Opportunities For Program Improvement Research Articles

An Evaluation of a Cooperative Extension Internship Program

The purpose of this project was to evaluate the Virginia Cooperative Extension internship program from the perspective of student participants and their supervisors. Three focus groups were conducted with internship supervisors from the summer of 2019. Student survey data was used to identify concerns from the student perspective to inform the supervisor focus group questions. In addition to the questions, a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was also used to collect qualitative data within the supervisor focus groups. Findings suggest areas of strength that can be used in marketing as well as opportunities for program improvement.

Abstract PO1-11-01: Effectiveness of Susan G. Komen’s national telehealth patient navigation model in reaching underserved populations and reducing cancer-related distress

Abstract Background: Despite its effectiveness in reducing breast cancer inequities, patient navigation (PN) is not accessible to all patients across the United States. To improve access, Susan G. Komen established a telehealth PN model, scaled to deliver PN services equitably across the country. Methods: Patients are referred to Komen patient navigators through Komen’s Helpline. Navigators conduct an initial distress screening and barrier assessment and create an individualized care plan. This information, recommended interventions, and other health data are documented, 62 days. Navigators communicate via the patient’s preferred method: phone, email, text, or video. A patient satisfaction survey is administered 30 days after the start of navigation. Results: From April 1, 2022, to March 31, 2023, 1,092 individuals were navigated. Navigation was provided throughout the continuum of care, including screening and diagnosis through treatment. Of the 3,064 barriers identified by patients, 63% were economic, 20% related to emotional health, 11% indicated lack of access to care and 6% related to care management. Eleven percent of individuals selected Spanish as their preferred language, 84% had a household income at or below 200% of the Federal Poverty Level and 24% were uninsured. Navigated individuals identified as: 46% Black or African American, 37% white or Caucasian, 20% Hispanic or Latino, 2% Asian, and 14% preferred not to answer. The average patient age was 54 years old, ranging from 20 to 101 years old. 588 patients identified as being diagnosed with breast cancer, with 69% diagnosed as early stage (Stage 0-III), 22% as metastatic (Stage IV), and 8% undesignated. Distress screening is administered, within the domains established by the National Comprehensive Cancer Network, at intake, major transitions in care and end of navigation. Average distress across all domains was 6.1 on an 11-point scale at first observation (a score of 10 indicating the highest level of distress). Financial distress was the highest average (7.5) followed by emotional distress (6.6). During navigation enrollment, financial distress decreased 14% and emotional distress decreased 14%. Survey respondents reported: the Komen navigation program helped them: follow their treatment plan (91%), will help them continue their care (92%), feel more prepared to talk with their care team (91%), to be able to get care faster (88%), and improve their quality of life (91%). Conclusion: Distress screening was developed for a clinical setting with in-network medical and mental health providers. This program’s demonstrates distress screening can be adapted for use in a non-clinical, virtual setting. Socioeconomic, survey, and distress data indicate Komen’s model succeeded in reaching people that research shows have numerous barriers to breast health services and cancer care, and overcome the most common barriers, thus improving access to timely, high-quality care. Opportunities for program improvement include: -To improve support for those experiencing high emotional distress, additional training in emotional support is being incorporated into onboarding and Komen’s Navigation Training Program. - Research shows that navigation is most effective when delivered by someone who shares a lived experience, so the diversity of navigators is important. More bilingual navigators have been added to the program to better serve the Spanish-speaking population. - To improve support of those living with metastatic breast cancer seeking navigation support, Komen has launched a research study to identify the unique needs of patients living with MBC, and use this information to enhance navigation services. Citation Format: Julie McMahon, Shelby Lautner, Mandy Spadine, Toni Lee, Janet Okamoto. Effectiveness of Susan G. Komen’s national telehealth patient navigation model in reaching underserved populations and reducing cancer-related distress [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-11-01.

Youth Suicide Prevention Programming among the Mississippi Band of Choctaw Indians: Effects of the Lifelines Student Curriculum.

