results: Overall.186 patients were surveyed. Nearly 62 % of the patients had visited hospital multiple times before. Referral pattern showed that about 7 % of the patients were referred by other patients who were treated here, 62 % of the patients were referred by other medical professional, including nearby cancer hospitals and specialists. More than half of the patients (54.1) had taken cancer treatment outside district hospital, at some point of time. On question of comparison of service 65 % felt services to be better in government run setup, the time to start of therapy was much faster (74%).The time given by the doctor to the patient was satisfactory, highly appreciated by 97% of the respondents. Ease of accessibility of the staff was positively accepted by 100 %. All were happy with the level of communication by the doctors and nursing staff. Chemotherapy experience was better in district hospital set up for 58 % of the patients. More than 95% rated nursing services of high quality and all were happy with the behaviour of nurses. 80% were interested in continuing chemotherapy in same government hospital. Majority said that they are happy with their decision of taking chemotherapy in district hospital and would definitely refer other patients here. Conclusions: The survey strongly favours the model of empowerment of alternate oncology workforce in government run district hospital, and achieves high level of satisfaction amongst cancer patients.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

QIM19-136: Developing an Ideal CAR-T Cell Therapy Patient Experience Through Human-Centered Design and Innovation

Background: The patient/caregiver experience during CAR-T therapy is stressful, overwhelming, terrifying, and often a patient’s last treatment option. The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Innovation and Design team has worked with the CAR-T therapy clinical team to develop a patient experience that provides patients with a sense of caring, supportive environment, timely knowledge, and realistic expectations. Using a human-centered design approach, the Innovation and Design team worked with patients and caregivers to understand latent and unspoken needs in order to develop an ideal CAR-T therapy patient journey. Methods: With qualitative interviewing techniques, patient observation, and low fidelity experimentation, 21 patients/caregiver pairs were interviewed throughout their CAR-T therapy experience in 2018. Patients were interviewed at several touch points as well as encouraged to reach out to the Innovation and Design team at any point with reflections on their experiences. Patients were recruited as they began their evaluation phase for CAR-T therapy. The interviews were unscripted to allow for a breadth of discovery by not constraining the conversations to previously developed themes. As themes emerged from patient/caregiver interviews, artifacts and interventions were designed to alleviate pain points and improve the patient/caregiver experience. These artifacts and interventions were integrated into the clinical processes in real time and patient/caregivers were interviewed to understand the impact of these activities. Results: Several themes emerged from qualitative interviews with patients and caregivers. From the themes, interventions were developed. We were able to demonstrate a qualitative improvement in patient/caregiver experience through these interventions (Figure 1). Conclusions: Patients/caregivers undergoing CAR-T therapy have unique issues surrounding the logistics of care, emotional burden, and physical effects of treatment. We implemented processes to address these issues and observed a qualitative improvement via patient interviews/feedback. Ongoing work includes optimizing remote monitoring, digital platforms for patient education, and a quantitative study looking at patient reported outcomes (PROs) in such patients. To our knowledge, this is the first report for care delivery optimization in real-world practice for this new therapy.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

Role of the Hospital in the 21st Century Opioid Overdose Epidemic: The Addiction Medicine Consult Service.

The aim of the study was to explore and describe the structure and design elements of addiction medicine consult (AMC) services within selected US hospitals. As part of a larger mixed methods study, 10 qualitative semi-structured telephone interviews were completed with board-certified addiction medicine physicians affiliated with the Addiction Medicine Foundation's Addiction Medicine Fellowship Programs at 9 US hospitals. Interviews were transcribed, coded, and analyzed using a directed content analysis. Interviews completed with established AMC services in 9 hospitals probed AMC structure and design commonalities and differences across 4 domains: (1) availability and coverage, (2) team composition, (3) scope and responsibility, and (4) financing. Only 1 service provided weekend consults and most services did not provide coverage in the emergency department. Interprofessional teams were common with a variety of discipline combinations. AMC service scope and responsibility, generally, included 3 types of activities: (1) education and culture change, (2) the delivery of psychosocial and medical services, and (3) hospital guidance document development. Finally, most AMC services existed within a fragile financial environment with idiosyncratic arrangements. As opioid use disorder (OUD)-related hospitalizations increase stakeholders look to innovative care delivery mechanisms to improve care and outcomes for persons with OUD. The implementation of an AMC service may be an organizational intervention for achieving these aims. Understanding the shared and different approaches to AMC service structure and design is an important first step for delivery systems interested in implementing or expanding these services.

