Need For Coordination Of Care Research Articles

The diagnostic journey of genetically defined neurodevelopmental disorders

BackgroundThe development of advanced genetic technologies has resulted in rapid identification of genetic etiologies of neurodevelopmental disorders (NDDs) and has transformed the classification and diagnosis of various NDDs. However, diagnostic genetics has far outpaced our ability to provide timely medical counseling, guidance, and care for patients with genetically defined NDDs. These patients and their caregivers present with an unmet need for care coordination across multiple domains including medical, developmental, and psychiatric care and for educational resources and guidance from care professionals. After a genetic diagnosis is made, families also face several barriers in access to informed diagnostic evaluations and medical support.MethodsAs part of Care and Research in Neurogenetics (CARING), a multidisciplinary clinical program for children and adults with neurogenetic disorders, we conducted qualitative clinical interviews about the diagnostic journey of families. This included the overall timeline to receiving diagnoses, experiences before and after diagnosis, barriers to care, and resources that helped them to navigate the diagnostic process.ResultsA total of 37 interviews were conducted with parents of children ages 16 months to 33 years. Several key themes were identified: (1) delays between initial caregiver observations and formal developmental or genetic diagnoses; (2) practical barriers to clinical evaluation and care, including long wait times for an appointment, lack of insurance coverage, availability of local evaluations, transportation difficulties, and native language differences; (3) the importance of being part of a patient advocacy group to help navigate the diagnostic journey; and (4) unique challenges faced by adults (18 years or older).ConclusionsFamilies of children with complex neurodevelopmental and genetic disabilities face numerous challenges in finding adequate medical care and services for their child. They experience considerable delays in receiving timely diagnoses and face significant barriers that further delay the process of receiving access to services needed for the child’s continued care. The gaps indicated in this study speak to the need for more comprehensive coordination of care for patients with intellectual and developmental disabilities, as well as the development of systematic, disorder-specific resources both for providers and families in order to improve patient outcomes.

P170 DISEASE IMPROVEMENT IN ATOPIC DERMATITIS THROUGH A MULTIDISCIPLINARY APPROACH WITH ALLERGY, DERMATOLOGY, AND CLINICAL PHARMACY

Severe and difficult to control Atopic Dermatitis (AD) patients often persist without disease improvement due to disjointed dialogue between specialties. The substantial population of these patients establishes a need for coordination of care across specialties.

The Role of Patient-reported Outcomes and Medication Adherence Assessment in Patient-focused Drug Development for Solid Organ Transplantation.

The Role of Patient-reported Outcomes and Medication Adherence Assessment in Patient-focused Drug Development for Solid Organ Transplantation.

MLTI-03. FIRST-LINE STEREOTACTIC RADIOSURGERY COMBINED WITH SYSTEMIC TARGETED AND IMMUNE CHECKPOINT INHIBITOR THERAPY IN MELANOMA PATIENTS WITH NEWLY DIAGNOSED BRAIN METASTASES

