Patient-centered Initiative Research Articles

Transforming Dialysis Access Together: A Multidisciplinary, Cross-Cutting, Patient-Centered Initiative.

Transforming Dialysis Access Together: A Multidisciplinary, Cross-Cutting, Patient-Centered Initiative.

The Needle Anxiety Program: A Patient-Centered Initiative for Individuals With Developmental Disabilities.

Objective To describe the development process of a patient-centered initiative focused on improving primary care health outcomes of patients with intellectual and developmental disabilities (IDD) and needle-related anxiety usingevidence-based practices andnovel approaches that canbe implemented in outpatient settings. The overall outcome of the program isto increase vaccine uptake andaccessibilityin the IDD population as well as improve needle-related procedures in primary care settings to be more humane and effective. Methods The development process occurred in the context of a large healthcare system serving a diverse patient population in the U.S. and was led by an expert committee made of an multidisciplinary team of physicians, psychologists, ambulatory and clinic nurses,pharmacists, and anesthesiologistscommitted to promoting quality healthcare for the IDD population. Committee members were recruited within the healthcare system based on their relevant expertise. The methodology included an iterative and collaborative process that took place over three development phases: ideation and design, literature review and synthesis, and expert engagement.The ideation and design phase included a series of planning meetings among the expert committee, in which committee members identified preliminary concerns based on their expertise in the field and background knowledge on the current procedures related to improving routine care for individuals with IDD and/or needle-related anxiety.The literature review and synthesis phase led to the development of an annotated bibliography of research and clinical guidelines that synthesized findingson needle anxiety in clinical care.The expert engagement phase included all Committee members meeting for a final discussion to establish a tiered approach to utilizing evidence-based strategies that could be implemented across clinics within the healthcare system. Results The multidisciplinary team of experts developed a three-tier system, deployed sequentially as needed. The first tier focuses on training nurses in evidence-based behavioral modification strategies to implement as standard of care. The second tier uses the addition of a distraction device and topical analgesic to reduce anxiety in patients with slightly elevated procedural anxiety. The third tier involves a novel minimal sedation protocol using intranasal midazolam for patients with needle phobia that can be administered in an outpatient setting. Conclusion The Needle Anxiety Program eases the administration of needle-related medical procedures in the primary care setting for patients with IDD and needle-related anxiety. The use of evidence-based practices and a novel minimal sedation protocol for individuals with needle phobia assists in the completion of routine healthcare procedures, such as vaccinations and phlebotomy, in a patient-preferred setting. The purpose of delineating needle-related processes and procedures through the Needle Anxiety Program is to reduce health disparities for patients with IDD and promote uptake of the Needle Anxiety Program in similar healthcare settings.

Interdisciplinary antipsychotic stewardship between operator and neurobehavioral consultant

AbstractBackgroundAntipsychotic utilization in skilled nursing facilities (SNFs) is a major focus of regulatory compliance and a key theme in resident care. At first, improvements via national rate lowering initiatives were effective, but as of late, reductions have slowed. Due to a slowing of industry‐wide advancements in the care of behavioral and psychological symptoms of dementia (BPSD), the Federally mandated patient centered care initiative has not widely incorporated “best practices” for BPSD care. This has opened an opportunity for innovations in clinical care of BPSD. In a shared initiative with this operator, we have implemented a joint program focused on rigorous clinical diagnosis and “best practices” in pharmacology support, specifically aimed at assessing and reducing antipsychotic use whenever appropriate.MethodsIn three targeted buildings, all patients identified as receiving antipsychotic medication were enrolled in a specific assessment and treatment protocol designed to mitigate antipsychotic use where possible. Diagnoses were reviewed by Clinical Psychology, Psychiatry, Consultative Gerontology (where indicated), and building Social Service. Additionally, behavioral documentation for each resident was reviewed, and a team approach to polypharmacy, all psychotropic medications, and antipsychotic reductions were implemented. Data was verified by facility pharmacy records, and reports detailing the proportion of residents taking antipsychotic medications were generated in January, March, and July of 2021.ResultsPrior to full implementation of the protocol (January 2021), antipsychotic rates were 32%, 14% and 18% in the three buildings. Immediately following initial review, rates were noted to be similar to baseline (Table 1). After implementation of clinical protocols, we found that the proportion of residents using antipsychotic medications declined to 9.6%, 4.2% and 6.3% respectively (Table 1, Figure 1). In addition, there were no noted harms, nor deteriorations related to the discontinuation of these medications.ConclusionImplementation of a shared cooperative clinical protocol between the SNF facility staff and clinical treatment team resulted in a reduction of antipsychotic use of more than 65% with no noted harms nor clinical decline.