Suicide continues to be a leading cause of mortality for young people. Given persistent intersecting forms of disadvantage, Native American adolescents are especially vulnerable to mental health adversities and other suicide risk factors. The Mississippi Band of Choctaw Indians (MBCI) implemented the Choctaw Youth Resilience Initiative (CYRI), a five-year SAMHSA-funded project that began in 2019. This study uses Choctaw student pre-test/post-test survey data to examine the effectiveness of the Hazelden Lifelines Suicide Prevention Training curriculum for youth. A lagged post-test design was used, whereby post-surveys were administered at least one month after program completion. Several intriguing results were observed. First, the lagged post-test model was subject to some pre-to-post attrition, although such attrition was comparable to a standard pre/post design. Second, analyses of completed surveys using means indicated various beneficial effects associated with the Lifelines curriculum implementation. The greatest benefit of the program was a significant change in student perceptions concerning school readiness in response to a suicidal event. Some opportunities for program improvement were also observed. Our study sheds new light on suicide prevention training programs that can be adapted according to Native American youth culture. Program implementation and evaluation implications are discussed in light of these findings.

A Qualitative Study on the Outcomes of Participation in a Longitudinal Clinician Educator Curriculum During Internal Medicine Residency.

Despite increasing prevalence of longitudinal clinician educator tracks (CETs) within graduate medical education (GME) programs, the outcomes of these curricula and how participation in these tracks affects early career development remains incompletely understood. To describe the experience and outcomes of participating in a CET and its effects on recent internal medicine residency graduates' perceived educator skills and early career development. We conducted a qualitative study between July 2019 and January 2020 using in-depth semi-structured interviews of recently graduated physicians from 3 internal medicine residencies at one academic institution who had participated in a CET, the Clinician Educator Distinction (CED). Iterative interviews and data analysis was performed via an inductive, constructionist, thematic analysis approach by 3 researchers to develop a coding and thematic structure. Results were sent electronically to participants for member checking. From 21 (out of 29 eligible) participants, thematic sufficiency was reached at 17 interviews. Four themes related to the CED experience were identified: (1) motivation to go beyond the expectations of residency; (2) educator development outcomes from Distinction participation; (3) factors enabling curricular efficacy; and (4) opportunities for program improvement. A flexible curriculum with experiential learning, observed teaching with feedback, and mentored scholarship allowed participants to enhance teaching and education scholarship skills, join a medical education community, transform professional identities from teachers to educators, and support clinician educator careers. This qualitative study of internal medicine graduates identified key themes surrounding participation in a CET during training, including positively perceived educator development outcomes and themes surrounding educator identity formation.

Improving sleep using mentored behavioral and environmental restructuring (SLUMBER): A randomized stepped-wedge design trial to evaluate a comprehensive sleep intervention in skilled nursing facilities

IntroductionPoor sleep is ubiquitous in skilled nursing facilities (SNFs) and is associated with a myriad of negative symptoms. Non-pharmacological interventions can improve sleep, yet sustainability has not been demonstrated. The Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER) trial will test whether a staff mentoring approach to address resident sleep issues positively impacts sleep quality and whether improved sleep benefits mood, cognitive performance, and activity engagement for residents living in SNFs. InterventionThis is a four-year hybrid type I effectiveness/implementation randomized stepped-wedge trial using a comprehensive sleep improvement program conducted in three urban SNFs. MethodsWe will provide SNF staff with sleep promotion strategies over a four-month intervention. Staff will have access to in-person workshops, webinars, weekly sleep pearls via text messaging, environmental data, and expert program mentors. We will consent residents for data collection (at baseline, end of intervention, and three- and six-months post-intervention) including resident observations, questionnaires, and wrist actigraphy (to objectively measure sleep). We will also use selected Minimum Data Set 3.0 (MDS) measures. ConclusionSLUMBER uses a unique strategy to iteratively improve sleep interventions through SNF staff buy-in, expert mentoring, and technological supports within a quality improvement framework. As a stepped-wedge trial, the initial SNF units provide opportunities for program improvement in subsequent units, accounting for variation across resident populations at different sites. Protocol limitations include strategies which may require substantial customization for greater spread. A comprehensive staff training program that addresses both sleep quality and related symptoms has the opportunity for considerable dissemination.Trial registration: USGOV Clinical Trials ID: NCT03327324