BACKGROUND: Of solid tumors, melanoma has the highest propensity for CNS spread with historic median survivals of 5–8 months following brain metastasis diagnosis. We evaluated the impact of systemic BRAF targeted and immune checkpoint inhibitor (ICI) therapies on survival outcomes in patients receiving stereotactic radiosurgery (SRS) for melanoma brain metastases (MBM) and assessed patient treatment burden associated with prolonged survival. METHODS: We retrospectively reviewed the demographics, disease characteristics, therapeutic regimens, overall survival, and first-year cumulative incidence of comorbid disease for patients with de novo MBM treated between 2013 and 2017 at a major melanoma referral center. RESULTS: Among 123 newly diagnosed MBM patients: 65% were male, 24% were 50 years old or less, 50% were BRAF mutated, 63% had multiple intracranial lesions at diagnosis. Locally, 73% received SRS as first-line treatment. Systemically, 73% received ICI, 46% received BRAF targeted therapy, and 12% received neither. With a median follow up of 11 months (mo), total cohort median OS was 13.2 mo. Median OS for first-line SRS combined with ICI and BRAF targeted therapy was 31.0 mo (47% 3-year OS), 17.5 mo (31% 3-year OS) with ICI monotherapy, and 6.1 mo (22% 3-yr OS) alone. SRS and BRAF targeted therapy were associated with improved OS. At one-year follow-up, comorbid conditions with the greatest cumulative incidence were fatigue, nausea, intracranial hemorrhage, deep vein thrombosis, major depressive disorder, and pneumonia. Patients averaged one inpatient visit every 4.5 mo (1 week average length of stay), and 2 advanced imaging studies (MR/CT/PET-CT) per month following MBM diagnosis. CONCLUSIONS: In one of the largest reported MBM series, survival has improved markedly for patients receiving first-line SRS combined with targeted and immunotherapies. Simultaneously, longer life expectancy comes with increasing incidences of comorbid conditions reflecting an evolving complexity of and need for coordination of care for patients with MBM.

First-line stereotactic radiosurgery combined with systemic targeted and immune checkpoint inhibitor therapy in melanoma patients with newly diagnosed brain metastases.

e13577 Background: Of solid tumors, melanoma has the highest propensity for central nervous system spread with historic median survivals of 5-8 months following brain metastasis diagnosis. We evaluated the impact of systemic BRAF targeted and immune checkpoint inhibitor (ICI) therapies on survival outcomes in patients receiving stereotactic radiosurgery (SRS) for melanoma brain metastases (MBM) and assessed patient treatment burden associated with prolonged survival. Methods: We retrospectively reviewed the demographics, disease characteristics, therapeutic regimens, overall survival, and first-year cumulative incidence of comorbid disease for patients with de novo MBM treated between 2013 and 2017 at a major melanoma referral center. Results: Among 123 newly diagnosed MBM patients:65% were male, 24%were 50 years old or less, 50% were BRAF mutated, 63% had multiple intracranial lesions at diagnosis . Locally, 73% received SRS as first-line treatment.Systemically, 73% received ICI, 46% received BRAF targeted therapy, and 12% received neither. With median follow up of 11 months (mo), totalcohort median OS was 13.2 mo, 20.5 mo for BRAF mutated patients, 10.8 mo for BRAF wild-type patients. Median OS for first-line SRS was 31.0 mo (47% 3-year OS) when combined with both ICI and BRAF targeted therapy, 17.5 mo (31% 3-year OS) when combined with ICI monotherapy, and 6.1 mo (22% 3-yr OS) with neither systemic therapy. SRS and BRAF targeted therapy were associated with improved OS. BRAF status, ICI therapy, intratumoral hemorrhage were not significant prognosticators for OS.At one-year follow-up, comorbid conditions with the greatest cumulative incidence were fatigue, nausea, intracranial hemorrhage, deep vein thrombosis, major depressive disorder, and pneumonia. Patients averaged one inpatient visit every 4.5 mo (1 week average length of stay), and 2 advanced imaging studies (MR/CT/PET-CT) per month following MBM diagnosis. Conclusions: In one of the largest reported MBM series, survival has improved markedly for patients receiving first-line brain radiosurgery combined with BRAF targeted therapies and immunotherapies. Simultaneously, longer life expectancy comes with increasing incidences of comorbid conditions reflecting an evolving complexity of and need for coordination of care for patients with MBM.

