Integrated Care Delivery Research Articles

Integrated care and interprofessional education.

Integrated care and interprofessional education.

Engagement of patient and family advisors in health system redesign in Canada.

Globally, there has been a shift towards integrated care delivery and patient-centredness in the design of health services. Such a transformation is underway in Ontario, which is progressively using an interprofessional team-based approach known as Ontario Health Teams (OHTs) to deliver care. During their initial development, OHTs were required to integrate patient and families' preferences, experiences and opinions in the form of consultation and partnership with patient and family advisors (PFAs). This study aimed to understand how PFAs were involved in the early stages of planning for health system change and the perceived benefits of including PFAs in system reform. This study used a qualitative descriptive design. Semi-structured interviews were conducted with 126 participants at 12 OHTs, including PFA (n = 16) and non-PFA (n = 110) members (e.g. clinicians). Data were analysed thematically. We identified four themes; mechanisms of engagement, motivations to engage, challenges to PFA engagement and PFAs' impact and added value. Overall, participants viewed PFA engagement positively and PFAs felt valued and empowered. There remain logistical challenges around PFA compensation, and the amount of time and training expected of PFAs. However, all participants believed that developing an understanding of the patient, caregiver and family experience will strengthen the engagement of PFAs in OHT planning, decisions and policies. Diverse approaches to and stages of PFA engagement fostered meaningful and highly valued contributions to OHT development. These were considered critical to successfully achieving the mandate of patient-centred care reform.

Co-Designing an Integrated Care Network with People Living with Parkinson's Disease: A Heterogeneous Social Network of People, Resources and Technologies.

As part of the iCARE-PD project, a multinational and multidisciplinary research endeavour to address complex care in Parkinson’s disease, a Canadian case study focused on gaining a better understanding of people living with Parkinson’s disease (PwP) experiences with health and medical services, particularly their vision for a sustainable, tailored and integrated care delivery network. The multifaceted nature of the condition means that PwP must continuously adapt and adjust to every aspect of their lives, and progressively rely on support from care partners (CP) and various health care professionals (HCP). To envision the integrated care delivery network from the perspective of PwP, the study consisted of designing scenarios for an integrated care delivery network with patients, their CP and their HCP, as well as identifying key requirements for designing an integrated care delivery network. The results demonstrate that numerous networks interact, representing specific inscriptions, actors and mediators who meet at specific crossing points. This resulted in the creation of a roadmap and toolkit that takes into consideration the unique challenges faced by PwP, and the necessity for an integrated care delivery network that can be personalized and malleable so as to adapt to evolving and changing needs over time.

The acceptability of integrated healthcare services for HIV and non-communicable diseases: experiences from patients and healthcare workers in Tanzania

BackgroundIn sub-Saharan Africa, the prevalence of non-communicable diseases (NCDs) has risen sharply amidst a high burden of communicable diseases. An integrated approach to HIV and NCD care offers the potential of strengthening disease control programmes. We used qualitative methods to explore patients’ and care-providers’ experiences and perspectives on the acceptability of integrated care for HIV-infection, diabetes mellitus (DM), and hypertension (HT) in Tanzania.MethodsA qualitative study was conducted in selected health facilities in Dar es Salaam and Coastal regions, which had started to provide integrated care and management for HIV, DM, and HT using a single research clinic for patients with one or more of these conditions. In-depth interviews were held with patients and healthcare providers at three time points: At enrolment (prior to the patient receiving integrated care, at the mid-line and at the study end). A minimum of 16 patients and 12 healthcare providers were sampled for each time point. Observation was also carried out in the respective clinics during pre- and mid-line phases. The Theoretical Framework of Acceptability (TFA) underpinned the structure and interpretation of the combined qualitative and observational data sets.ResultsPatients and healthcare providers revealed a positive attitude towards the integrated care delivery model at the mid-line and at study end-time points. High acceptability was related to increased exposure to service integration in terms of satisfaction with the clinic setup, seating arrangements and the provision of medical care services. Satisfaction also centred on the patients’ freedom to move from one service point to another, and to discuss the services and their own health status amongst themselves. Adherence to medication and scheduling of clinic appointments appeared central to the patient-provider relationship as an aspect in the provision of quality services. Multi-condition health education, patient time and cost-saving, and detection of undiagnosed disease conditions emerged as benefits. On the other hand, a few challenges included long waiting times and limited privacy in lower and periphery health facilities due to infrastructural limitations.ConclusionThe study reveals a continued high level of acceptability of the integrated care model among study participants in Tanzania. This calls for evaluation in a larger and a comparative study. Nevertheless, much more concerted efforts are necessary to address structural challenges and maximise privacy and confidentiality.

