Shared Care Model Research Articles

Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic

Background and AimsChronic pain is a debilitating condition that requires prompt access to care for effective treatment. Wait times for care often exceed benchmark recommendations, with potential consequences to patient health outcomes. The goal of this paper is to gain the perspectives of patients attending a chronic pain clinic regarding the acceptability of current wait times and the impact of their experiences of waiting for chronic pain care. MethodsThe study took place in a chronic pain clinic at an academic-affiliated teaching hospital in Ottawa, Canada, which housed seven clinicians at the time of the study. New patients attending the chronic pain clinic between July 14, 2014 and August 5, 2015 were eligible to participate based on the availability of the research and clerical staff who administered the survey on a variety of days over the course of the study. Patients completed a self-administered 29-item survey. The survey took approximately five to ten minutes to complete. Questions pertained to patients’ socioeconomic factors, chronicity and burden of pain symptoms, and satisfaction with current wait times. Actual wait times were self-reported. Survey results were entered into an Excel spreadsheet, exported to SPSS, and coded numerically to facilitate descriptive analyses using comparative graphs and tables. Open-text responses were reviewed by the authors. ResultsSixty-six patients completed the survey. While 83% of patients stated that their ideal wait time was less than three months, 32% reported receiving an appointment within this period, and 31% reported waiting a year or more. Only 37% of patients felt the wait time for their appointment was appropriate. During their wait, 41% of patients reported receiving written information about chronic pain and 47% were referred to a local chronic pain management group. 94% reported interference with social/recreational activities and normal activities of daily living, 31% had to miss work or school due to the frequency of ongoing symptoms, and 22% reported being unable to attend work or school altogether. Furthermore, 37% of patients reported visiting the emergency room within the previous year and 65% worried about having a serious undiagnosed disease. ConclusionsOur study found that wait times for chronic pain care, even those triaged as urgent cases, far exceeded what patients considered ideal. Only a third of patients received care within three months of making their appointment, while nearly another third waited over a year. During the waiting period, nearly all patients experienced some impact on their day-to-day activities and work or school attendance, half were unemployed, and nearly a quarter reported a complete inability to attend work or school because of pain. ImplicationsWait times for chronic pain care exceed timelines deemed acceptable by patients, causing anxiety and reducing function. The patient perspective must be considered in initiatives attempting to improve access to care for this population with specific needs and goals. Innovative solutions, such as electronic consultation and shared care models, hold promise.

"To be followed up in general practice" - developing and implementing a shared care model for prostate cancer.

Introduction: The prevalence of PC is rising and upon completion of the initial treatment PC patients are followed-up in the hospital OPD frequently and for many years. Guidelines recommend that patients with PC in stable phase can be monitored, controlled and treated in general practice. We describe how a shared care model for patients with PC was developed and implemented in a Region in Denmark covering 1.2 mill people Methods: (Intervention model): A shared care model was developed by a steering committee, which consisted of general practitioners, patients, urologists and nurses from all urological departments in the Region. The model included (1) a clear description patient categories suitable for transferral to shared care and how follow up should be done, (2) a fixed structure for communication with GPs and (3) systematic patient involvement. With these “hard core” elements in place each department was allowed a “soft periphery” for local adaptation of the model. _Implementation_: The “hard core” elements in the implementation process that should bring the model into the daily clinical life included: Cross-departmental learning, continuous monitoring of patients transferred to shared care and feedback. The “soft periphery” allowed for local decision on how the different elements of the shared care model should be introduced. Results: A total of 2585 patients with PC were enrolled in the study. A total of 758 (29%) patients were elegible for transferral to their GP, and 531 patients (21%) were, in fact, transferred. The main reason that a patient could not be transferred to GP follow-up was unstable PSA and a patient wish to continue hospital follow-up. Patients transferred to shared care were followed up with a questionnaire with a response rate of 71% of which 69% stated that they felt safe “to a great extent” and 27% ” to some degree”. Only 4 % answered ”to a lesser extent/not at all”. The new model was successfully implemented in the study period in all three outpatient departments. However, change was only sustained in the departments where a bottom-up, nurse-led approach, without extra resources had been followed whereas things went back to “usual care” when a top-down project manager based approach was applied. Conclusions: An intervention model for transferral of patient from OPD to general practice was implemented across a Region which freed the equivalent of one month appointments in the OPD. An inclusive implementation process ensured sustainability. Lessons learned: A cross sectorial model for shared care can be successful if developed from a GP perspective and if it includes all stakeholders. The model can be implemented with little external support, but will only be sustainable if implementation is flexible and driven by clinical staff on the ground. Limitations: It is difficult to determine which elements of the model was more important and to what extent and how the specific context influenced the finding. Future research: More cases across different topics and in diverse context will improve generalisability of the implementation principles found in this study