QIM19-127: Novel Admission Checklist for Malignant Bowel Obstruction

Background: Malignant bowel obstruction (MBO) is a frequent presentation of advanced abdominal malignancy. Despite the frequency of MBO and the availability of NCCN Guidelines for its management, clinicians struggle to create a personalized care plan accounting for a patient’s current condition, prognosis, and goals of care. The aim of this project is to develop a discussion tool to implement on admission to ensure realistic prognostication and appropriate involvement of the patient, caregivers, and multidisciplinary team in treatment decisions. Methods: At our tertiary care center, a multidisciplinary team composed of surgical oncologists, medical oncologists, palliative care specialists, hospitalists, social workers, and nutritionists developed an algorithm to implement when a patient is admitted with MBO. The algorithm was influenced by the NCCN Guidelines for palliative care but was designed as a single-page checklist that could be easily executed by all team members. Results: The MBO admission checklist is divided into 4 sections. The general assessment section includes information about the etiology, severity, and reversibility of the current and past MBO. Also, the patient’s resuscitation and functional status are reviewed. The cancer care coordination/communication section covers the patient’s oncological history and estimated lifespan, as well as the need for further coordination of care and a goals of care discussion. The subsequent portion covers the management plan, with specific decisions resulting from a goals of care discussion as well as the need for specialized consults. The medical, procedural, and operative interventions the team and patient discussed as options are also documented. A key portion is the risks and benefits discussion for each treatment modality. Lastly, the discussion about future considerations section explores the patient’s wishes for the next episode of MBO. Conclusions: The goal of this checklist is to ensure that a comprehensive discussion is held between the different services involved in a patient’s care at every admission for MBO in order to provide a personalized management plan and improve communication. The next step in our study is to assess the effectiveness of implementation of the checklist as well as its impact on patient satisfaction, quality of life, early hospice referral, and outcomes.

Python Tools for Stem Cell Transplantation

Background Transplant programs, unlike other clinical programs, have a need for coordination of care before, after and during the transplant process. Milestones, outcomes, and metrics need to be tracked for patient care, quality improvement, regulatory and financial purposes. Transplant specific software platforms can provide the functionality needed for a transplant program however they tend to require considerable financial commitments that is often beyond the reach of small transplant programs. Python is a very popular programming language that is easy to use and highly extensible. Open source tools such as Jupyter Notebook, Python data analysis library (PANDAS) along with visualization tools such Matplotlib as well as seaborn provide easy to use tools for automating day to day tasks and generate reports without a lot of technical know-how or financial commitments. Methods Transplant-related data in our program is maintained on a Microsoft Excel spreadsheet that is shared over a secured network drive. As our transplant volumes increased it became increasingly difficult to use and the ability to coordinate care became more and more challenging with the increasing number and complexity of the transplants. To overcome these difficulties we turned to the python data analysis library (PANDAS). This library is ideal for data manipulation and analysis. Reports generated using the PANDAS library are sent out in an automated fashion to the members of the transplant team via email through custom python scripts. Quality data such as survival metrics were calculated using the python survival analysis package Lifelines and this along with other metrics such as engraftment, infections, referral patterns etc were visualized using visualization tools such as Matplotlib and seaborn. All of these tools were designed to be run in an automated fashion without much need for coding or maintenance. We have also been able to use python tools to access external API's such as Google Maps, Geocoding and Distance Matrix API's to better understand the geographical location and needs of our patients. Results Python tools and packages has improved our efficiency and has helped us provide high quality coordinated care. Quality improvement and reporting requirements have been greatly simplified and team members can get survival and other quality metrics in an automated fashion with little to no effort. Discussion The python tools that we have developed has helped us in different aspects of the program. We intend to continue to build on this using open source tools that can be customized to the needs of our program. We plan to eventually transition our data to a modern database that can be accessed via a web framework. Python with its Django framework would be an ideal open source platform for such an endeavor and could be used with the AGNIS system to exchange data with CIBMTR.

Utilization of Health Services in the Burkina Faso Health System: Empirical Evidence of Health System Fragmentation and Integration

In this paper, the utilization of health services in the context of health system fragmentation in Burkina Faso is analyzed using household living condition survey data. The methodology explores the relationships between population health risk factors and health services utilization. The results of the analysis highlighted eight reference care providers in the Burkina Faso health system; thus, the probability of service use in the first level of the system, assumed to be its point of entry, is significantly and negatively associated with age and sex, with a lower probability for female gender. As a whole, the health risk factors positively influence the probability of service use at the higher levels of the health system and in the private sector. The results suggest that utilization of the traditional health sector remains predominated by the elderly. These results thus suggest the need for coordination of care across the levels of the public healthcare sector, on the one hand, and the presence of interaction and integration between the traditional or private sector and the public sector, on the other hand.