Formulary management guiding principles for automated systems.

Structural and financial changes in US healthcare are the driving forces reshaping care delivery and the technologies that clinicians use in their practice. Structural-level changes in healthcare organizations bringing facilities varying in size, systems, and complexity under the new integrated care delivery networks create unprecedented challenges. This paper develops guiding principles for formulary management in automated systems that facilitate medication management and alignment of medication information technology (IT) solutions in healthcare organizations ranging in size from a single facility to very large enterprise/multifacility networks. This paper describes formulary management best practices for healthcare organizations as they follow crucial medication management processes: formulary item builds, urgent and nonformulary medication requests, and formulary item build testing and maintenance. As medication management practices are embedded in automated technologies that are similar yet nuanced, we pay special attention to practices and change control processes that maximize coordination among systems while preserving medication data integrity and reducing medication errors. For increasingly complex healthcare systems with multiple medication management system demands, formulary drug database builds and maintenance are challenging and time-consuming. Formulary item build, testing, and maintenance processes involve multifunctional teams collaborating to ensure the integrity of data, prevent unexpected system incompatibilities, and improve patient safety by reducing medication errors. Ideally, formulary item build, testing, and maintenance processes produce consistent final drug records in IT systems meeting user needs.

Innovations in Care Delivery for Patients With Serious Mental Illness Among Accountable Care Organizations.

This study examined whether and how organizations participating in accountable care organization (ACO) contracts integrate primary care and treatment for patients with serious mental illness. This study used responses to the 2017–2018 National Survey of ACOs (55% response rate) to measure ACO-reported use of three integrated care strategies: care manager to address physical health treatment coordination or nonmedical needs (e.g., job support and housing), patient registries to track physical health conditions, and primary care clinician colocated in a specialty mental health setting. Logistic regression was used to determine associations between ACO characteristics and strategy use. Of 399 respondents who answered questions on integration, 303 (76%) reported using at least one integrated care strategy in at least one location. Use of care managers (defined by the respondent) was most common (N=281, 70%), followed by use of a patient registry (N=146, 37%) and colocation of a primary care clinician in a specialty mental health setting (N=118, 30%). Respondents reporting that their largest Medicaid contract or largest commercial contract included quality measures specific to serious mental illness (e.g., antipsychotic adherence) were more likely to use each integrated care delivery strategy. Self-reported use of three collaborative care strategies (care management, patient registry, or mental health consulting clinician) for treatment of depression or anxiety was associated with use of integrated primary care and treatment for serious mental illness. In a national survey of ACOs, few respondents reported using either patient registries or primary care colocation to integrate primary care and treatment for serious mental illness.

Abstract P2-09-05: Germline BRCA1/2 mutation testing in human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC): A real-world study in the Syapse Learning Health Network (LHN)