Lessons learned for public health workforce development: An evaluation of the centers for disease control and prevention’s laboratory leadership service fellowship

The Centers for Disease Control and Prevention launched the Laboratory Leadership Service (LLS) Fellowship Program in July 2015 to develop public health laboratory (PHL) leaders who will improve PHL quality and safety. This article describes a retrospective, summative evaluation to determine the extent to which LLS has met its short-term goals for PHL workforce development. The evaluation relied on existing data from routine LLS data collection and reporting, supplemented with a new alumni survey. The purpose of the design was threefold: 1) to reduce data collection burden on program staff and participants, 2) to assess the value and limits of routine fellowship data for comprehensive public health workforce development program evaluation, and 3) to identify ways to improve LLS’s routine data collections for program evaluation. We used descriptive statistics, qualitative analysis, and participatory methods (i.e., a data party) to analyze and interpret data. Results show LLS short-term outcome achievement and highlight opportunities for program improvement, particularly related to the design of certain training requirements and for future evaluations. Overall, the evaluation contributes to lessons learned for PHL workforce development efforts, including how routine data collections can contribute to comprehensive public health workforce development evaluations.

Insights into a Recovery Community Center Model: Results from Qualitative Interviews with Staff and Member Facilitators from Recovery Cafe in Seattle, Washington

ABSTRACT Many people living with substance use disorder require multiple types of support to reduce use and mitigate harms. Recovery community centers have emerged alongside formal substance use treatment and mutual self-help groups as another option to support peoples’ recovery. Research on the helpfulness of recovery community centers is limited. The purpose of this paper was to describe what Staff and Member Facilitators perceived as helpful components of a recovery community center. Semi-structured interviews were conducted with 10 Staff and six Member Facilitators of a recovery community center, Recovery Café, in Seattle, Washington. Qualitative interviews were analyzed via grounded theory approach. Eleven themes emerged on the helpful components of Recovery Café, including tangible/infrastructure and intangible/experiential strengths. Three themes related to opportunities for program improvement. Many themes on the helpful components were consistent with prior research on recovery community centers and other supports for recovery. Findings provide insight into potential active ingredients and mechanisms of recovery community centers and highlight the potential role of recovery capital. Additional research is needed to test these components to improve the understanding of if and how recovery community centers work to support people with substance use disorders in recovery.

Abstract TP38: Evaluation Of A Stroke Survivor To Survivor Program

Background: Since 2015 a Primary Stroke Center in the Midwest has had a Stroke Survivor to Survivor Program (SS2S). The SS2S program was developed by a local non-profit organization whose mission is to provide advocacy, support, education and resources to stroke survivors and their families. SS2S is a telephone-based peer support program that aims to encourage, support, network, and provide resources to stroke survivors post discharge. The SS2S program provides at least 2 monthly calls from trained SS2S stroke volunteers to participants and/or caregivers. The volunteers educate on treatment and appointment adherence, offer community resources, information on support groups, access to Podcasts, and a connection to survivors and/or caregivers with other survivors. Purpose: An evaluation of SS2S was conducted to inform program effectiveness, as well as identify opportunities for program improvement for replication and scalability. Methods: The evaluation study was a one-group, post-only design. Adults who experienced a stroke and received treatment at the study hospital were eligible to participate. Participants who met the inclusion criteria were invited to participate in the SS2S program evaluation. A third party conducted the interviews using a semi-structured interview guide approved by the IRB. Interviews were transcribed and coded for themes using an inductive and deductive thematic approach and analyzed using NVivo 12. Results: Interviews were conducted for four months. 32 participants were contacted, 6 agreed to a full interview and 2 agreed to provide limited feedback. The majority were male and had at least 2 calls with a SS2S volunteer. The majority indicated they had a positive experience. Both participants and coordinators agreed that stroke survivors with residual stroke complications, limited resources and limited social support would benefit from the program the most. The majority of participants agreed that they enjoyed receiving a follow up phone call and were encouraged by them. Conclusions: Although the study sample size was small, the results support the SS2S program aims. The program works best when it connects patients with relevant and timely resources as well as offers the survivors the emotional support to talk freely and feel heard.

