Innovative Care Delivery Research Articles

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

Commentary: COVID-19 and Obesity: Exploring Biologic Vulnerabilities, Structural Disparities, and Weight Stigma

commentary: COVID-19 and Obesity: Exploring Biologic Vulnerabilities, Structural Disparities, and Weight Stigma

Chronic disease management in the COVID-19 era.

In the coronavirus disease 2019 (COVID-19) era, clinical registries and innovative virtual care delivery tools should be leveraged to engage populations in effective chronic disease management.

Paying for Performance Improvement in Quality and Outcomes of Cardiovascular Care: Challenges and Prospects.

Over the past two decades, Medicare and other payers have been looking at ways to base payment for cardiovascular care on the quality and outcomes of care delivered. Public reporting of hospital performance on a series of quality measures began in 2004 with basic processes of care such as aspirin use and influenza vaccination, and it expanded in later years to include outcomes such as mortality and readmission rates. Following the passage of the Affordable Care Act in March 2010, Medicare and other payers moved forward with pay-for-performance programs, more commonly referred to as value-based purchasing (VBP) programs. These programs are largely based on an underlying fee-for-service payment infrastructure and give hospitals and clinicians bonuses or penalties based on their performance. Another new payment mechanism, called alternative payment models (APMs), aims to move towards episode-based or global payments to improve quality and efficiency. The two most relevant APMs for cardiovascular care include Accountable Care Organizations and bundled payments. Both VBP programs and APMs have challenges related to program efficacy, accuracy, and equity. In fact, despite over a decade of progress in measuring and incentivizing high-quality care delivery within cardiology, major limitations remain. Many of the programs have had little benefit in terms of clinical outcomes yet have led to marked administrative burden for participants. However, there are several encouraging prospects to aid the successful implementation of value-based high-quality cardiovascular care, such as more sophisticated data science to improve risk adjustment and flexible electronic health records to decrease administrative burden. Furthermore, payment models designed specifically for cardiovascular care could incentivize innovative care delivery models that could improve quality and outcomes for patients. This review provides an overview of current efforts, largely at the federal level, to pay for high-quality cardiovascular care and discusses the challenges and prospects related to doing so.

Gaps in the Organization of Emergency Room Care and Services for Women Experiencing Miscarriage: A Multiple Case Study of Four ERs in Quebec

Introduction: Miscarriage is common, occurring in nearly 20% of pregnancies. Most women experiencing symptoms such as bleeding or abdominal pain in early pregnancy consult emergency services, the front line of care. While research has shown the psychological and physical effects of miscarriage on women, less is known about how emergency services are organized to manage their care. Objective: To describe and analyze the organization of emergency services for women experiencing miscarriage. Methods: A multiple case study was conducted in four emergency rooms in Quebec, Canada, between 2014 and 2015. A reference framework setting out an organized system of action in care adapted to emergency services was used to analyze 198 medical records of women who experienced miscarriage and were treated in these emergency rooms. Results: From the analysis, observations were made regarding the accessibility, responsiveness, and productivity of emergency services, as well as deficiencies in care continuity. While medical treatments generally corresponded to standards, system responsiveness was poor, with long waits that may have added to women’s psychological distress. Gaps were observed in care continuity, effectiveness, and quality, including missing notes in charts, high readmission rates, and lack of referrals to relevant psychosocial and other support services. Discussion and conclusion: Recommendations include developing clinical guidelines, care trajectories, and checklists for nurses’ clinical assessments. As well, early pregnancy assessment clinics are an innovative care delivery model that has proven effective in reducing admissions, shortening hospitalizations, and providing comprehensive support services.

Integrated Measures of Health Literacy, Language Access, and Cultural Competency Would Improve Health Care Quality and Value.

Improving health care quality and value requires increased attention to patient and family-centeredness as well as care equity. Although health literacy, language access, and cultural competency have been perceived as separate constructs. each represents a dimension of patient and family-centeredness and care equity. Developing and using integrated measures of health literacy, language access, and cultural competency could provide a viable strategy to improve patient and family-centeredness and equity in health care. While there are challenges to the development and use of integrated measures, some responsive strategies include: using more patient, family and caregiver-reported information; utilizing patient demographic data from electronic health records; and incorporating the latter elements within measures of patient experience. Integrated quality measures also create opportunities for collaborative and interdisciplinary research, and for health care delivery innovation.