Abstract Background: Germline (g)BRCA1/2 mutations represent approximately 5% of metastatic breast cancer. Poly ADP-ribose polymerase inhibitors (PARPi) have shown improved clinical outcomes, a manageable toxicity profile, and favorable patient (pt)-reported outcomes versus chemotherapy in pts with gBRCA1/2 mutated HER2- locally advanced or metastatic breast cancer. With the advent of PARPi, clinical guidelines have broadened eligibility criteria for gBRCA1/2 testing. However, limited information is available on the impact of the COVID-19 pandemic on gBRCA1/2 testing rates. We assessed trends and factors associated with gBRCA1/2 testing in pts with HER2- ABC before and during the COVID-19 pandemic. Methods: This retrospective study included pts from the Syapse LHN, a longitudinal database of pts with cancer cared for in community-based, integrated care delivery networks in 25 states in the United States. Pts were eligible for gBRCA1/2 testing from initial ABC diagnosis until death or date of last contact with the participating health system. Information on gBRCA1/2 testing was obtained from scaled sources and further curated by Certified Tumor Registrars. Logistic regression evaluated the associations between age at diagnosis, family history of relevant cancer, race/ethnicity, median household income, health system, and diagnosis year with gBRCA1/2 testing among HER2- ABCs; models included hormone receptor status. Results: The study population included 1769 pts with HER2- ABC, including 577 pts with triple negative ABC initially diagnosed from 2010: 96% were women, 69% were non-Hispanic White, and 94% had an estimated median household income >$30,000 USD; median age at initial diagnosis was 61 years. The percentage of pts ever gBRCA1/2-tested among those eligible increased over time: 26%, 28%, and 31% by end of 2018, 2019, and 2020, respectively. Similarly, the percentages of new testing among eligible but not previously tested pts increased from 2018-March 2020, decreased from April-September 2020, and trended upwards thereafter (Table 1). In logistic regression models combining data from pre- and post-COVID-19 periods, family history of relevant cancer (odds ratio [OR]=1.9; 95% CI, 1.5-2.4), younger age at diagnosis (>65 reference; <45: OR=12.8, 95% CI, 8.9-18.3; 45-54: OR=6.7, 95% CI, 4.9-9.3; 55-64: OR=2.0, 95% CI, 1.5-2.8), and diagnosis year of 2013 or later (OR=1.9, 95% CI, 1.4-2.6) were significantly associated with increased odds of gBRCA1/2 testing. Positive hormone receptor status (OR=0.5; 95% CI, 0.4-0.6) and Hispanic ethnicity (OR=0.5; 95% CI, 0.3-0.9) were significantly associated with reduced odds; associations with non-Hispanic Black ethnicity did not reach statistical significance (OR=0.8; 95% CI, 0.6-1.1). Conclusion: Following the expanded eligibility criteria for gBRCA1/2 testing, testing rates increased from 2018 to 2019 and decreased only slightly during the national COVID-19 lockdown. Age at diagnosis, family history, diagnosis year, ethnicity, and hormone receptor status impacted the odds of testing. Given that gBRCA1/2 mutations are actionable, focused efforts should be developed to resume the pre-pandemic trajectory of gBRCA1/2 mutation testing. Funding: Pfizer Inc Table 1.Percentages of Newly gBRCA1/2-Tested Pts with HER2- ABC Who Were Eligible for Testing Anytime During the Time Period and Not Previously TestedTime Period2018, % (n/N)2019, % (n/N)2020, % (n/NJanuary-March2.3 (10/427)2.7 (14/512)4.3 (23/537)April-June2.9 (13/447)3.4 (18/536)2.8 (14/495)July-September4.3 (20/468)4.7 (27/569)2.5 (13/517)October-December1.9 (9/478)3.1 (17/548)3.5 (16/456)Total8.4 (52/622)10.0 (76/757)8.8 (66/747)A pt diagnosed in February and tested in April of 2018 would be included in the denominator (N) for January-March and April-June of 2018 and in the numerator (n) for April-June of 2018. Citation Format: Alexander Niyazov, Monika Izano, Colden Johanson, Sheetal Walters, Anna Berry, Bhakti Arondekar, A. Douglas Laird, Lillian Shahied Arruda, Henry Kaplan. Germline BRCA1/2 mutation testing in human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (ABC): A real-world study in the Syapse Learning Health Network (LHN) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-09-05.

Abstract 13990: Tightly Connected Provider Networks Are Associated With Lower Spending for Patients Undergoing Left Ventricular Assist Device Implantation