Informed Decision-Making as a Patient-Centered Initiative in Surgical Planning: In Reply to Fink and Colleagues

Informed Decision-Making as a Patient-Centered Initiative in Surgical Planning: In Reply to Fink and Colleagues

A trainee-led quality improvement project to improve fertility preservation counseling and access to fertility preservation services for persons with cancer.

237 Background: For patients of reproductive age with cancer, counseling regarding reproductive risks associated with systemic therapy and facilitating access to fertility services are essential to quality care. We conducted a quality improvement study to improve rates of fertility preservation counseling at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center (SKCCC) in Baltimore, MD. Methods: We formed a multidisciplinary team as part of the ASCO Quality Training Program. We aimed to increase the rate of fertility preservation counseling for patients of reproductive age (18-40 years) with newly diagnosed cancer who were initiating systemic therapy from a baseline (June 2019- January 2020) of 36.7% (25/ 68) to 70.0% by February, 2021. Data sources included the electronic medical record and direct verification with patients by phone. We surveyed patients, oncologists, and experts in reproductive endocrinology and urology to identify barriers to optimal care. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles. Results: We identified the following improvement opportunities: (1) oncologist under confidence about counseling, (2) oncologist lack of knowledge about local fertility preservation options/ processes, and (3) lack of a standardized referral mechanism to reproductive endocrinology/ urology. The first PDSA cycle was disrupted due to COVID-19; from February 2020-August 2020, we introduced the initiative at oncology disease site meetings (e.g., leukemia). In September 2020, we implemented a second PDSA cycle. Our interventions included (1) presenting the baseline data and fellow-led initiative at Oncology Grand Rounds (attended by 150 staff members), (2) creating and distributing paper and electronic informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. This order set included instructions for providers and patients, necessary laboratory studies, and a referral to reproductive endocrinology or orders for cryopreservation of sperm. It also added the following to a patient’s after visit summary: contact information for a dedicated fertility coordinator, estimated costs of services, and financial assistance programs. Post-implementation (September 2020- February 2021), the percentage of patients who reported receiving fertility preservation counseling increased from 36.7% to 80.9% (38/ 47). A sustained shift in the process was apparent on a control chart. Conclusions: Despite disruptions caused by the COVID-19 pandemic, we demonstrate how a trainee-led, patient-centered initiative improved fertility care services for people with cancer. Ongoing work focuses on ensuring sustainability of change, assessing the quality of counseling, and evaluating the impact on utilization of fertility care services.

Trainee-Led Quality Improvement Project to Improve Fertility Preservation Counseling for Patients With Cancer.

Oncofertility counseling regarding the reproductive risks associated with cancer therapy is essential for quality cancer care. We aimed to increase the rate of oncofertility counseling for patients of reproductive age (18-40 years) with cancer who were initiating systemic therapy at the Johns Hopkins Cancer Center from a baseline rate of 37% (25 of 68, June 2019-January 2020) to 70% by February 2021. We formed an interprofessional, multidisciplinary team as part of the ASCO Quality Training Program. We obtained data from the electronic medical record and verified data with patients by phone. We surveyed patients, oncologists, and fertility specialists to identify barriers. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles. We identified the following improvement opportunities: (1) oncologist self-reported lack of knowledge about counseling and local fertility preservation options and (2) lack of a standardized referral mechanism to fertility services. During the first PDSA cycle (February 2020-August 2020, disrupted by COVID-19), we introduced the initiative to increase oncofertility counseling at faculty meetings. From September 2020 to November 2020, we implemented a second PDSA cycle: (1) educating and presenting the initiative at Oncology Grand Rounds, (2) distributing informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. In the third PDSA cycle (December 2020-February 2021), we redesigned the order set to add information (eg, contact information for fertility coordinator) to the patient after-visit summary. Postimplementation (September 2020-February 2021), counseling rates increased from 37% to 81% (38 of 47). We demonstrate how a trainee-led, patient-centered initiative improved oncofertility care. Ongoing work focuses on ensuring sustainability and assessing the quality of counseling.

