Health Care Delivery Models Research Articles

Creative Destruction in the Field of Healthcare

This research paper will cover in detail the evolution of telemedicine over time and its prospects while explaining the theory of creative destruction. In the past, healthcare involved medical professionals delivering specialized expertise and care to patients. Throughout most of the history of healthcare, medical care was produced and administered by a small group of professionals. Under that traditional approach, medical services were provided only through in-person consultations and exclusively in facilities that were specifically designated for the purpose of in-person consultations—such as hospitals, clinics, and private offices of medical professionals. Over time, healthcare has become more affordable and the convergence of the Information Technology sector has revolutionized the way medicine is dispensed to patients (Thimbleby). We are seeing the dawn of a new model of healthcare delivery, where in-person consultations at medical facilities are replaced by remote consultations and monitoring of the patient (Coughlin 1). Joseph Schumpeter devised the term 'creative destruction' in 1942, which he described to be a "process of industrial mutation that incessantly revolutionizes the economic structure from within, incessantly destroying the old one, incessantly creating a new one” (Schumpeter 83). This research paper will be discussing the current structure and the inefficiencies of the healthcare industry. Moreover, it will elaborate upon how telemedicine might eliminate payment models like the Fee to Service Model and how the incentives different insurers provide will be altered. Overall, this paper explores how telemedicine can possibly take over the medical industry thanks to its economic benefits and convenience.

Healthcare workers’ experiences of transitioning natalizumab infusions from hospital services to an in-home setting: a qualitative study

Objective: This study explored healthcare workers’ experiences of transitioning infusions of natalizumab from hospital to a patient-centred model of home care. Background: Hospital in the home is one of the fastest growing healthcare delivery models. In Australia, intravenous infusions are rarely available at home for chronic disease patients, such as those with multiple sclerosis. A recent trial of natalizumab infusions at home for patients with multiple sclerosis required both the hospital and hospital in the home staff to consider the logistics of how this transition could be achieved safely. Study design and methods: This was a qualitative study using an exploratory-descriptive approach. Twelve participants from two main groups of healthcare workers participated in delivering natalizumab infusions during the six-month trial period and were subsequently interviewed about their experience. Participants were recruited from a hospital ambulatory care day unit and a Home Infusion Team from a private provider of home nursing care located in South Australia. The data was analysed thematically. Results: Three main themes were identified from the interviews: ‘preparing for change’, ‘focussing on the patient’, and ‘enhancing professional support and relationships’. These findings demonstrated the importance of understanding healthcare workers’ experiences of transitioning to a patient-centred model of care, from hospital to home infusion of natalizumab. Discussion: Flexibility and good management of logistics is necessary to maintain the standards of the health services, which highlights the need for training and professional support to facilitate quality home care. This may enhance workers’ sense of professional confidence and trust and reduce stress when delivering the home model of care. Conclusion: Healthcare workers and patients worked to support one another, not only therapeutically but also logistically within collegial relationship and interdependent communications. Being flexible, communicating clearly and being willing to work together within the team, especially between the hospital in the home staff and the hospital staff, was demonstrated to be an important factor for the safe delivery of infusions at home. Managing the logistics of delivering a flexible and safe home therapy service was an important part of this model of care. Implications for research, policy, and practice: The results of this study will be used to inform healthcare teams about the key logistical components that are important for healthcare services, when considering transitioning to a home-based model of care for treating people with relapsing-remitting multiple sclerosis.

COVID-19 Postacute Sequela Rehabilitation: A Look to the Future Through the Lens of Chronic Obstructive Pulmonary Disease and Pulmonary Rehabilitation

Post–COVID-19 condition is characterized by a myriad of persistent symptoms experienced up to 60 days after the acute infection, not only in those hospitalized, but also in patients with mild to moderate acute symptoms. The overwhelming evidence on multisystem involvement in post–COVID-19 condition brings to attention the need for integrated delivery models to address health care needs of this population. The World Health Organization recently highlighted critical gaps in adequately providing the level of integrative care required to address the multisystem needs of this population in current health care delivery models and recommended development of new innovative models of delivery. This article presents a novel approach to addressing these gaps from a rehabilitation perspective.