Introduction: Patients receiving a durable left ventricular assist device (LVAD) implant for advanced heart failure require multidisciplinary care but integration of care delivery may vary among provider groups. Prior studies found that greater provider network connectivity may be associated with more integrated care and better clinical outcomes. Hypothesis: Greater connectedness in provider networks is associated with lower LVAD payments. Methods: Drawing on social network theory, a measure of connectedness was developed based on the number of shared patients among providers (e.g. primary care physicians, cardiologists, surgeons) caring for 4,985 Medicare beneficiaries, starting 180 days prior to LVAD admission until 180 days post-discharge, from July 2009-April 2017. Connectedness was measured as average network path length, with shorter path lengths indicating more connected networks. Total payments were captured from admission to 180 days post-discharge. Multivariable regression was used to analyze the relationship between connectedness and LVAD payments. Results: The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with a mean age of 63.1 years (SD 11.1). The median path length (IQR) for a provider network was 1.7 (1.6, 1.8) and median (IQR) payments from admission to 180 days post-discharge was $162,774 ($151,279, $202,932). Median (IQR) payments at the lower, middle, and upper terciles of connectedness were $162,249 ($150,543, $198,709), $162,577 ($151,424, $199,471), and $163,922 ($152,263, $212,072), respectively. After adjusting for center, patient demographics, and clinical factors, greater connectedness was associated with lower payments (β=-22097.88, p<0.01), Figure. Conclusions: Greater provider network connectedness is associated with lower payments for Medicare beneficiaries receiving durable LVAD implants. Interventions to improve network connectedness may improve the value of care in this population.

Community Experience with Pediatric Inspired Treatment of Acute Lymphoblastic Leukemia in the Adolescent and Young Adult Population in Kaiser Permanente Northern and Southern California Regions

Background:Pediatric inspired treatment for Acute Lymphoblastic Leukemia has been increasingly used for treatment of adolescents and young adults in the United States and Europe. In 2019 Dr. Stock published results of CALGB 10403 which showed that a pediatric inspired regimen was tolerable and efficacious in a population of ALL patients up to the age 40. Prior to that publication the use of pediatric inspired treatment was quite variable and mostly used in academic hospital systems. There was concern about tolerability, utilization and efficacy of pediatric inspired protocols. Kaiser Permanente is a vertically integrated care delivery system. The Northern and Southern California regions are the two largest regions each caring for approximately 4.5 million members and cared for in a network of medical offices and hospitals.Methods:We reviewed the Cancer Registries of the Kaiser Permanente Northern and Southern California regions for patients aged 15-39 diagnosed with acute lymphoblastic leukemia between 2010 - 2018. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. We examined the initial induction plan selected and determined if the induction used steroids, vincristine, an anthracycline and asparaginase and if so was classified as pediatric inspired. If not induction was classified as an adult protocol. Patients were characterized as pediatric inspired or adult then followed based on the initial induction plan selected. Neither the sub type of ALL, the molecular characteristics or the MRD status at the end of induction was reviewed. The selection of chemotherapy agents after the initial induction plan was not reviewed. The use of pediatric inspired induction over the time of the study was reviewed. The patients clinical course was reviewed for the next 6 months and utilization including hospital days, ICU days was reviewed. Patients were followed for toxicities of treatments including sepsis, lab abnormalities, and documented side effects of chemotherapy. The pattern of BMT referral was reviewed. The vital status known at the end of the evaluation was also reviewed.ResultsA total of 222 patients were evaluated. In our patient cohort, 60% of patients were under 26 and 40% were older than 26. Over the study period 66.7 % of the patients received a pediatric inspired induction. The use of pediatric inspired treatments increased over the study period with 38% use in 2010 to 90% in 2018. For patients over age 21 in 2010 the use was 10% in 2018 84%. There was a significantly greater number of inpt days for patients initiated on adult protocols at months, 1, 3 and 6. There was no difference in ICU days. For outpatient utilization there was a significantly higher use of the ED at months 1,3,6 for patients initiated on adult treatments. For patients over 21 there was a significantly increased number of BMT consults during the first 6 months after diagnosis. There was no statistical difference in documented bacteremia, mucositis, pancreatitis, neuropathy or sepsis between the 2 groups. For patients over 26 there was a significant increase in peripheral neuropathy in the adult treated group. There was a significantly elevated risk of mortality at 2 years after diagnosis for the adult treated group. For patients over the age 26 the risk of mortality was similar at 2 years.ConclusionWe saw a rapid increase of utilization of pediatric inspired inductions over the study period within the Kaiser Permanente California regions. Patients who initiated treatment on adult protocols had over the first 6 months more inpatient days, were more likely to utilize the ED, were more likely to have a BMT consult. Patients who received adult protocol treatments had higher mortality at 2 years after diagnosis. We conclude that adult oncologists now favor pediatric inspired treatment approaches and there do not seem to be any safety concerns with this approach and in fact pediatric inspired treatments may lead to lower utilization and decreased mortality. DisclosuresNo relevant conflicts of interest to declare.