Health Advocacy Learning Activities for Medical Students in Clinical Clerkship Training: Why We Are Changing Our Model.

Purpose: Health advocacy is a key physician skill to address social determinants of health and promote health and health equity. 1 We noted a lack of medical school curricula that both address skills necessary to develop partnerships with advocacy stakeholders and students’ desires to self-determine advocacy topic areas. A novel learning project was therefore designed to address these goals. Outcomes were followed for 3 years. We aim to describe student and community health partner outcomes and key lessons learned through the delivery of this project. Approach: The health advocacy project (“HAP”) was incorporated as part of a required ambulatory clinical course at the University of Wisconsin School of Medicine and Public Health (UW-SMPH). The HAP allowed medical students to identify a topic and community partner and required students to arrange meetings with the partner to identify shared goals and a mutually agreed-upon project. Students dedicated approximately 8 hours of work over the 10- to 12-week course to this effort. Projects were focused on community partner goals. At the end of the course, students delivered their project, wrote a summary paper, and completed a self-evaluation on changes in attitudes and practice. Community partners submitted qualitative feedback. Outcomes: After 12 cycles of the course (January 2018 through December 2020), 408 students completed the HAP and 328 students completed a self-evaluation. Of these, 218 (~66%) rated increased likelihood of “Doing Health Advocacy Work in the Future,” and 267 (~81%) rated increased “Comfort Level with Health Advocacy Work.” More than 250 different organizations partnered with students (some hosted >1 student) and 222 organizations gave a definitive response to a survey question regarding the helpfulness of the HAP. Of these, 220 (99%) of these indicated the HAPs were helpful, while the other 2 (1%) responses indicated that there was not sufficient time to complete the project. Additionally, 211 organizations gave a definitive response to question regarding interest in “Partnering with a UW-SMPH student in the future related to Health Advocacy.” Of these, 187 (89%) responded that they were interested in future partnerships; and among the 24 community partners who answered no, the need to have a preexisting relationship with the organization and limited organizational capacity were among the most commonly noted reasons. Discussion: Overall, the HAP was well received by community partners and promoted self-reported student comfort with and interest in future advocacy efforts. Despite these positive outcomes, rare negative feedback from community health stakeholders offered critical insight and clear opportunities for program improvement. The short nature of the HAP likely served as a barrier to successful relationship building in some cases, and possibly contributed to increased pressure on our community partners for capacity due to the recurring cycle of the HAP and student outreach. This prompted curriculum leaders to move beyond the short-term positive impacts and reflect on the long-term institutional footprint of this curriculum within the community. Consequently, after 3 years, we opted to discontinue the current HAP curriculum at the end of 2020, with these lessons informing the next iteration of the health advocacy curriculum. The reimagined health advocacy curriculum will have additional learning activities to address advocacy-related communication, including standardized training before engaging with community partners. In addition, standardized assessment will occur through use of simulated encounters with advocacy stakeholders. Finally, new curriculum will ensure sufficient time and support to community partners when students engage community partners on advocacy efforts. Significance: The HAP demonstrated the feasibility of medical school curricula that promoted student independence and skills in community partnership development; and the majority of student and community partner feedback was favorable. Nonetheless, it was important to address the few exceptions and design a curriculum that adheres to principles of community engagement. 2

Engaging Consumers in Medicaid Program Design: Strategies from the States.

Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies.Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers’ experiences and perspectives into their program design and governance. ContextConsumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient‐centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done.MethodsWe conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio‐recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses.FindingsFirst, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer‐term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers’ participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement.ConclusionsSharing best practices across states could help strengthen programs’ engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.

Consumer Engagement Strategies Among State Medicaid Agencies

Research ObjectiveTo understand how state Medicaid agencies engage consumers in programmatic and administrative decision making, including motivations behind these efforts; perceived benefits; and barriers and facilitators.Study DesignSemi‐structured interviews with 50 Medicaid program leaders across 14 states were conducted using a stratified purposive sampling method based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interviews were audiorecorded and professionally transcribed, and content and thematic analyses were conducted using an inductive approach.Population StudiedState Medicaid agencies.Principal Findings States vary in approaches to consumer engagement. All states reported a federally mandated Medical Care Advisory Council (MCAC), but a number of states customized these standing committees and adopted multi‐pronged approaches to engage different Medicaid populations. Common mechanisms of consumer engagement included standing committees for specific Medicaid topics (eg, long‐term care) or specific programmatic changes (eg, implementing a new managed care program); advocacy group meetings; town halls; and a variety of survey, focus group, and online input‐gathering mechanisms. Motivations for engaging consumers included identifying problems proactively; utilizing enrollee perspectives to improve health prevention and services; and assessing program efficacy, consumer experience, and impact of policy or care delivery changes. Few states linked consumer engagement with the mission of Medicaid; those that did emphasized goals like improving program value, enhancing “patient‐centered” care, and strengthening health equity. Active states formed partnerships with advocacy groups, foundations, and community organizations to support consumer recruitment and participation, facilitate meetings, and provide transportation or travel reimbursement. Strategies for meaningful consumer engagement included ensuring a feedback loop to communicate how consumer feedback is being used; investing time and staffing to facilitate effective interactions with consumers; aligning agency goals with consumer expectations; and training consumer participants to better understand technical language and Medicaid policy complexities. States with less‐robust engagement efforts described a number of common barriers, notably budget and staffing constraints, difficulty recruiting a diverse group of consumers, and sustaining participation over time. While many states could point to theoretical and anecdotal benefits of early consumer engagement, none collected data or monitored its effects. Few states knew of consumer engagement efforts occurring elsewhere in Medicaid, and none reported formal mechanisms for sharing experiences and learnings with other states. States with managed care plans described requiring plans to implement consumer engagement efforts, but none had systematic mechanisms to bring MCO level feedback back to state agencies. ConclusionsThere is significant heterogeneity in states’ efforts to involve consumers in Medicaid policy and programmatic decision making. States with robust efforts tended to be proactive, using diverse approaches and partnering with community organizations. While most states ensured minimum public‐ and consumer‐advocate representation on oversight committees, representation alone was insufficient.Implications for Policy or PracticeAs Medicaid programs grow in size and complexity, leaders face increased expectations to include input from consumers when making programmatic and administrative decisions. Sharing best practices across states could help strengthen consumer engagement efforts despite varying resource constraints and Medicaid program characteristics; identify opportunities for program improvement that reflects community needs; and increase public engagement among a population that has traditionally lacked political voice.Primary Funding SourceThe Robert Wood Johnson Foundation.

Exploring the Outcomes of a Pilot Education Program Tailored for Adults With Type 2 Diabetes and Mental Illness in a Community Mental Health Care Setting