Barriers and facilitators to adopting horizon scanning to identify novel integrated care models: a qualitative interview study

ObjectivesHorizon scanning methodologies are employed in healthcare to identify and prioritise innovations at the early stages of development processes. To date, horizon scanning has been predominantly applied to early awareness...

Improving Family-Centered Care for Infants in Neonatal Intensive Care Units: Recommendations From Frontline Healthcare Professionals.

Family-centered care is a philosophy and healthcare delivery model adopted by many neonatal intensive care units (NICUs) worldwide, yet practice varies widely. The aim of this study was to synthesize recommendations from frontline NICU healthcare professionals regarding family-centered care. Data were obtained from the baseline phase of a multicenter quasi-experimental study comparing usual family-centered NICU care (baseline) with mobile-enhanced family integrated care (intervention). Members of the NICU clinical care team completed a family-centered care survey and provided free-text comments regarding practice of family-centered care in their NICU and recommendations for improvement. The comments were analyzed using a directed content analysis approach by a research team that included NICU nurses and parents. Of the 382 NICU healthcare providers from 6 NICUs who completed the survey, 68 (18%) provided 89 free-text comments/recommendations about family-centered care. Almost all comments were provided by nurses (91%). Six main themes were identified: language translation; communication between staff and families; staffing and workflow; team culture and leadership; education; and NICU environment. The need for greater resources for staffing, education, and environmental supports was prominent among the comments, as was team culture and staff-parent communications. The NICU healthcare professionals identified a range of issues that support or impede delivery of family-centered care and provided actionable recommendations for improvement. Future research should include economic analyses that will enable determination of the return on investment so that NICUs can better justify the human and capital resources needed to implement high-quality family-centered care.

Training and education to advance multicultural mental health-care delivery (the “TEAM mental health-care delivery model”): A pilot evaluation of outcomes, acceptability, and feasibility.

Training and education to advance multicultural mental health-care delivery (the “TEAM mental health-care delivery model”): A pilot evaluation of outcomes, acceptability, and feasibility.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review.

AimThe aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes.MethodsEight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high‐income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools.ResultsThree articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias.ConclusionThere is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high‐income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review.

BackgroundA free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke’s Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina.ObjectiveThis study aims to measure the change, over time, in patient hemoglobin A1c measurements at the SLFMC to quantify the success of the clinic’s diabetes treatment program.MethodsA prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A1c<7.0, n=53) or uncontrolled (hemoglobin A1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A1c from other free clinics.ResultsPatients with uncontrolled diabetes experienced significant reductions in median hemoglobin A1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A1c over the study window. The SLFMC’s wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic’s Hispanic population (n=47) showed the greatest average improvement in hemoglobin A1c of any ethnic group from baseline. Additionally, 61% of the SLFMC’s Black population (n=33) achieved a hemoglobin A1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control.ConclusionsWe present free clinic hemoglobin A1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A1c, which is comparable to nationwide standards, although average hemoglobin A1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.

Pediatric Primary Health Care: The Central Role of Pediatricians in Maintaining Children's Health in Evolving Health Care Models.

Pediatric primary health care (PPHC) is of principal importance to the health and development of all children, helping them reach their true potential. Pediatricians, as the clinicians most intensively trained and experienced in child health, are the natural leaders of PPHC within the context of the medical home. Given the rapidly evolving models of pediatric health care delivery, including the explosion of telehealth in the wake of the COVID-19 pandemic, pediatricians, together with their representative national organizations such as the American Academy of Pediatrics (AAP), are the most capable clinicians to guide policy innovations on both the local and national stage.

A survey of patients visiting an Ayurvedic teaching hospital for factors influencing the decision to choose ayurveda as a health care provider