Knowledgeability, Attitude and Practice Behaviors of Dental Providers Toward Provisions of Integrated Care Delivery for Patients With Prediabetes/Diabetes: Wisconsin Statewide Survey

Introduction: To conduct a statewide survey among Wisconsin-based dental providers evaluating current knowledgeability, attitudes and practice behaviors surrounding management of patients with diabetes/prediabetes in the dental setting. The study explored perceptions on feasibility, value, barriers, and current status of integrated care model (ICM) adoption by dental practicesMaterials and Methods: A 32-question paper-based survey was mailed to all licensed dentists and dental hygienists practicing in Wisconsin. The study was conducted over a 4 week period in 2019. The survey instrument was adapted from a previous validated survey and was expanded to include questions on ICM adoption. Content and validity analyses and beta testing were conducted prior to dissemination of the survey. Descriptive statistics and chi-square tests were applied for data analyses. Thematic analyses was performed on open-ended questions.Results: Survey response rate was 12% (N = 854/7,356) representing 41% dentists and 59% dental hygienists. While 68% reported educating patients on oral health-diabetes association, only 18% reported medical consultations to inform dental treatment, and “frequent” (22%) or “occasional” (40%), medical triage. Knowledge-based questions were correctly answered by >70% of participants. While 50% valued chair-side glycemic screening and 85% supported non-invasive chair-side screening to identify at-risk patients,>88% relied on patient-reported diabetic status. Barriers to ICM adoption included time investment (70%), patient activation/cooperation (62%), cost (50%), insurance coverage (50%), infrequent interdisciplinary communication (46%), lack of equipment (33%) and provider (31%).Conclusion: Low rates of ICM adoption, chair-side testing, medical consultation and triage, and need for educational curricula reform were identified.

Perspectives of Adolescent Girls and Young Women on Optimizing Youth-Friendly HIV and Sexual and Reproductive Health Care in Zambia.

Youth-friendly health care delivery models are needed to address the complex health care needs of adolescent girls and young women (AGYW). The aim of this study is to explore the lived experiences of AGYW seeking comprehensive HIV and sexual and reproductive health (SRH) care and to elicit their preferences for integrated health care services. We conducted in-depth interviews and focus group discussions in Lusaka, Zambia among 69 AGYW aged 10-20 who were HIV-negative or of unknown status and 40 AGYW aged 16-24 living with HIV. The data were coded through deductive and inductive processes and analyzed thematically using modified World Health Organization (WHO) dimensions of quality for youth-friendly services. AGYW expressed preference for one-stop clinics with integrated services that could provide HIV services along with other services such as pregnancy testing and family planning. AGYW also wanted information on staying healthy and approaches to prevent disease which could be delivered in the community setting such as youth clubs. An integrated clinic should address important attributes to AGYW including short wait time, flexible opening hours, assurance of confidentiality and positive staff attitudes. Youth-friendly, integrated care delivery models that incorporate AGYW preferences may foster linkages to care and improve outcomes among vulnerable AGYW.

The cost-saving effect of continuity of care (COC): an analysis of institutional COC on diabetic treatment costs using panel 2SLS regressions

BackgroundThe high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC).MethodsWe analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs.ResultsOur results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care.ConclusionsInstitutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect.

Insights into a regional collaboration for improving heart care across the complete care chain