The Inner Sydney Urban Partnership for Health and Wellbeing

The Inner Sydney Urban Partnership is a Collaborative Impact Initiative (CII) bringing together a network alliance of consumers, carers, health, social service providers and local community organisations determined to address the complex needs and adverse trajectories of a vulnerable inner city populations affected by drug and alcohol, mental illness, physical co-morbidities, housing instability or homelessness. The Urban Partnership has bought together people, practitioners and leaders across a local network of care, to support the co-design and co-development of alternative community based systems that will not only reduce barriers to health and support but will create the driving force to shift from the current dependence on crisis care through ambulance, police, ED attendances and inpatient admissions, that are expensive in resources and ineffective in addressing the complex situations and drivers of people’s health and wellbeing. The Urban Partnership has been an important innovation by placing St Vincent’s Hospital, one of Australia's major tertiary health services, at the centre of an integrated mental health care partnership with a full range of community organisations, enabling the skills of a large hospital to be available to support smaller mental health organisations and those providing care in the community, who can touch and make a difference to the individuals involved. For St Vincent’s this is a return to its heritage of ‘curb-side care’ - a return of mental health care to the homes, places and communities where people live, rather than in hospital. It provides the opportunity to redevelop the network and model of care for people who are frequent users of crisis and ED services by supporting a shared care capability across primary care, community based mental health and social care and hospital based mental health, alcohol and drug support. We have used a collaborative system design approach to shape the Urban Partnership, firstly as a relationship and trust building process to create a shared understanding of the role of individual services and capacity available through the partner members of the network and how these can be linked and coordinated through a shared model of care at a system level. We are moving from there to shared training and practice approaches for practitioners and finally a shared person centred plan to support integration at an individual level. These are supported by a UP network infrastructure: - A quality improvement and coordination capability to ensure alignment, quality, coherency and impact is achieved by the individual services and providers. - A resource coordination and allocation capability to reorient resources currently consumed in crisis care towards building community based alternative capacity, using social investment approaches sponsored by state and national government. - A shared data driven learning and performance development infrastructure to enables the Urban Partnership to understand the patterns and journeys through the network that frequent crisis users are making, to focus improvement and measure impact. - An Urban Partnership Stewardship capability that includes leaders from across the network and local community to provide ongoing governance of the Urban Partnership as a whole.

Paediatric Optometry Alignment Project: towards interprofessionalilty between paediatric eye care providers