Study BackgroundIn a pluralistic health care delivery model, it is important to assess whether the individual's health care choices are based upon evidences of efficacy and safety. Since the essence of medical pluralism lies in the fact that all such systems are equally accessible to a seeker, in such situation, it is highly relevant to check what defines such choices in real life. ObjectiveTo identify the factors influencing the health care choices in a subpopulation seeking Ayurveda health care in an Ayurvedic teaching hospital. Materials and MethodThe study was an all-inclusive cross sectional survey, done on randomly selected out patients visiting an Ayurveda teaching hospital. The data was collected using a 21 items questionnaire refined through pilot testing from 7.9.2017 to 30.9.2017. ResultsThe data of 289 respondents who have given their consent were included in statistical analysis. Out of 21 variables studied for their agreement or disagreement in the study population 8 were found to have a significant proportion in favour of agreement. Among these relative safety (Item 9); disease eradicating potential (Item 14); belief (Item 3) and indirect evidences of efficacy (Item 4) were found to have high significance (p < 0.001). ConclusionParticipants chose Ayurveda treatment due to its perceived safety and probability of helping in a particular clinical condition. Contrary to the common perception, enabling factors like availability, accessibility and affordability were given less importance by the participants in making health care choices related to Ayurveda.

FDA Accelerated Approval for Malignant Hematology and Oncology Indications in the Canadian Environment.

Accelerated approval (AA) by the FDA enables earlier access to promising new therapies. Health Canada has a similar process. Canada implemented a national health technology assessment (HTA) for reimbursement decisions in 2011. This study evaluated regulatory and funding timelines and decisions for FDA AA cancer therapies in Canada. The FDA’s AA of malignant hematology and oncology from January 2000–December 2019 was reviewed. Dates from Health Canada, HTA decisions and provincial listings were collected. There were 94 FDA AAs, two of which were subsequently withdrawn. Of the 92 AAs, 70 received full (46)/conditional (24) Health Canada approval, and 22 were not filed. Since the introduction of HTA, 31 out of 45 of Health Canada’s approved indications underwent HTA review: 18 received a positive recommendation conditional on cost-effectiveness, 8 were not recommended and 5 were withdrawn/suspended. The median time from the AA to any Health Canada approval is 9.4 months, from any Health Canada approval to HTA decision is 5.8 months and from HTA decision to the first formulary listing is 12.0 months. The access and timeline for the first formulary listing differences were observed between the USA and Canada due to the decision of pharmaceutical companies to submit (or not) to regulatory/HTA bodies, national procedural delays with different healthcare delivery models and submission timelines. This study demonstrates that there is delayed access to promising new therapies in Canada.

The qualitative experience of telehealth access and clinical encounters in Australian healthcare during COVID-19: implications for policy

BackgroundAdaptive models of healthcare delivery, such as telehealth consultations, have rapidly been adopted to ensure ongoing delivery of essential healthcare services during the COVID-19 pandemic. However, there remain gaps in our understanding of how clinicians have adapted to telehealth. This study aims to explore the telehealth experiences of specialists, based at a tertiary hospital in the Hunter Region, and general practitioners (GP), including barriers, enablers and opportunities.MethodsAn interpretative qualitative study involving in-depth interviews explored the telehealth experiences of specialists, based at a tertiary hospital in the Hunter Region of Australia, and GPs, including barriers, enablers and opportunities. Data were analysed using an inductive thematic approach with constant comparison.ResultsIndividual interviews were conducted with 10 specialists and five GPs. Key themes were identified: (1) transition to telehealth has been valuable but challenging; (2) persisting telehealth process barriers need to be addressed; (3) establishing when face-to-face consults are essential; (4) changes in workload pressures and potential for double-up; (5) essential modification of work practices; and (6) exploring what is needed going forward.ConclusionsWhile there is a need to rationalize and optimize health access during a pandemic, we suggest that more needs to be done to improve telehealth going forward. Our results have important policy implications. Specifically, there is a need to effectively train clinicians to competently utilize and be confident using this telehealth and to educate patients on necessary skills and etiquette.

Communicating Precision Medicine Research: Multidisciplinary Teams and Diverse Communities

Introduction: Precision medicine research investigates the differences in individuals’ genetics, environment, and lifestyle to tailor health prevention and treatment options as part of an emerging model of health care delivery. Advancing precision medicine research will require effective communication across a wide range of scientific and health care disciplines and with research participants who represent diverse segments of the population. Methods: A multidisciplinary group convened over the course of a year and developed precision medicine research case examples to facilitate precision medicine research discussions with communities. Results: A shared definition of precision medicine research as well as six case examples of precision medicine research involving genetic risk, pharmacogenetics, epigenetics, the microbiome, mobile health, and electronic health records were developed. Discussion/Conclusion: The precision medicine research definition and case examples can be used as planning tools to establish a shared understanding of the scope of precision medicine research across multidisciplinary teams and with the diverse communities in which precision medicine research will take place. This shared understanding is vital for successful and equitable progress in precision medicine.

Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes

Orthopaedic surgery has revolutionized the expectations for restoration of physical function after musculoskeletal injury and, along with physical therapy, has transformed the limits of recovery. Many orthopaedic procedures have a high success rate for improving quality of life and patient-reported outcomes, yet these procedures carry some level of risk, including postoperative complications. The stepped-care model of health care delivery, when applied to musculoskeletal care, recommends implementing less-intense and lower-risk treatments with known efficacy, such as promotion and education of self-management strategies and physical therapy, before more-invasive and higher-risk treatments such as surgery. This model of managing musculoskeletal disability can improve efficiency of care delivery and reduce medical costs at the health system level. Unfortunately, there is a documented lack of implementing an appropriate course of conservative care, especially physical therapy, prior to surgery across multiple orthopaedic disciplines including sports, spine, and trauma medicine and joint arthroplasty. Failure to respond to nonsurgical treatment has been suggested as a requisite component of the surgical appropriateness criteria, yet practical application can be elusive. Multiple barriers to adequate utilization of conservative treatment exist, including U.S. payment models that increase out-of-pocket expense for patients, negative patient perception of therapy, unreasonable patient expectations from therapy versus surgery, and communication barriers between patient, surgeon, and therapist. Surgeons should ensure that high-quality guideline-appropriate care is delivered early and adequately to their patients. Rehabilitation professionals have a responsibility to deliver high-value care, properly documenting the type and extent of treatment to improve surgical decision-making between surgeons and patients. Criteria to determine appropriateness for surgery should include a standardized and extensive assessment of failed therapies prior to certain elective surgeries. Improved collaboration between surgeons and rehabilitation professionals can result in improved outcomes for patients with musculoskeletal disorders. Level of EvidenceV, expert opinion

Health Care Perspectives of Adult Patients with Lower Educational Attainment in Inflammatory Bowel Disease: A Qualitative Study.

Patients with lower educational attainment are underrepresented in inflammatory bowel disease (IBD) research. To increase our understanding of the health care perspectives of patients with less than a university degree, semi-structured interviews were conducted among 23 outpatients at the McGill University Health Centre IBD Centre (Montreal, Canada). Thematic analysis was used to analyze the qualitative data. Perspectives focused on communication with health care professionals, access to care, symptoms and treatment, and outside support. Access to an IBD specialist was the most important aspect of care. Good care, kind and receptive staff, and a lengthy delay to diagnosis were frequently reported experiences. IBD specialists, nurses, and family and friends were most helpful in managing disease. Physical and emotional symptoms, reduced social engagement, and medications were difficult aspects of living with IBD. An ideal IBD clinic would provide access to traditional and non-traditional services and assist with obtaining support to help patients engage in social activities, increase affordability of care, and maintain employment. Study findings may be helpful in designing equitable models of health care delivery.

Primary care and the older person with complex needs: reflections on the implementation of a primary&#x2013;secondary model of integrated care.

The demand and complexity of the health needs of older people is growing. Traditionally siloed, condition-centric care is no longer appropriate. It is costly to the Australian health system and life-threatening to the individual. In parallel to demographic change is increasing global awareness of the impact of social, behavioural, and environmental factors on health outcomes. Although significant when not addressed, the amenable nature of many personal contextual factors is an opportunity to improve health and quality of life. A move away from reactive, episodic models of health care delivery towards patient focussed integrated care is required to meet the changing demands of an aging population. This forum article provides a reflection on the current state of integration for older people with complex needs through the lens of a local community facing model: OPEN ARCH. Australia still has some way to go to establishing system level enablers for an integrated approach to care. However, the OPEN ARCH experience furthers the evidence for ground-up approaches of integrated care that can meet the increasing demand and complexity of older people's needs.

Transforming Primary Care in New York Through Patient-Centered Medical Homes: Findings From Qualitative Research.