Abstract Background The Netherlands Heart Network is a joint-effort of all relevant healthcare providers in primary, secondary, and tertiary care across the complete care chain in a region with an adherence of approximately 1,000,000 inhabitants. This regional collaboration features four non-academic hospitals, over 450 general practitioners and various other healthcare professionals who cooperate for the continuous improvement of cardiac patient care using Value Based Healthcare principles. Purpose Due to predicted demographic changes and the expected rise of cardiovascular diseases, novel initiatives are needed to optimize present-day healthcare systems. Therefore, the NHN has focused on the implementation of transmural integrated care delivery systems and impactful innovations for four major cardiovascular diseases: atrial fibrillation (AF), heart failure (HF), coronary artery disease and valvular diseases. Methods Various new health care initiatives and innovations have been implemented and evaluated in the region. For example, dedicated outpatient clinics and transmural care standards have been implemented for AF and HF across the full care cycle. The effect of the implementation of these care standards on patient-relevant outcomes and healthcare costs has been evaluated using large scale prospective and retrospective quality registries. Furthermore, new health care innovations include, among others, the opportunistic screening for AF within general practices and an optimized pre-hospital triage protocol for NSTEMI patients. Results Patient-relevant outcomes in 446 AF patients who visited dedicated outpatient clinics improved within 6 months of follow-up (EHRA score (1.93 to 1.36; p<0.01), hypertension (55.4% to 52.7%; p<0.01) and persistent AF (30.1% to 12.5%; p<0.01)). The introduction of transmural care standards for HF led to significant improvements in patient-relevant outcomes when comparing data before and after implementation (NYHA class (X2=9.1; p=0,03) and LVEF (41.7% vs. 38.4%; p<0.01)) and a reduction of mean healthcare costs by 25%. Moreover, the results of various innovations, including the AF screening protocol and potential benefits of pre-hospital triage of NSTEMI patients, are currently being evaluated. Conclusion(s) This regional collaboration by health professionals is unique in its approach and highlights that healthcare improvements are not exclusively reserved to large academic centers or referral hospitals. The present approach may serve as a blueprint for the organization of healthcare in other regions. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMWHealth insurance CZ/VGZ

410 - A Systematic Review on Digital Health Interventions (DHIs) supporting the administration of Comprehensive Geriatric Assessments (CGAs) use in long-term and home care settings

Background:Health systems are in the need for novel approaches to tackle the challenges from the demographic transition to ageing populations. An effective approach to face these challenges is integrated care delivery. Implementing Comprehensive Geriatric Assessments (CGAs) in Health Ageing might be highly relevant to incorporate this approach. However, this implementation should be supported by Digital Health Interventions (DHIs) in order to reach their full capacity.Research Objective:To identify the DHIs facilitating the administration of CGAs used in long-term care and home care settings and provide an insight on their characteristics and stage of maturity and evaluation.Method:A search strategy was conducted in PubMed, CINAHL, and Web of Science, targeting studies evaluating the DHIs facilitating the administration of CGAs used in long-term care and home care settings. Studies in English and Spanish and published up to July 26, 2021 were considered.Preliminary results of the ongoing study:A total of four papers describing three digital platforms supporting the administration of the CGAs were identified. Information on implementation reported less completion of some sections affecting the CGAs outcomes, assessments mostly being the responsibility of nurses, and missing data related with less quality of care. Limitations and barriers regarding their usability and feasibility were also identified.Conclusion:The inclusion of safe data storage, automatic notifications for assessment completion, automatic calculation of final outcomes, and facilitation of multidisciplinary assessments, were identified as key features to enhance the implementation of digital platforms facilitating the administration of CGAs. Nonetheless, information regarding technical features and hardware information of the digital platforms was scarce.This project is part of the Marie Skłodowska Curie Actions Innovative Training Network H2020-MSCA-ITN, under grant agreement number 813196