ObjectivesPeople with mental illness and type 2 diabetes are more likely to experience diabetes complications than the general population. Diabetes management can be improved with tailored lifestyle intervention content. The purpose of this pilot study was to investigate diabetes insights of mental health-care patients after participation in a tailored education intervention. MethodsA 12-session diabetes education program was created to address the learning needs and challenges that people with mental illness may experience. The program was assessed through conducting interviews with 6 participants combined with quantitative data to describe the population. Interviews were transcribed verbatim, assessed for quality and coded to identify relationships and meanings between identified themes. ResultsThroughout the year of participation, blood sugar control and physical activity level improved for some and worsened for others. Weight remained stable and dietary intake patterns appeared to improve overall. Participants described the appropriateness of the teaching strategies and program structure developed, and all improved their understanding about diabetes and gained practical self-management knowledge. Opportunities for program improvement included extending care beyond the counselling room to address financial limitations, incorporating a practical activity component and creating opportunities for social support. Additionally, leaving some sessions as patient directed would further individualize education care. ConclusionsOur study offers a concrete education program strategy that aligns with Diabetes Canada’s self-management education guidelines to support the provision of diabetes care for people with mental illness. Modifying program delivery may help to curtail the increasing rates of morbidity and mortality currently observed in this population.

Leadership Development for Future Medical School Deans: Outcomes of the AAMC Council of Deans Fellowship Program.

To determine the outcomes of the Association of American Medical Colleges (AAMC) Council of Deans (COD) Fellowship Program with respect to participants' achieving the goals of becoming a medical school dean and developing leadership skills, and to ascertain fellows' views about the program's value, beneficial aspects, and areas for improvement. The 37 COD fellows from 2002 to 2016 were invited to participate in a 2017 survey addressing demographics, training, current leadership position, and value of the program. The survey also included 3 open-ended questions. A 2018 web-based search was conducted to determine fellows' senior leadership roles since their program participation. The survey response rate was 73% (27/37). The majority of respondents were male (82%, 22), aged 51-70 (89%, 25), and white (82%, 22). The top 5 medical specialties reported were internal medicine, pediatrics, anesthesiology, psychiatry, and surgery. Most respondents (63%, 17) reported having a graduate degree. All reported being in leadership positions in academia and/or health care. The web-based search found that 27% (10/37) of the fellows became medical school deans (average tenure 5.6 years); 2 fellows became deans of other types of schools. Overall, survey respondents perceived the program as valuable. Respondents identified shadowing a dean mentor, attending COD meetings, and attending the AAMC Executive Development Seminar for Deans as the most valuable program components. The majority (88%, 23/26) indicated their fellow experience persuaded them to pursue being a dean; 2 (8%) indicated it did not. Respondents identified 4 key opportunities for program improvement: more sponsorship by deans, development of a learning community, enhanced mentoring, and coaching. The COD Fellowship Program appears to be successful in preparing senior faculty to become deans and assume other senior leadership roles in academia and/or health care. Fellows' feedback will be used to inform future revisions to the program.

A Peritoneal Dialysis Access Quality Improvement Initiative: A Single-Center Experience.

Background:Little evidence exists regarding optimal peritoneal dialysis (PD) access insertion pathways, benchmarking for patency targets, and definitions of access dysfunction.Methods:This quality improvement (QI) project evaluated patients with PD catheters inserted at a single center in Toronto, Canada, following: establishment of PD catheter insertion protocols, a PD access coordinator, PD access operator training, and outcomes reporting. We define primary vs secondary PD catheter dysfunction by presentation before/after initial home PD treatment. We report catheter dysfunction rates, interventions restoring PD catheter patency (interventional radiology [IR] vs advanced laparoscopic [AL]) (embedded vs non-embedded) between 2012 and 2017.Results:A total of 297 first PD catheters were inserted between January 2012 and December 2017. Interventional radiology PD catheters (n = 94) were placed in older patients with greater comorbidities and less prior abdominal surgery than AL-placed catheters. Indications for IR insertion included need for urgent dialysis given resource availability (36.2% [n = 34]) and prohibitive surgical risk (26.6% [n = 25]). Interventional radiology-inserted catheters had overall (primary and secondary) dysfunction rates of 17%. Non-embedded AL catheters had 16.1% overall dysfunction. Embedded AL-inserted PD catheters had a 24.6% overall dysfunction rate. Among all dysfunctional catheters, IR manipulation was successful in 31% (n = 11), and surgical revision was necessary in all unsuccessful cases with either lysis of adhesions or omentopexy to establish patency.Conclusion:Our PD catheter QI initiative involved tracking, outcome reporting, defining PD catheter dysfunction and PD access insertion pathway development, yielding important insights into opportunities for program improvement. Multicenter research initiatives are needed to further improve PD access dysfunction definitions and to establish the best benchmarks for these metrics.