Minding the Gap Between the Policy and Practice of Patient-Centeredness: Cocreating a Model for Tensional Dialogue in the “Active Patient Support” Program

Several studies identify obstacles to patient-centered care that can be eradicated by bridging the gap between policy goals and practice. In this article, "patient-centeredness" is theorized as an unstable entity riddled with intrinsic, ineradicable tensions. The purpose of the article is to propose a reflexive approach to the tensions as the most appropriate strategy for narrowing the gap between policy and practice. The reflexive approach is illustrated in an account of an action research project on a Danish, patient-centered initiative, "Active Patient Support." The account focuses on the development of a dialogic communication model through collaborative, reflexive analyses of the tensions in the enactment of "patient-centeredness" in dialogue between health care practitioners and citizens-in particular, the tension between empowerment and self-discipline. Finally, the conceptual expansion of one of the dimensions of patient-centeredness, "health-practitioner-as-person," is discussed as a platform for reflexivity, and the limitations of reflexivity are addressed.

Pharmacist Statin Prescribing Initiative in Diabetic Patients at an Internal Medicine Resident Clinic

Background: Despite general increases in statin use in the United States, statin therapy may be underutilized in diabetic patients and vulnerable populations. Objective: To determine the impact of a collaborative pharmacist initiative on statin prescribing for diabetic patients in an internal medicine residency clinic. The primary outcome was the change in prevalence of patients on statin therapy before and after intervention implementation. Secondary outcomes included recommendation acceptance rates and reported adverse effects. Methods: This was a single-center, quasi-experimental pre–post intervention study. The study site was a hospital-based primary care residency clinic serving patients regardless of financial or insurance status. Diabetic patients 40 to 75 years old who were not on a statin and had an upcoming primary care physician appointment were included. Over 3 months, a clinical pharmacist and pharmacy resident evaluated clinical appropriateness and cost of statin therapy, provided recommendations to physicians, facilitated statin prescribing, and provided patient education. Results: Of 454 patients, 343 were on statin therapy (75.6%) prior to the initiative. The mean age was 58 years, 59.7% were female, 76.4% were black, and 90% had hypertension. After implementation, 375 (82.6%) patients were on statins (P < .0001). Recommendations were well received (90.2% accepted) and no significant adverse effects were reported. Conclusion: Pharmacist implementation of a collaborative, patient-centered initiative increased statin prescribing in diabetic patients, most of which were black and had hypertension, in an internal medicine resident clinic.

Is Electronic Access to Medical Records an Empowering and Patient-centered Initiative? – a Qualitative Contextual and Linguistic Analysis of Danish Electronic Records

Political correctness demands a patient empowering and patient-centered approach to health care and today patients are increasingly involved in, and responsible for, their own health. Patients are potentially subjected to large amounts of health information and, in a Danish context, patients have recently gained easy electronic access to their hospital records. Access, which used to be by application, is now only a few clicks away. This initiative is praised as patient empowering and patient-centered even though the e-records are not written for patients, but are the working tool of health professionals. Thus, an expert language text, as it stands, has to function as patient information. In this article, we examine the language of the e-records with a view to determining potential lay-friendliness and thus patient-centeredness. We also discuss whether access, by definition, is a progressive initiative and whether patient empowerment is always the same as patient-centeredness.