121 Embedding Palliative Consultants in the Emergency Departmet Creates Significant Value for Healthcare Systems

A vast majority of patients with serious illness present to emergency departments (EDs) in their last year of life with unmet palliative needs. ED-requested palliative care (PC) consults have been shown to reduce hospital length-of-stay and costs. As integrated care delivery models evolve, many health systems are considering how to best deploy PC resources and protocols to the ED to facilitate earlier engagement. Our objective was to demonstrate the financial and operational viability of embedding a palliative consultant in the ED. This single-site hospital with 42,000 annual ED visits featured a mature PC team, with historically high ICU/ward but minimal ED engagement. Institutional alignment was acquired from key stakeholders (ED, PC, ICU, hospitalists, administration) to fund a new ED-embedded PC consult service. A single PC physician or nurse practitioner was co-located in the ED fishbowl between the hours of 11am-7pm daily, initially weekdays and expanded to weekends after 10 weeks. ED consults were both proactively identified by PC and actively requested by ED clinicians. Clinical and financial data from 08/2020-04/2021 were tracked through the electronic health record, Palliative Care Quality Network registry, and McKesson Horizon Performance Manager. Over 8.5 months, the ED-embedded PC service saw 565 consults. Of these, 46% had a code status change, 8% admitted to a lower level of care, 9% avoided hospitalization, and 13% newly referred to hospice. ED consult volume was consistent month-over-month. ED length-of-stay did not appreciably lengthen. None of these cases were related to COVID-19. Importantly, this additional consult team did not cannibalize inpatient consult volume from usual practice. Compared to inpatient PC consults, median hospital length-of-stay decreased from 10.8 days to 3.3 days (p<0.001). Likewise, median direct costs per hospitalization decreased from $17,726 to $4,617, a 75% reduction or $13,019 per hospitalization (p<0.001). Annualized direct cost avoidance will be $6.5M. Subsequently, the ED provider group volunteered to include ED-palliative consults as a performance metric in their compensation model. ED-embedded palliative consultants are a high cost but even higher-reward intervention. For this hospital, return on investment will exceed 15x. True impact is likely even greater given analyses were not compared against all-comers, and did not account for future deferral of ED revisits and healthcare utilization from earlier introduction into outpatient palliative and hospice services. ED-palliative partnerships significantly advance the quadruple aim and position the ED to lead change in healthcare systems which increasingly prioritize value-based care.

409 - Psychometric features of Comprehensive Geriatric Assessments (CGAs) in long-term and community care settings: A Systematic Review

Background:Comprehensive Geriatric Assessments (CGAs) incorporate the key principles of integrated care delivery, which is regarded as the most effective approach of care provisioning to face challenges of dementia care, such as uncoordinated care, risk of hospitalizations, care planning and unmet needs. For this reason, implementing CGAs in care practice might be highly relevant, however, to do so, we must consider their psychometric characteristics.Research Objective:To provide insight into the content and the reliability and validity of CGAs used in long-term care and home care settings.Method:A search strategy was conducted in PubMed, CINAHL, and Web of Science, targeting studies that have focused on the validity and reliability of available CGAs for long-term and home care settings. Studies in English and Spanish and published up to July 13, 2021, were considered.Preliminary results of the ongoing study:A total of 72 studies reporting on the validity/reliability of 13 different CGAs were identified. For long-term care facilities, five CGAs were reported; for home care, eight assessment tools were targeted. Most of the CGAs covered a wide range of domains, such as Physical Health, Functional, Mental Health, and Social Status. Evidence for good to excellent validity and reliability was reported for various instruments.Conclusion:Resident Assessment Instrument-Minimum Data Set (RAI-MDS) and subsequent updated instruments reported strong evidence of good to excellent validity and reliability for multiple countries. For this reason, interRAI LTCF and interRAI HC are recommended to be use for long-term and home care facilities, as they are the latest versions of the RAI-MDS.This project is part of the Marie Skłodowska Curie Actions Innovative Training Network H2020-MSCA-ITN, under grant agreement number 813196

Disparities in clinical trials participation in a vertically integrated care delivery system.

128 Background: Sparse data exists on the diversity clinical trial enrollment in community settings. This information is important to ensure equity of care and generalizability of results. Methods: We conducted a retrospective cohort study of members of an integrated healthcare system diagnosed with invasive malignancies (excluding non-melanoma skin cancers) between 2013-2017 to examine demographics of the oncology population compared to those who enrolled in a clinical trial. Logistic regression was used to assess correlates of clinical trial participation, comparing general and screened samples to enrolled sample. Odds ratios were adjusted for gender, geocoded median household income, cancer type, and stage. Results: Of the 84,977 patients with a cancer diagnosis, N = 2606 were screened for clinical trial participation and consented, and of those N = 1372 enrolled. The percent of Latinx (25.8% vs 24.0%; OR 0.9? CI 0.72-1.05) and African American/Black (10.9% vs 11.1%; OR 0.92 CI 0.75-1.11) clinical trial participation mirrored that of the general oncology population, respectively using Non-Hispanic Whites as reference. Asian/Pacific Islander had equal odds of clinical trial enrollment (OR 1.08 CI 0.92-1.27). The enrolled population was younger than the general oncology population. Conclusions: This study suggests that in an integrated healthcare system with equal access to care, the clinical trials population is well representative of its general oncology population.[Table: see text]

Optimizing Health Outcomes Among Newly Dual Eligibility Beneficiaries in Managed Care: Patient‐Provider Language, Race and Technology Discordance