The Paediatric Optometry Alignment Project (POAP) was established in response to unsustainable demand for paediatric ophthalmology services in Queensland. In June 2015, 1700 children waited for an ophthalmology appointment at the Lady Cilento Children’s Hospital (LCCH), many longer than clinically recommended. Multiple factors contributed to this, including large numbers of children with stable, treated conditions returning for monitoring. It was apparent that collaboration with community optometrists reviewing these patients would improve access. However, a long history of mistrust exists between ophthalmology and optometry, creating a barrier to implementation. Change implemented : LCCH held a workshop on evidence-based paediatric eye care for community optometrists. Optometrists paid to attend the course, consisting of lectures and case discussions. They received referral guidelines, templates and access to online education. Following the workshop, optometrists could become ‘aligned’ with LCCH. Alignment was conditional upon having current registration/insurance, agreeing to follow clinical pathways, and having no affiliation with the Australasian College of Behavioural Optometry (ACBO). Communication channels were established to facilitate discussion and re-referral if necessary. The department began discharging to these optometrists in May 2016. Aim : To develop a shared model of outpatient care for children with specific chronic eye conditions; to manage tertiary hospital demand, improve access to specialist care and improve interprofessionality between ophthalmologists and optometrists. Targeted population/stakeholders : Children over 8yrs with stable, treated strabismus and amblyopia. Stakeholders include: patients/ families, community optometrists, Optometry Australia, Optometry Queensland Northern Territory, Royal Australian and New Zealand College of Ophthalmologists, Children’s Health Queensland and Queensland Department of Health. Timeline : • September 2015 – funding received • October 2015 - project officer recruited • March 2016 – workshop held • May 2016 – 42 optometrists aligned • May 2016 - discharge commenced • June 2016 - interim evaluation Highlights : First Australian project demonstrating collaboration between paediatric ophthalmologists and community optometrists. First international project demonstrating shared management of children with strabismus and amblyopia. Sustainability : Low ongoing costs: • optometrists pay to attend course; bill under Medicare • project officer cost offset by fewer travel subsidies for patients attending LCCH • future workshops planned in regional centres Transferability : The range of conditions discharged should expand over time as ophthalmologists’ trust in the model grows. Training of community providers to align with specialist management has been based on the success of antenatal shared-care programs. The model can be replicated in other specialties. Conclusions : POAP addressed a gap in optometry education, improved family-centredness of care, enhanced access to services and improved collaborative working arrangements between ophthalmologists and optometrists. Lessons learned : We failed to address the potential reputational and clinical risks involved in aligning with behavioural optometrists – a subset of ‘conventional optometrists’ before commencement of the project. Following legal advice, stricter inclusion and exclusion criteria were developed. Discussions : Formal evaluation will occur 12 months post-implementation, including clinical outcomes, wait list analysis and family and clinician satisfaction surveys. Final evaluation should demonstrate cost-effective, family-centred care for children with stable eye disease has been delivered, with excellent clinical outcomes and high family and clinician satisfaction.

Kids GPS Integrated Care - Leaving the Ivory Tower

Introduction : Children are increasingly surviving antenatally with complex and chronic conditions. Their families face significant challenges in navigating the health system, and managing transport, cost, and school and work days missed to access care from the network of tertiary children’s hospitals in NSW - Sydney Children's Hospitals Network. Transformational change is required from this organisation, frequently seen as an ivory tower that isolates children from primary care and local health services. Practice change implemented : Partnerships have been formed with local hospitals and general practitioners, to support an integrated model of care that helps families feel safe wherever they are accessing health services. Care Coordinators are responsible for facilitating shared care models, identifying opportunities to localise care and guiding the child and their family in navigating the health system. The project is using a QI framework, with each of the project streams testing the model of care conducting a series of Plan, Do, Study, Act cycles to refine the model through the experience of each child referred to the program. Aim and theory of change : The aim is for everyone to understand their role in a child’s care plan and feel supported in their work, and for families to feel connected to their local health services. There is emerging evidence that Care Coordination decreases Emergency Department presentations and admissions, and increases parental satisfaction and family functioning. Targeted population and stake holders : The cohorts amongst this population include babies discharged from the neonatal intensive care unit; children with naso-gastric and gastro-jejunal feeding tubes; school children in rural areas; children who present frequently to ED with asthma; and children with food allergies. 160 care professionals have partnered with the Kids GPS initiative, ranging from sub-specialists, paediatricians and nurses, to GPs and Allied Health practitioners in the community. Timeline : The project commenced in 2015 and is currently implementing across three regions. Highlights : Amongst the 190 children enrolled in the Care Coordination service, an estimated 36,500kms in travel and 168 day only admissions have been avoided in the year to June 2016. The program has facilitated GP engagement for more than thirty families who did not have a relationship with a general practitioner when initially enrolled. A parent activation measure is being used to establish a measure of parental satisfaction and empowerment in their involvement in their child’s care. Sustainability : The cultural change, cross-boundary clinical networks and system capacity created by the project will continue to support the Care Coordinators – a permanently funded clinical service – after the project’s conclusion. Transferability : The model tested within the initial cohorts will become standard practice for the Care Coordination Team. Conclusions : Children with even the most complex of conditions can have elements of their care delivered safely in the community provided there is open communication and support available to everyone in the care team, including the family. Lessons learned : A QI framework allows the project to start small and continue to refine as it scales, and the incremental change does not feel threatening to the participants.