Interprofessional team-based approach to patients with chronic hepatitis C and personality disorder: Three case studies

Hepatitis C virus is a blood borne pathogen that infects 130 million people worldwide. After a prolonged period of slowly progressive liver injury, those infected are at risk of advancing to end stage liver disease, with its associated complications, and hepatocellular carcinoma. Rates of past and/or current substance use and behavioral comorbidities are higher among those infected with hepatitis C compared to the general population. A number of patient, provider and system barriers to care and treatment have led to low rates of treatment initiation in this population despite pharmacologic advances that have made hepatitis C a curable disease. Innovation in care delivery is considered a key strategy that will help reach more patients. We present three case studies of patients with chronic hepatitis C and multiple psychiatric comorbidities who were successfully engaged in care and treated for their chronic hepatitis C in our multidisciplinary primary care-based program.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

Innovating Cancer Care Delivery: the Example of the 4R Oncology Model for Colorectal Cancer Patients.

Care delivery innovation is necessary to address the growing complexity of cancer care across specialties and integrate new diagnostics, treatments, and services into care delivery. Informed by Cancer Care Delivery Research (CCDR), multilevel intervention research, and other disciplines, this article describes the 4-step cancer care delivery innovation cycle. The cycle guides collaborative efforts of cancer clinicians, researchers, patients, and other stakeholders to systematically define care delivery problems and formulate, test, and implement care innovations to effectively address problems. We illustrate the 4 steps of the innovation cycle with the example of developing the 4R Oncology Model for colorectal cancer (4R is Right Information and Right Care for the Right Patient at the Right Time). The 4R is a multilevel intervention informed by CCDR, the team science, and lessons learned from other models, such as survivorship care planning. We offer additional considerations for balancing the need to innovate with concerns about constrained resources and overextended workforce. We suggest to focus on care delivery models which are synergistic with other efforts and do not require extensive information systems support in earlier cycles of development.

Lucia and Beyond: Development of an Affordable Keratoprosthesis.

Severe corneal disease contributes significantly to the global burden of blindness. Corneal allograft surgery remains the most commonly used treatment, but does not succeed long term in every patient, and the odds of success fall with each repeated graft. The Boston keratoprosthesis type I has emerged as an alternative to repeat corneal allograft. However, cost limits its use in resource-poor settings, where most corneal blind individuals reside. All aspects of the Boston keratoprosthesis design process were examined to determine areas of potential modification and simplification, with dual goals to reduce cost and improve the cosmetic appearance of the device in situ. Minor modifications in component design simplified keratoprosthesis manufacturing. Proportional machinist time could be further reduced by adopting a single axial length for aphakic eyes, and a single back plate diameter. The cosmetic appearance was improved by changing the shape of the back plate holes from round to radial, with a petaloid appearance, and by anodization of back plate titanium to impute a more natural color. We have developed a modified Boston keratoprosthesis type I, which we call the "Lucia." The Lucia retains the 2 piece design and ease of assembly of the predicate device, but would allow for manufacturing at a reduced cost. Its appearance should prove more acceptable to implanted patients. Successful keratoprosthesis outcomes require daily medications for the life of the patient and rigorous, frequent, postoperative care. Effective implementation of the device in resource-poor settings will require further innovations in eye care delivery.