G301(P) Medical intervention for children with medical complexity (micmac)

Aim To evaluate the effect of targeted consultant time in sharing mental models with parents and nursing staff for children with medical complexity (CMC). Background CMC are part of a mixed caseload covered by the acute paediatric team. We define them here as children with a length of stay ≥ 7 days with ≥ 2 system involvement. Feedback shows these children experience prolonged length of stays (LOS) with a need for coordination of care often between different teams. Parents have highlighted that that better communication with them, within teams and between different teams could improve their child’s journey. Methods All team members were briefed using written and verbal communication as were parents and children taking part. Patients were allocated a weekly slot over a four week period to meet with the MICMAC consultant and a member of the nursing team. Sharing of mental models was facilitated using a targeted proforma covering current expectations and barriers to discharge. The MICMAC consultant was briefed by the service team prior to the meeting and handed back afterwards. Qualitative feedback was obtained using structured debriefing interviews with ward managers and parents. Group debriefing sessions were carried out with the junior medical team and the consultant body covering key themes highlighted by the parental feedback. Results A total of 12 patients with an average LOS of 90 days (range 13–241) over 6 wards were included. 11 consultants led a total of 34 meetings. 3 children were discharged home and 2 patients had withdrawal of care. A total of 6 nursing manager interviews and 9 parental interviews and one substituted lead clinician interview were undertaken. Debriefing of the medical teams was undertaken in 2 group sessions. Positive feedback was centred around improved coordination of care, understanding of overall direction and sharing of information. Conclusions The CMC group is recognised as an expanding patient group. Key factors influencing their inpatient journey involve communication between caregivers and the responsible teams. We highlight how a simple targeted communication tool can improve quality of patient journey.

Improving regional and rural cancer services in Western Australia.

This paper examines health reform which has been designed to improve cancer services across Western Australia. Western Australia is a large state divided into nine regions each with differing demographics. The diversity of the state and the distribution of the population over a large area of land create significant challenge in ensuring equality in service delivery. A comparison was conducted looking at cancer services in Western Australia pre-2005 and service delivery in 2014. A review of the partnership initiatives and programs provides a clear discussion on the need for coordination of care between service providers. The approach undertaken in Western Australia has seen an increase in the delivery of cancer services closer to the patient's home as well as greater involvement of primary care professionals in cancer care. This work has resulted in demonstrated improvements in patient care and support. Services for cancer patients need to be accessible closer to home with distance being an appreciable barrier to treatment access.A statewide approach needs to be developed to ensure all people have equitable access to service delivery.

Which frail older patients use online health communities and why? A mixed methods process evaluation of use of the Health and Welfare portal.