The Program Evaluation Committee in the Adult Cardiothoracic Anesthesiology Fellowship – Harnessing Opportunities for Program Improvement

The Program Evaluation Committee has an essential role in the quality improvement process of the adult cardiothoracic anesthesiology fellowship. The annual program evaluation presents all stakeholders with an opportunity to evolve with the changing needs and opportunities of the fellowship milieu. The active engagement of the program in this process is a high-quality approach to successful planning, preparation and conduct of the self-study and site visit that are important extensions of the annual program evaluation and the program evaluation committee.

Actions in Support of Newborn Screening for Critical Congenital Heart Disease - United States, 2011-2018.

In 2011, the U.S. Department of Health and Human Services added critical congenital heart disease (CCHD), which occurs in two of every 1,000 births, to the list of conditions recommended to states for universal newborn screening (1). Without early detection, infants with CCHD are at risk for substantial morbidity and death in the first weeks and months of life (2). Based on 2007-2013 data, deaths from CCHD and other cardiac causes in infants aged <6 months significantly declined in infants born in eight states after they had fully implemented mandated newborn CCHD screening policies by June 2013 (3). CDC collaborated with the American Academy of Pediatrics (AAP) and the Association of Public Health Laboratories' Newborn Screening Technical Assistance and Evaluation Program (NewSTEPs) to update a 2015 report (4) on states' actions toward adopting and implementing policies supporting CCHD newborn screening. In 2018, all 50 states and the District of Columbia (DC) had implemented CCHD screening policies, and, with one exception, all states mandated that screening be done (California mandates that screening be offered). However, not all states had data systems in place for tracking all screening results and outcomes. Ongoing evaluation activities, which rely on screening data, could help identify program improvement opportunities and monitor the impact of early identification of CCHD.

Challenges and opportunities for outreach workers in the Prevention of Mother to Child Transmission of HIV (PMTCT) program in India.

BackgroundThe Prevention of Mother-to-Child Transmission of HIV (PMTCT) program in India is one of the largest in the world. It uses outreach workers (ORWs) to facilitate patient uptake of services, however, the challenges faced by the ORWs, and their views about the effectiveness of this program are unknown.MethodsThe COMmunity-Home Based INDia (COMBIND) Prevention of Mother to Child Transmission of HIV study evaluated an integrated mobile health and behavioral intervention to enhance the capacity of ORWs in India. To understand the challenges faced by ORWs, and their perceptions of opportunities for program improvement, four group discussions were conducted among 60 ORW from four districts of Maharashtra, India, as part of the baseline assessment for COMBIND. Data were qualitatively analyzed using a thematic approach.ResultsNumerous personal-, social-, and structural-level challenges existed for ORW as they engaged with their patients. Personal-level challenges for ORWs included disclosure of their own HIV status and travelling costs for home visits. Personal-level challenges for patients included financial costs of travelling to ART centers, non-adherence to ART, loss of daily wages, non-affordability of infant formula, lack of awareness of the baby’s needs, financial dependence on family, four time points (6weeks, 6 months, 12 months and 18 months) for HIV tests, and need for nevirapine (NVP) prophylaxis. Social-level challenges included lack of motivation by patients and/or health care staff, social stigma, and rude behavior of health care staff and their unwillingness to provide maternity services to women in the PMTCT programme. Structural-level challenges included cultural norms around infant feeding, shortages of HIV testing kits, shortages of antiretroviral drugs and infant NVP prophylaxis, and lack of training/knowledge related to PMTCT infant feeding guidelines by hospital staff. The consensus among ORWs was that there was a critical need for tools and training to improve their capacity to effectively engage with patients, and deliver appropriate care, and for motivation through periodic feedback.ConclusionsGiven the significant challenges in PMTCT programme implementation reported by ORW, novel strategies to address these challenges are urgently needed to improve patient engagement, and access to and retention in care.