Remaking Health Care Delivery

Summary The fourth issue of NEJM Catalyst Innovations in Care Delivery shows how health care leaders and clinicians are rising to meet the challenges of the day.

Slowing Medicare Spending by Optimizing Late-Life Needs

Summary In this article, we highlight three care delivery innovations that could be implemented by Medicare Advantage plans as a late-life care model to better meet the needs of older adults and reduce per capita spending. The elements of this model include (1) community (engaging well-functioning seniors as in-home health workers), (2) capability (improving seniors’ functional capabilities and home environments), and (3) communication (using telemediated behavioral health specialists to help patients articulate their health care goals). We propose that these solutions fall within the scope of the recently expanded Medicare Advantage supplemental benefits, and we estimate that the new care model would offer substantial annual savings for the Medicare Advantage population and individual plans.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

2234-PUB: The Impact of a Community Paramedicine Program on Diabetes Outcomes and Health Care Utilization

Background: As of 2017, South Carolina ranked 5th highest in the U.S. for percentage of adults with diabetes, which has negative health and cost implications. The innovative community paramedicine program (CPP) aims to improve management of patients with chronic diseases and high utilization of the Emergency Department (ED), by providing in-home disease management, education, and care/community resource connection by paramedics. The impact of CPs has not been extensively studied in diabetes. Objective: To assess impact of CPP participation on health outcomes and healthcare utilization for patients with diabetes. Methods: Retrospective analysis of CPP participants diagnosed pre-enrollment with diabetes. Demographics and variables reported as percentages, and differences between A1c values pre/post CPP tested using Student’s t-test. Healthcare cost and utilization data was extracted from EMR using SAP BusinessObjects and analyzed with Qlik. Results: From 2015-2019, 64 people with diabetes enrolled. Participants were primarily insured by Medicare (48.4%) and/or Medicaid (35.9%) or uninsured (32.8%). Comparing pre and post-enrollment average values, participants in CPP for >180 days (d) demonstrated a clinically significant improvement in A1c, although this did not reach statistical significance (181-270d: 10.04+/-1.33 to 8.51+/-1.35, p=0.159; 271-365d: 10.83+/-2.95 to 7.65+/-2.39,p=0.098; 365+d: 9.31+/-2.58 to 7.76 +/-1.45, p=0.23). Participants also showed increased rates of screening for microvascular complications. To date, the utilization analysis for the 52 CPP graduates who participated >14d suggests decrease in average cost of care and ED visits per person comparing 6 months prior and up to 6 months post CPP enrollment ($16,514 vs. $4,717; 2.77 vs. 0.73 ED visits). Conclusions: The CPP demonstrated improvement in disease control and reduced costs/ED visits for patients with diabetes. This is a promising care delivery innovation that merits further research. Disclosure M. Eicken: None. D. Lee: None. J.A. Ewing: None. J.N. Butler: None. M.E. Lutz: None. J.Z. Snow: None. C. Hipp: None. D.T. Thomas: None. C.P. Head: None. R.S. Hudson-Dobbs: None. V.E. Green: None. S.L. Weber: None.

COVID-19: long-term effects on the community response to cardiac arrest?

COVID-19: long-term effects on the community response to cardiac arrest?

Essential Case Management Practices Amidst the Novel Coronavirus Disease 2019 (COVID-19) Crisis: Part 2: End-of-Life Care, Workers' Compensation Case Management, Legal and Ethical Obligations, Remote Practice, and Resilience.