Research ObjectiveOver one‐third of individuals dually eligible for Medicaid and Medicare coverage (“dual eligibles”) receive care in managed care settings. Despite improvements in care processes, access and overall satisfaction, suboptimal outcomes persist. We investigated whether lack of patient portal use and/or language/race discordance were associated with potentially avoidable hospital and emergency room admissions.Study DesignLeveraging electronic health record data in a large integrated care delivery system, we applied a retrospective observational cohort design and Cox proportional hazards models to estimate the risk of potentially avoidable hospital and emergency room admissions during the first two years following dual eligibility. We examined three factors previously identified as important to patient‐provider interactions: patient engagement with providers via a patient portal, race concordance, and language concordance. Models controlled for potential patient (e.g., age, sex, race, ethnicity, comorbidity, distance to the nearest clinic, behavioral risk factors, coverage type), and health system (e.g., neighborhood deprivation index, hospital) confounders.Population StudiedWe identified 36,961 adults enrolled in Kaiser Permanente Northern California health plans who became newly eligible for dual enrollment in Medicaid and Medicaid between 2016 and 2019. We excluded individuals with any hospice services and long‐ term skilled nursing facility residents. The final model included 36,689 individuals.Principal FindingsAt time of new dual eligibility, patients were 64.7 years old on average and 59% were female. The cohort was racially and ethnically diverse: 37.4% white; 22.1% Asian; 13.5% Black or African American; 21.2% Latinx; 1.7% other; and 4.1% unknown. 4.8% had the outcome of interest within two years of new dual eligibility. Consistent with our hypothesis, individuals who did not use the patient portal were at significantly increased risk for potentially avoidable admissions [HR: 1.32; 95% CI: (1.17, 1.49)]. Race discordance was also associated with increased [HR: 1.13; 95% CI: (1.00, 1.27)]. In contrast with our hypothesis, language discordance was associated with a lower risk of avoidable hospital and ED admissions [HR: 0.72 CI: (0.61, 0.85)]. In addition, multi‐morbidity, new enrollment into the Kaiser Permanente health system, lack of exercise and living in a lower socioeconomic status neighborhood was associated with elevated risk. Younger age, enrollment in both Dual Eligible Special Needs Plans (D‐SNP) and Medicaid or in Medicare alone (versus D‐SNP only), and Asian race was associated with lower risk.ConclusionsAmong individuals newly eligible for dual coverage from Medicare and Medicaid, both race discordance and non‐use of the patient portal, was associated with increased risk of potentially avoidable hospital events. Limitations of this study include potential lack of generalizability to individuals transitioning from fee‐for‐service to managed care and reliance on indirect measures of cultural and linguistic discordance.Implications for Policy or PracticeIncreasing the use of telehealth services among dual eligibles may be critical to close the gap between potential and realized access to manage care services.Primary Funding SourceKaiser Permanente.

Remote-Management of COPD: Evaluating the Implementation of Digital Innovation to Enable Routine Care (RECEIVER): the protocol for a feasibility and service adoption observational cohort study

IntroductionReductions in exacerbation and hospitalisations are the outcomes rated as most important by people with chronic obstructive pulmonary disease (COPD). Most COPD management is currently based on a reactive approach,...

How Patient-Centered Medical Homes Integrate Dental Services Into Primary Care: A Scoping Review.

Integrated care delivery is at the core of patient-centered medical homes (PCMHs). The extent of integration of dental services in PCMHs for adults is largely unknown. We first identified dental-medical integrating processes from the literature and then conducted a scoping review using PRISMA guidelines to evaluate their implementation among PCMHs. Processes were categorized into workforce, information-sharing, evidence-based care, and measuring and monitoring. After screening, 16 articles describing 21 PCMHs fulfilled the inclusion criteria. Overall, the implementation of integrating processes was limited. Less than half of the PCMHs reported processes for information exchange across medical and dental teams, referral tracking, and standardized protocols for oral health assessments by medical providers. Results highlight significant gaps in current implementation of adult dental integration in PCMHs, despite an increasing policy-level recognition of and support for dental-medical integration in primary care. Understanding and addressing associated barriers is important to achieve comprehensive patient-centered primary care.