BackgroundFrail older people often receive fragmented care from multiple providers. According to the literature, there is an urgent need for coordination of care. Online and eHealth tools are increasingly used to improve coordination. However, there are significant barriers to their implementation in frail older people.ObjectiveOur aim was to (1) evaluate differences in use of a personal online health community (POHC) for frail older people in relation to personal characteristics, and (2) explore barriers and facilitators for use as experienced by older people and their informal caregivers, using the case of the Health and Welfare Information Portal (ZWIP).MethodsThis is a mixed methods study. For the quantitative analysis, we used POHC usage information (2 years follow-up) and baseline characteristics of frail older people. For the qualitative analysis, we used semistructured interviews with older people and their informal caregivers. Participants were recruited from 11 family practices in the east of the Netherlands and frail older people over 70 years. The ZWIP intervention is a personal online health community for frail older people, their informal caregivers, and their providers. ZWIP was developed at the Geriatrics Department of Radboud University Medical Center. We collected data on POHC use for 2 years as well as relevant patient characteristics. Interview topics were description of use, reasons for use and non-use, and user profiles.ResultsOf 622 frail patients in the intervention group, 290 were connected to ZWIP; 79 used ZWIP regularly (at least monthly). Main predictors for use were having an informal caregiver, having problems with activities of daily living, and having a large number of providers. Family practice level predictors were being located in a village, and whether the family practitioners had previously used electronic consultation and cared for a large percentage of frail older people. From 23 interviews, main reasons for use were perceiving ZWIP to be a good, quick, and easy way of communicating with providers and the presence of active health problems. Important reasons for non-use were lack of computer skills and preferring traditional means of consultation.ConclusionsOnly 27.2% (79/290) of frail older enrolled in the POHC intervention used the POHC frequently. For implementation of personal online health communities, older people with active health problems and a sizable number of health care providers should be targeted, and the informal caregiver, if present, should be involved in the implementation process.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 11165483; http://www.controlled-trials.com/isrctn/pf/11165483 (Archived by WebCite at http://www.webcitation.org/6U3fZovoU).

Disparity of Care for Children With Parent-Reported Autism Spectrum Disorders

ObjectiveAlthough children with autism spectrum disorders (ASDs) are eligible to receive special education services via an individualized education program (IEP), approximately 12% to 20% do not. Our objective was to determine which clinical and demographic characteristics are associated with IEP receipt among a nationally representative sample of children with ASD. MethodsUsing data from the 2007 National Survey of Children's Health, we determined which clinical and demographic covariates are associated with IEP receipt for children ages 6 to 17 years with a current, parent-reported ASD diagnosis (n = 759). Logistic regression models were used to assess the association of covariates with IEP receipt. Application of weighting techniques made the findings representative of the noninstitutionalized population of US children 6 to 17 years old. ResultsIn the weighted model, 90% of children with ASD receive an IEP. Maternal education level above high school (adjusted odds ratio [aOR] 4.08, P = .01) and presence of perceived need for coordination of care (aOR 3.62, P = .02) were associated with IEP receipt, while Hispanic children were less likely to receive an IEP compared with white children (aOR 0.12, P = .001). The following factors were not associated with IEP receipt: severity of ASD, speech, and behavior problems. ConclusionsFor children with ASD in the United States, socioeconomic factors, not disability severity, are associated with IEP receipt. Future research should address methods to overcome this disparity in care. Health care providers may help to advocate for appropriate educational services for patients with ASD.

Abstract 193: Primary Care Utilization Reduces Risk of Readmission among High-Risk Vascular Surgery Patients: Coordinating of Post-Discharge Care Matters

Objectives: Readmissions are a common and costly occurrence following high-risk surgical procedures, but may be avoided if problems are identified early in the post-discharge period. We hypothesized that routine follow-up with a primary care provider (PCP) might reduce 30-day readmissions following a high-risk vascular surgery procedure, thoracic aortic aneurysm (TAA) repair. Methods: We conducted a retrospective cohort study of 42,935 Medicare beneficiaries who were discharged home from US hospitals following open TAA repair in 2003-2010. Primary care utilization was determined within 307 hospital referral regions described by the Dartmouth Atlas, as well as using a 20% sample of Medicare claims for outpatient primary care services within 30-days following TAA repair. We used hierarchical regression models, adjusted for patient and regional level differences, to examine the relationship between primary care utilization with 30-day readmission & mortality following TAA repair. Results: 8,429 (20%) patients were readmitted within 30-days after open TAA repair, and more than 42% of readmissions occurred by 11 days post discharge. Among patients discharged following an uncomplicated hospital course, follow-up with a PCP within 30-days significantly reduced the risk of readmissions (Figure). Even after adjusting for differences in age, race, gender, and complications, PCP follow-up reduced the likelihood of 30-day readmission following TAA repair by over 30% (OR: 0.69; 95%CI: 0.49-0.97; P<0.05). As with most major surgical procedures, readmissions following TAA repair were more likely to occur among patients experiencing postoperative complications (21% vs. 19%, P<0.01). Finally, readmissions were less likely to occur in hospital referral regions with high primary care utilization as compared to regions with low rates of primary care utilization (19.4% high vs. 23.6% low; P<0.01). Conclusions: Medicare recipients discharged following open TAA repair were significantly less likely to be readmitted in regions with high primary care utilization and when primary care follow-up occurred after surgery. These results highlight the need for better coordination of care between surgeons and primary care providers, and suggest an opportunity to focus quality improvement efforts to limit readmission.