Objectives:This is the second of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as a global pandemic. Part II continues to describe reenvisioned roles and responsibilities of case managers and their leaders to meet the needs of patients/support systems during the crisis. It focuses on the increased need for end-of-life care, impact on workers' compensation case management practice, and the self-care needs of the professional case manager.Primary Practice Settings:Applicable to the various case management practice settings across the continuum of health and human services, with special focus on acute care.Findings/ConclusionsThe COVID-19 global pandemic has resulted in a crisis case managers and other health care professionals never faced something like it before. At the same time, it has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and human services to those who need them regardless of location. It has also resulted in the development of necessary and impactful partnerships within and across different health care organizations and diverse professional disciplines. Most importantly, this pandemic has required special attention to the increased need of patients for timely palliative and end-of-life care. In addition, it has prompted a focus on the safety, health, and well-being of case managers and other health care professionals, resulting in expanded workers' compensation case management practice coupled with the need for self-care and resilience.Implications for Case Management Practice:Professional case managers are integral members of interprofessional health care teams. Their roles and responsibilities are even more necessary during the uncertainty of a global pandemic such as COVID-19. So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care. Self-care and resilience of health care professionals and case managers, especially due to the complex dynamics of the COVID-19 pandemic, have advanced a desirable and necessary view of remote/virtual practice and as a strategy for enhancing the person's health and well-being. This pandemic has forced the development of impactful partnerships and collaborations among the diverse contexts of health care organizations and support service providers. These contexts of care delivery have also emphasized the necessary legal and ethical practice of case managers and the other involved parties. Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.

Telehealth Triage and Oncology Nursing Practice.

To provide an overview of telehealth and explore the roles that the registered nurse can play in the context of a telehealth setting. Review of articles via PubMed and CIANHL from 2009 to present and relevant telehealth websites. The advancement of technology, the need to improve access to health care, and the changing expectations of consumers to have access to information has helped to expand telehealth as an innovative care delivery model and has created new opportunities for telehealth nursing care. The use of telehealth in the oncology setting continues to evolve and provide nurses the opportunity for new and potentially expanded roles. Registered oncology nurses need to understand the various methods used to deliver care via a telehealth environment and how establish and work in this new environment to assure that they are practicing safely and within the full scope of their license.

Using Machine Learning to Predict Early Onset Acute Organ Failure in Critically Ill Intensive Care Unit Patients With Sickle Cell Disease: Retrospective Study.

BackgroundSickle cell disease (SCD) is a genetic disorder of the red blood cells, resulting in multiple acute and chronic complications, including pain episodes, stroke, and kidney disease. Patients with SCD develop chronic organ dysfunction, which may progress to organ failure during disease exacerbations. Early detection of acute physiological deterioration leading to organ failure is not always attainable. Machine learning techniques that allow for prediction of organ failure may enable early identification and treatment and potentially reduce mortality.ObjectiveThe aim of this study was to test the hypothesis that machine learning physiomarkers can predict the development of organ dysfunction in a sample of adult patients with SCD admitted to intensive care units (ICUs).MethodsWe applied diverse machine learning methods, statistical methods, and data visualization techniques to develop classification models to distinguish SCD from controls.ResultsWe studied 63 sequential SCD patients admitted to ICUs with 163 patient encounters (mean age 30.7 years, SD 9.8 years). A subset of these patient encounters, 22.7% (37/163), met the sequential organ failure assessment criteria. The other 126 SCD patient encounters served as controls. A set of signal processing features (such as fast Fourier transform, energy, and continuous wavelet transform) derived from heart rate, blood pressure, and respiratory rate was identified to distinguish patients with SCD who developed acute physiological deterioration leading to organ failure from patients with SCD who did not meet the criteria. A multilayer perceptron model accurately predicted organ failure up to 6 hours before onset, with an average sensitivity and specificity of 96% and 98%, respectively.ConclusionsThis retrospective study demonstrated the viability of using machine learning to predict acute organ failure among hospitalized adults with SCD. The discovery of salient physiomarkers through machine learning techniques has the potential to further accelerate the development and implementation of innovative care delivery protocols and strategies for medically vulnerable patients.

Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya

BackgroundNon-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs.MethodsWe created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members.ResultsUsing human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context.ConclusionsContextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings.Trial registrationClinicaltrials.gov, NCT02501746, registration date: July 17, 2015.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

From Theory to Practice: Implementation of Strategies to Reduce Acute Care Visits in Patients With Cancer

Patients with cancer frequently seek acute care as a result of complications of their disease and adverse effects of treatment. This acute care comes at high cost to the health care system and often results in suboptimal outcomes for patients and their caregivers. The Department of Health and Human Services has identified this as a gap in our care of patients with cancer and has called for quality-improvement efforts to reduce this acute care. We highlight the efforts of three centers-a community practice, an academic practice, and a cancer center-to reduce acute care for their patients. We describe the foundational principles, the practice innovation and implementation strategy, the initial results, and the lessons learned from these interventions. Each of the described interventions sought to integrate evidence-based best practices for reducing unplanned acute care. The first, a telephone triage system, led to 82% of calls being managed at home and only 2% being directed to an emergency department (ED) or hospital. The second, a 24-hour continuity clinic, led to a 26% reduction in ED utilization for patients with cancer. The third, a digital symptom monitoring and management program for high-risk patients on active treatment, led to a 17% reduction in ED presentations. There is a need for innovative care delivery models to improve the management of symptoms for patients with cancer. Future research is needed to determine the elements of these models with the greatest impact and how successful models can be scaled to other institutions.

What's happening in Innovations in Care Delivery

What's happening in Innovations in Care Delivery

Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home

Study objectiveThe perioperative surgical home (PSH) is a recent innovation in perioperative care delivery that coordinates the pre-, intra-, and post-operative elements of surgical care under one organizational umbrella. Although significant research supports the efficacy of individual elements of the PSH in improving outcomes, there is not a published systematic review of the efficacy of entire PSH programs in improving patient outcomes. This article summarizes descriptions of PSH programs available in the literature and examines outcomes of original studies of PSH implementation. DesignWe conducted a systematic literature review to identify relevant articles on PSH implementation and synthesize our findings. SettingThe studies included in our review took place at multiple academic and community hospitals in the United States. PatientsPatients involved in the PSH studies included surgical patients of various ages and ASA classifications in various surgical specialties. InterventionsAll studies included in our review involved the implementation of a PSH program. MeasurementsOutcomes examined include length of stay, postoperative recovery, readmission rates, and patient discharge destination, among others. Main resultsWe identified 11 studies of PSH implementation that met our inclusion and exclusion criteria. Most PSH programs described in these studies included an emphasis on preoperative education, standardization of care protocols in all phases of surgery, use of opioid-sparing multimodal analgesia, and collaborative staffing models. PSH program implementation was often associated with decreased length of stay, decreased utilization of postoperative opioids, decreased utilization of the ICU, and increased probability of discharge to home. PSH implementation was not meaningfully associated with reductions in readmission rates. Findings for cost reductions following PSH implementation were mixed. ConclusionsEarly evidence indicates that through elements that emphasize care coordination, standardization, and patient-centeredness, PSH programs can improve patient postoperative recovery outcomes and decrease hospital utilization.

Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model.

IntroductionEarly access to cancer palliative care is recommended. Descriptions of structures and processes of outpatient palliative care clinics operated within smaller hospitals are scarce. This paper presents the development and operation of a fully integrated cancer and palliative care outpatient clinic at a local hospital in a rural region of Mid-Norway offering palliative care concurrent with cancer treatment. A standardized care pathway was applied.MethodsPalliative care is in Norway part of the public healthcare system. Official recommendations recent years point out action points to improve delivery of palliative care. An integrated cancer and palliative care outpatient clinic at a local hospital and an innovative care delivery model was developed and operated in this setting. Patients were recruited for a descriptive study of the patient population. Clinical data were collected by clinical staff and 13 symptom intensities were reported by the patients.ResultsCancer and palliative care were provided by one team of healthcare professionals trained in both fields. There was a close collaboration with the other departments at the hospital, with its affiliated tertiary hospital, and with community health and care services to provide timely referral, enhanced continuity, and improved coordination of care. Eighty-eight patients were included. Mean age was 65.6 years, the most common cancer diagnoses were digestive organs (22.7%), male genital organs (20.5%) or breast (25.0%), 75.0% had metastatic or locally advanced cancer, 59.1% were treated with non-curative intention and 93.1% had Karnofsky Performance Status ≥ 80%. Median scores of individual symptoms ranged from 0 to 3 (numerical rating scale, 0–10) and 61.0% reported at least one clinically significant symptom rating (≥ 4).ConclusionThis delivery model of integrated outpatient cancer and palliative care is particularly relevant in rural regions allowing cancer patients access to palliative care earlier in the disease trajectory and closer to home