Background:The patient-centered medical home (PCMH) model, an important component of healthcare transformation in the United States, is an approach to primary care delivery with the goal of improving population health and the patient care experience while reducing costs. PCMH research most often focuses on system level indicators including healthcare use and cost; descriptions of patient and provider experience with PCMH are relatively sparse and commonly limited in scope. This study, part of a mixed-methods evaluation of a multi-year New York State initiative to refine and expand the PCMH model, describes patient and provider experience with New York State PCMH and its key components.Methods:The qualitative component of the evaluation included focus groups with patients of PCMH practices in 5 New York State counties (n = 9 groups and 67 participants) and interviews with providers and practice administrators at New York State PCMH practices (n = 9 interviews with 10 participants). Through these focus groups and interviews, we elicited first-person descriptions of experiences with, as well as perspectives on, key components of the New York State PCMH model, including accessibility, expanded use of electronic health records, integration of behavioral health care, and care coordination.Results:There was evident progress and some satisfaction with the PCMH model, particularly regarding integrated behavioral health and, to some extent, expanded use of electronic health records. There was less evident progress with respect to improved access and reasonable wait times, which caused patients to continue to use urgent care or the emergency department as substitutes for primary care.Conclusions:It is critical to understand the strengths and limitations of the PCMH model, so as to continue to improve upon and promote it. Strengths of the model were evident to participants in this study; however, challenges were also described. It is important to note that these challenges are difficult to separate from wider healthcare system issues, including inadequate incentives for value-based care, and carry implications for PCMH and other models of healthcare delivery.

Abstracts Presented at the 2nd Annual Advancing Healthcare Innovation Summit: Nov 11, 2022, Cincinnati, OH

Abstracts Presented at the 2nd Annual Advancing Healthcare Innovation Summit: Nov 11, 2022, Cincinnati, OH

Future challenges in rheumatology - is telemedicine the solution?

The COVID-19 pandemic has become an unprecedented facilitator of rapid telehealth expansion within rheumatology. Due to demographic shifts and workforce shortages in the future, new models of rheumatology care will be expected to emerge, with a growing footprint of telehealth interventions. Telehealth is already being used to monitor patients with rheumatic diseases and initial studies show good results in terms of safety and disease progression. It is being used as a tool for appointment prioritization and triage, and there is good evidence for using telehealth in rehabilitation, patient education and self-management interventions. Electronic patient-reported outcomes (ePROs) offer a number of long-term benefits and opportunities, and a routine collection of ePROs also facilitates epidemiological research that can inform future healthcare delivery. Telehealth solutions should be developed in close collaboration with all stakeholders, and the option of a telehealth visit must not deprive patients of the possibility to make use of a conventional ‘face-to-face’ visit. Future studies should especially focus on optimal models for rheumatology healthcare delivery to patients living in remote areas who are unable to use or access computer technology, and other patient groups at risk for disparity due to technical inequity and lack of knowledge.

Improving healthcare systems and services in the face of population ageing: policy considerations for low- and middle-income countries.

Worldwide, the proportion and absolute numbers of over 60-year-olds in the population is rising: it was 1 billion in 2019 and is expected to get to 1.4 billion in 2030 and 2.1 billion by 2050, with the progression being more pronounced in developing countries. Degenerative and non-communicable diseases are more common with ageing, which means they would become the major disease problems for countries. Long-term care poses financial risks to individuals/families and governments. These warrant urgent policy and structural adjustments of health systems in low- and middle-income countries to cater for the probable change in health needs and make their society more age-sensitive. There is the need for policymakers to begin to change focus from traditional models of healthcare delivery and give more attention to aged care and create separate financing mechanisms/programmes for the elderly, most of whom are already unemployed, to protect them from the effects of cream-skimming by private health insurers. Informed decisions on healthcare purchasing can be made using Economic Evaluation, as well as Programme Budgeting and Marginal Analysis, a presentation of discrete categories of healthcare expenditure (specialties, disease-groups, etc.) and the resources appropriated to each as an aid to reviewing subsequent resource allocation. Reforms in healthcare financing should pay particular attention to the elderly considering that technical efficiency concerns of the private sector may mean that they are discriminated against. There is need for retraining/reorientation of health workers on identification and comprehensive management of NCDs, including palliative care, in a culturally competent way, on the essence of shifting from an acute care model to a chronic care model, and on providing services to people within defined catchment areas.