Active Search of Patients in Cervical Cancer Control: The Initiative of a Pathology Laboratory in Brazil

Background and context: According to the Global Cancer Observatory, in 2012, worldwide, there were an estimated 266,000 deaths from cervical cancer, accounting for 7.5% of all cancer deaths in females. The pathology and cytopathology laboratories have a very important role in screening and diagnosing cases of cervical cancer. A percentage of suspicious for or diagnosed patients for cervical cancer will be lost in the health system without getting any kind of treatment, resulting in early death. Aim: Analysis of a patient-centered initiative of Active Patient Search (APS) program in cervical cancer control to increase the access of patients to healthcare systems for early detection and treatment. Strategy/Tactics: Performance monitor of the active search program for patients with suspicion or positive for intraepithelial lesion or cervical cancer developed by Centro de Diagnósticos Anátomo-Patológicos (CEDAP) in Joinville-SC, Brasil from January 2002 to December 2017 in a transversal and observational study. Program/Policy process: The CEDAP Laboratory Information System was set to monitor patients suspicious for or positive for intraepithelial lesion or cervical cancer according to pre-established criteria based on the Brazilian National Cervical Cancer Screening Program directives by the National Institute of Cancer (INCA). The system automatically includes patients suspicious or positive for cervical cancer with either Papanicolaou test, biopsy, surgical specimen or high-grade HPV DNA exam. Within the given time interval determined for each category of diagnosis, the ASP starts a process of active search of the targeted patients, being the first step the contact with the clinician regarding the patient monitoring and treatment. Whenever there is lack of response from the clinician or loss of follow-up of the patient reported by the clinician, the laboratory would try to contact the patient or her family directly. Outcomes: From an amount of 1,105,712 cervical cytology exams, conventional and liquid based, with 8573 cases (0.75%) suspicious for or diagnosed with intraepithelial neoplasia or invasive cervical carcinoma and were inserted in the Active Patient Search Program (APSP). Direct contact with the assistant clinician were made in 66.4% of the cases inserted in the APSP, and 4.2% needed direct contact with the patients to finalize the process and bring those patients back to the system for monitoring or for treatment. The index of cases resolved with the APSP actions was 89.7%, with a loss of follow-up of patients of 10.3%. What was learned: Considering the index of clinician adherence and the index of affected patients, the patient-centered Active Search Program initiative is effective, allowing the pathology laboratory to act as a protagonist in monitoring patients with suspicion or positive for cervical cancer, not only as a diagnostic center but also as an active part of the healthcare system in cervical cancer control.

Operationalizing Patient-Centered Integrated Care: The Gap between Discourse and Action

Introduction: Complex patients have multiple chronic conditions, often compounded by psychosocial challenges They require a mix of services delivered by multiple providers across settings, which are optimally coordinated through integrated care models. A key success factor of these models is patient-centeredness and engagement. In 2012, Ontario, Canada launched Health Links (HL), a patient-centered initiative that aims to better coordinate care for patients with complex needs. This is achieved via individualized, coordinated care plans (CCPs) that are tailored to the needs and preferences of every patient. HL documents had a clear vision about how to put patients front and center and engage them in every step of the intervention, including co-designing the program, engaging in implementation and evaluation of the patients’ experience with HL. This study aimed to explore if the vision of patient-centeredness and engagement was operationalized in the same way it was planned. Theory/Methods: We conducted evaluative case studies of three HLs within one regional health authority in the spring/summer of 2016. Data was collected through semi-structured interviews with leaders and providers working within the three HLs and an in-depth document analysis of business plans, pre-implementation documents, meeting minutes and all publicly available electronic materials. We compared documentation to interview data, conceptualizing documents as the source of the planned view and draw the operationalizing view from the interviews. Results: Our preliminary results show that leaders and providers agree with the HLs’ planned view that patient-centeredness and engagement is the key philosophy behind HL as a program. However, in terms of operationalization participants identified a lack of clarity about the mechanisms of execution especially when working with such complex patients. Although the documents emphasized the importance of the role of patients in managing their own care, leaders and providers found many barriers to this for example the low buy-in from some patients and the lack of access to medical records. While having the voice of the patients on HL committees was acknowledged in all HL documents, leaders and providers highlighted that most of the time the patients do not have a voice and even when they do, a single patient will never represent all patients. Conclusions: (Comprising Key Findings) Patient-centeredness is a primary goal of HLs. However, in practice, participants struggled to clearly incorporate and execute patient-centeredness in the design, implementation, and evaluation of HL. Discussion: Our case studies provide analysis on how operationalization of patient-centeredness and engagement can be a challenge to integrated care models. The results can help inform decision-makers on how to better deliver patient-centered integrated care. Lessons Learned: Successful implementation of complex interventions like HL requires detailed clarity on the operational level alongside the policy level. Limitations: Our findings are limited to three HLs in Ontario, however, the results highlight an important discrepancy between discourse and action that may be relevant for other patient-centered integrated care initiatives. Suggestions for Future Research: Future work can examine the challenges in operationalizing a patient-centered approach to integrated care and test interventions that support the engagement of complex, high-needs patients.