Sa1089 Crohn's Disease Patients Need Timely Follow-up Intestinal Surgery: A Potential Role for Integrated Medical-Surgical Post-Operative Care

Background: Coordination of Crohn's disease (CD) post-operative care is essential in order to identify surgical site infections, initiate or resume medical therapy, and identify early signs of disease recurrence. The aim of this study is to evaluate the post-operative gastroenterology (GI) and surgical follow-up care received by CD patients at a tertiary IBD referral center. Methods: We performed an retrospective study of colorectal surgery patients captured in the National Surgical Outcome Improvement Program (NSQIP) database that were admitted to a tertiary IBD referral center with a principal discharge ICD-9 code of 555.x between January 2009 and January 2012. Variables of interest included pre-operative medical therapy, surgical history, and disease phenotype/ location. Primary outcomes of interest were times to post-operative surgical and medical outpatient follow-up, post-operative prophylactic therapy and endoscopic recurrence. Endoscopic recurrence was defined as a Rutgeerts score of greater than i2 on colonoscopy within 6 months post-operatively. Results: During the 3year study period, 114 CD patients underwent intestinal surgery. 70 patients (61.4%) were referrals from academic and 34 patients (28.6%) were referred from community gastroenterologists. Duration from diagnosis to first surgery was 6.6 years (95% CI 4.5-8.7). Among the academic center referrals, the majority (88.6%) had stricturing or penetrating disease, 28.6% were current smokers (n=20), and 40% (n=28) had prior surgical resections. Approximately half (48.6%) of patients were on biologics pre-operatively, with 42.9% on steroids, 22.9% on immunomodulators, and 41.4% on antibiotics. The vast majority of post-operative patients (91.4%; n=64) had surgical follow-up within 4 weeks of discharge compared to less than half (47.1%; n=33) with GI outpatient follow-up (p,0.0001). However, most patients started post-operative medical therapy within 6 months (n=51; 72.8%), with most patients starting or resuming anti-TNF therapy (n=33; 66.7%). Only 54.3% (n= 38) of patients underwent post-operative colonoscopy within 6 months with a 21.1% postoperative recurrence rate by 6 months of discharge. All of the patients with post-operative recurrence were on post-operative therapy, 37.5% on immunomodulators and 62.5% on biologics. Conclusion: For CD patients requiring surgery, follow-up physician visits, initiation of medical therapy, and surveillance colonoscopy remain critical to providing quality postoperative care. The discrepancy in surgical compared to GI follow-up underscores the need for coordination of care between the surgical and GI medical teams. Integrated GI and surgical clinics for post-operative care may improve health care delivery and allow for earlier escalation of therapy, particularly among those at higher risk for aggressive disease recurrence.