Improving team-based care for children: shared well child care involving family practice nurses.

Well child care (WCC) is the provision of routine preventative care and vaccinations to infants and children. In Canada, physicians provide the majority of this type of care, whereas in other developed countries, nurses provide most WCC. New models of shared care between nurses and family physicians should be explored. This pilot project aimed to evaluate the feasibility and acceptability of shared nurse-physician WCC for a cohort of healthy children. A total of 20 participants had nurse-physician alternating WCC visits, which were compared with physician-provided WCC visits. The feasibility was evaluated through chart audits and the acceptability was evaluated through interviews with the physicians, nurses, and the patients' parents. The results showed that physicians and nurses discuss a similar percentage of Rourke Baby Record topics, and that families and clinic staff were accepting of this new model of care. This intervention could liberate time for Canadian family physicians, thereby improving access to care.

Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes

Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.

Advances in rheumatoid arthritis.

There are now eight approved biological disease-modifying antirheumatic drugs (bDMARDs), two biosimilars and one targeted synthetic DMARD in Australia with a number of new products and biosimilars in the pipeline. bDMARDs have excellent efficacy, especially when combined with traditional DMARDs, and a well characterised but manageable safety profile. These expanded therapeutic options have revolutionised patient care and made remission (including drug free remission) a realistic goal. Evidence of a "window of opportunity" that changes the long term phenotype of the disease has been well established, so therapy should be commenced as early as possible in the disease process and a shared care model between general practitioner and rheumatologist provides the best outcomes. While there is no cure for rheumatoid arthritis, treatment has improved to the point where many patients can achieve a normal quality of life.

Experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood lymphoma.

Given childhood cancer survivors' risk of treatment-induced late effects, long-term follow-up care is recommended. We explored experiences with late effects-related care and preferences for long-term follow-up care among adult survivors of childhood malignant lymphoma in Norway. We conducted five focus group interviews with 34 survivors (19 females; 21 Hodgkin/13 non-Hodgkin lymphoma survivors; mean age 39years; mean time from diagnosis 26years). Data was analyzed using principles of thematic analysis. Two main themes were identified: (1) the survivors' experiences with late effects-related care and (2) their preferences for long-term follow-up care. Most of the survivors were dissatisfied with their late effects-related care due to perceptions of poor coordination of healthcare needs in a fragmented system, combined with a perceived lack of knowledge of late effects among themselves and general practitioners (GPs). All survivors valued long-term follow-up care. Oncologists were the preferred care providers, but GPs were considered acceptable providers if they had sufficient knowledge of late effects and routine examinations, short waiting times, and improved GP-oncologist collaboration. Our results suggest that a shared care model of long-term follow-up care involving specialists, GPs, and the survivors themselves is likely to fulfill several of the currently unmet needs among adult survivors of childhood cancers. Improved patient education about late effects and follow-up care would aid self-management. The survivors' concerns regarding lack of sufficient knowledge of late effects among GPs suggest a need for improving access to, and dissemination of, information of late effects.

Shared care across the interface between primary and specialty care in management of long term conditions.

Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care. To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.Secondary questions include the following:1. Which shared care interventions or portions of shared care interventions are most effective?2. What do the most effective systems have in common? We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015. One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting. Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types. We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty). This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.

Rethinking cancer surveillance with shared-care models and survivorship plans: the time is now!

Rethinking cancer surveillance with shared-care models and survivorship plans: the time is now!

The role of the general practitioner in cancer care: a survey of the patients' perspective.