Unpacking the performance of a mobile health information messaging program for mothers (MomConnect) in South Africa: evidence on program reach and messaging exposure.

Despite calls to address broader evidence gaps in linking digital technologies to outcome and impact level health indicators, limited attention has been paid to measuring processes pertaining to the performance of programs. In this paper, we assess the program reach and message exposure of a mobile health information messaging program for mothers (MomConnect) in South Africa. In this descriptive study, we draw from system generated data to measure exposure to the program through registration attempts and conversions, message delivery, opt-outs and drop-outs. Using a logit model, we additionally explore determinants for early registration, opt-outs and drop-outs. From August 2014 to April 2017, 1 159 431 women were registered to MomConnect; corresponding to half of women attending antenatal care 1 (ANC1) and nearly 60% of those attending ANC1 estimated to own a mobile phone. In 2016, 26% of registrations started to get women onto MomConnect did not succeed. If registration attempts were converted to successful registrations, coverage of ANC1 attendees would have been 74% in 2016 and 86% in 2017. When considered as percentage of ANC1 attendees with access to a mobile phone, addressing conversion challenges bring registration coverage to an estimated 83%–89% in 2016 and 97%–100% in 2017. Among women registered, nearly 80% of expected short messaging service messages were received. While registration coverage and message delivery success rates exceed those observed for mobile messaging programs elsewhere, study findings highlight opportunities for program improvement and reinforce the need for rigorous and continuous monitoring of delivery systems.

Evaluation of Hepatitis B Virus Screening, Vaccination, and Linkage to Care Among Newly Arrived Refugees in Four States, 2009-2011.

Many U.S.-bound refugees originate from countries with intermediate or high hepatitis B virus (HBV) infection prevalence and have risk for severe liver disease. We evaluated HBV screening and vaccination of newly arrived refugees in four states to identify program improvement opportunities. Data on HBV testing at domestic health assessments (1/1/2009-12/31/2011) were abstracted from state refugee health surveillance systems. Logistic regression identified correlates of infection. Over 95% of adults aged ≥19 years (N = 24,647) and 50% of children (N = 12,249) were tested. Among 32,107 refugees with valid results, the overall infection prevalence was 2.9% (0.76-9.25%); HBV prevalence reflected the burden in birth countries. Birth in the Western Pacific region carried the greatest infection risk (adjusted prevalence ratio = 4.8, CI 2.9, 7.9). Care linkage for infection was unconfirmed. Of 7409 susceptible persons, 38% received 3 doses of hepatitis B vaccine. Testing children, documenting care linkage, and completing 3-dose vaccine series were opportunities for improvement.

Fighting America’s Highest Incarceration Rates with Offender Programming: Process Evaluation Implications from the Louisiana 22nd Judicial District Reentry Court

Reentry programs, when adequately funded and delivered with fidelity, can render recidivism reduction and other positive outcomes such as abstinence and employment stability. This paper reports process evaluation findings for the Louisiana 22nd Judicial District Reentry Court program, a joint SAMHSA/BJA-sponsored multiphase programming intervention for high-risk/high-need offenders featuring job readiness training in the Louisiana State Penitentiary at Angola and transition services during reentry, including program engagement, job placement, and treatment services continuation in the community under strict judicial supervision. Research procedures entailed 1) observation of court appearances, treatment team meetings, educational activities, and counseling sessions, 2) review of all program participant case files enabling progress tracking, and 3) in-depth and focus group interviews with program stakeholders both at Angola and post-release in community settings. Findings relate the evidence based nature and quality of services delivery to date, as well as fidelity demonstrated across major programmatic domains. Program improvement opportunities, outcome evaluation implications, and performance measures signaling early success center discussion around vanguard elements of the court and evaluation design, respectively.