Examining Palliative Care Team Involvement in Automatic Consultations for Children on Extracorporeal Life Support in the Pediatric Intensive Care Unit

Extracorporeal life support (ECLS) is an advanced form of life-sustaining therapy that creates stressful dilemmas for families. In May 2009, Seattle Children's Hospital (SCH) implemented a policy to involve the Pediatric Advanced Care Team (PACT) in all ECLS cases through automatic referral. Our aim was to describe PACT involvement in the context of automatic consultations for ECLS patients and their family members. We retrospectively examined chart notes for 59 consecutive cases and used content analysis to identify themes and patterns. The degree of PACT involvement was related to three domains: prognostic uncertainty, medical complexity, and need for coordination of care with other services. Low PACT involvement was associated with cases with little prognostic uncertainty, little medical complexity, and minimal need for coordination of care. Medium PACT involvement was associated with two categories of cases: 1) those with a degree of medical complexity but little prognostic uncertainty; and 2) those that had a degree of prognostic uncertainty but little medical complexity. High PACT involvement had the greatest medical complexity and prognostic uncertainty, and also had those cases with a high need for coordination of care. We describe a framework for understanding the potential involvement of palliative care among patients receiving ECLS that explains how PACT organizes its efforts toward patients and families with the highest degree of need. Future studies should examine whether this approach is associated with improved patient and family outcomes.

Costs and drivers of complementary and alternative medicine (CAM) use in people with type 2 diabetes or cardiovascular disease

AimTo describe the key drivers and costs to individuals of complementary and alternative medicine (CAM) use in a population with type 2 diabetes and/or cardiovascular disease. MethodsTwo datasets were utilised. The first derived from a purpose-designed survey of individuals in Australia, all with type 2 diabetes and/or cardiovascular disease (n=2705). As the vast majority (91%) of the sample had type 2 diabetes, socio-demographic variables were compared to those of people with type 2 diabetes and the general population using the National Health Survey (NHS) of Australia. Step-wise multinomial logit and ordered logit regressions were used for the main analysis. ResultsPeople with type 2 diabetes and/or cardiovascular disease appear more likely than the general population to use both CAM products and practitioners. Concurrent chronic conditions appear to be the key motivators of CAM use, however, CAM use is also associated with lower quality of life. Previous attendance at a chronic disease self-management programme and current attendance at a social or health-related support group were also associated with an increased likelihood of CAM use. Median CAM expenditure was estimated at AU$240 per annum for practitioner use, and AU$360 per annum for product use. ConclusionsChronic conditions appear to be strong independent predictors of CAM use in this population, raising many issues for integrative medicine. In particular, health professionals should be aware that this population are more likely to be using both conventional medicine and CAM, highlighting the need for coordination of care and communication between professionals.

Fractured Care: Doctor of Nursing Practice Opportunities

This case study examines the care provided for a young man with two complex disease processes. Management of the pain caused by one disease resulted in acceleration of the associated comorbid illness. This patient scenario demonstrates the need for coordination of care by one health care provider and illustrates the fractured nature of our specialist-driven health care system. Doctor of nursing practice–prepared advanced practice registered nurses who specialize in comprehensive care are prepared to coordinate care and improve quality of services provided by establishing a patient-centered medical home (PCMH) for every patient, especially those with complex or comorbid illnesses.

Takayasu’s arteritis: a challenging diagnosis

The practices of medicine and surgery are inherently and irrevocably entwined. This case report highlights the need for an integrated, multi-disciplinary approach to care of the modern patient. Our patient fulfils the traditional Ishikawa's criteria and the modified Ishikawa's criteria for the clinical diagnosis of Takayasu's disease. Her case underpins the need for co-ordinated care and careful periodic review of the symptomatology and signs of the multiple clinic attendees.

Health care utilization by persons with severe and persistent mental illness.

Claims for physical health care among 220 Medicaid enrollees with severe mental illness and 166 Medicaid enrollees who were not enrolled in the public mental health system were compared. Claims for the mentally ill group were 18 percent less than for the group without severe mental illness. Twenty-eight percent of claims for mentally ill patients were for treatment in emergency rooms and ambulances, compared with 11 percent for patients without mental illness; 26 percent of claims for patients without mental illness were for care in outpatient surgical and outpatient hospital settings, compared with 14 percent for mentally ill patients. Results suggest inefficient use of the health care system by mentally ill patients and highlight the need for coordination of care.