Dermatology in an age of fully transparent electronic medical records.

More than 4 decades have passed since the call for “giving patients their medical records” was first proposed to increase patient engagement in health care delivery.1Today, this vision—once considered radical—is quickly becoming reality, with millions of Americans routinely accessing their medical records through web-based patient portals.1 The electronic health record content that patients can access online is expanding to include physicians’ documentation of patient visits. Recent studies evaluating OpenNotes, a patient-centered initiative enabling online access to providers’ clinical notes, have demonstrated high levels of patient utilization and improved self-reported understanding of care planning and medication adherence, resulting in patients “feeling more in control of their health care.”1 One year after implementation of OpenNotes in 3 diverse health care environments in 2010 (Beth Israel Deaconess Medical Center in Boston, Massachusetts; Geisinger Health System in northeastern and central Pennsylvania; and Harborview Medical Center in Seattle, Washington), more than 99% of patients wished to have ongoing online access to clinicians’ notes, paralleled by similar rates of primary care provider satisfaction.1 Open-access notes have since become standard of care at several large health care systems,2 including the Veterans Health Administration; as of January 2014, more than 1.4 million veterans have registered for full online access to their clinical notes.3 However, medical specialties may face distinct challenges consequent to adoption of open-access medical records. As more patients seek—and demand—comprehensive online availability of open-access notes, what will this mean for the field of dermatology? We believe the following issues merit particular attention among dermatologists in the era of medical record transparency.

The Development of a Care Transition Model

Improving population health, providing accessible, high-quality services, and lowering costs are goals that all of us in healthcare share today. 1 the emphasis of healthcare reform on quality, efficiency, and outcomes with the goal to decrease the fragmentation of care, the Care Transition Coalition was developed. This is a patient-centered initiative designed to improve the patient's transition across settings. During an episode of illness, patients may receive care in multiple settings, often resulting in fragmented and poorly executed transitions. our collaborative focus and enhanced continuity of care across health settings, the Care Transition Coalition addresses the deficiencies that occur during transitions by minimizing unnecessary hospitalizations and overutilization of the emergency department (ED). With declining reimbursement and rising health care expenses, nursing leadership must look to new models for leading their patient care staff and achieve exceptional outcomes. 2 As a system of care was being developed, several leadership models were utilized.

An Initiative to Improve Patient Discharge Satisfaction

To provide patients with knowledge needed to make a smoother transition from inpatient rehabilitation to the community or another level of care. The Journey to Discharge concept developed from efforts to clearly communicate the stages a patient travels through on the path to discharge from inpatient rehabilitation. The creation and implementation of this concept led to marked improvement in patient satisfaction scores as measured by Press Ganey Associates. Specifically, measures of discharge-specific questions increased from the 39th percentile in fiscal year (FY) 2009 to the 84th percentile in FY 2011 and gains were maintained through FY 2012 and into this year. The Journey to Discharge guides Marianjoy Rehabilitation Hospital associates in helping patients understand expectations for their inpatient rehabilitation stay. This patient-centered initiative demonstrates an innovate approach to better understanding of the rehabilitation process and to easing the patient's transition across the continuum of care (Brady, 2013). The concept includes a post discharge follow-up component designed to ensure patients are following instructions, thereby potentially lowering the incidence of readmission following discharge. Optimizing patient discharge preparation can lead to improvement in satisfaction scores. Discharging well-prepared patients, coupled with proactive post discharge follow-up has the potential to lower the incidence of readmissions.