Modern cancer care is provided in highly specialized structures as certificated centres and comprehensive cancer center, as well as specialized practices. In contrast, the position of the general practitioner (GP) is less well characterised and there is a lack of information about his importance in the care for cancer patients. The aim of our survey was to assess the role of GPs in German cancer care from patients' perspective. In several steps we developed a standardized anonymous questionnaire in cooperation with the German Association of General Practitioners and the Federal Association of German Self-Help Groups. This questionnaire was used in a print and an online version and distributed by the self-help organizations to their members. Seven hundred and forty participants took part in the survey, 66.5% women and 30.1% men. 71% had visited the GP during cancer therapy and 34.5% discussed decisions concerning diagnostics and therapy with him. The most relevant reasons to visit the GP during cancer therapy were to get a blood test (63.3%), comorbidities (42.7%) and complaints and side effects (38.3%). For the latter, most often a detailed discussion ensued (57%), fooled by a prescription (37.7%). In 63.4% the GP offered support when patients had some questions or worries concerning their cancer. Yet, 17% of the patients reported that the GP did not try to help. 85.5% of the participants thought that it is important that their GP is informed about the therapy on a regular basis. For 77.0%, a simultaneous care provided by the GP is important or very important. Our survey points to the importance of the GP during cancer therapy from the patient's point of view. Patients want their GP to take an active part in the cancer therapy. Furthermore, early integration of the GP may also enhance early integration of palliative care and also help family members and caregivers. A strategy to integrate GPs is the establishment of shared care models, in which GPs are supported by specialists and get additional training in cancer care.

Evaluating preliminary outcomes among primary care and oncology providers who participated in the cancer survivorship e-learning series for primary care providers.

78 Background: The American Cancer Society estimates there are 15.5 million cancer survivors in the U.S. and projects this number will rise. Survivors are at increased risk for a variety of issues due to cancer and its treatment including long-term and late effects. In recent years, there has also been increased focused on ensuring coordinated care for survivors to address these and other issues. Methods: Launched in 2013, the E-Learning Series evaluation employs self-report pre/post surveys using a 5-point Likert scale of agreement. In an initial analysis conducted with available data, participants who took more than one module were represented more than once in the total sample. Independent samples t-tests and Mann Whitney U tests were used for tests of significance for comparisons between PCP and oncology providers. Results: Of the respondents (n = 1,662), PCPs were represented on average 30% across modules. Both PCP and oncology providers reported knowledge gains across modules from pre (Mean pre-range for PCP = 2.96-3.71, SD = 0.797-1.022; Mean pre-range for oncology = 3.28-3.92, SD = 0.717-0.964) to post (Mean post-range for PCP = 4.05-4.44, SD = 0.568-0.716; Mean post-range for oncology = 4.28-4.49, SD = 0.525-0.611). Mean change scores for PCPs ranged from 0.66-1.15 (SD = 0.671-1.093) and for oncology providers change scores ranged from 0.58-1.04 (SD = 0.700-0.967). Related to shared-care model, differences in perceived knowledge gain about treatment late effects were statistically significant (p = 0.001) between PCPs (change score mean = 0.92, SD = 0.975) and oncology providers (change score mean = 0.58, SD = 0.799). Differences were also seen in rehabilitation module, with PCPs indicating gain in ability to identify appropriate interventions (p = 0.047). Conclusions: Initial results indicate the E-Learning Series is effective in improving knowledge about needs of survivors as well as recommended care practices among providers.

Telepsychiatry- Prevention and Treatment in the Outskirt Areas, A Shared-Care Model within a Danish Context

This article reports on a project running over 24 months from July 2010 until July 2012, conducted by The Little Prince Psychiatric Centre in Copenhagen in cooperation with three general practitioner’s clinics on the outskirts of Denmark. The article outlines the conceptual shared care model, in which psychiatrists and psychologists collaborate with general physicians in the assessment, diagnosis and treatment of mental health patients in the context of the general physician’s office by use of telepsychiatry service. A formal evaluation of the project was conducted and outcomes are discussed along with issues related to the requirements for sustaining the service over time and broadening its applicability. The results has shown that collaboration via use of videoconferencing across levels of health care sectors can be a useful alternative that offers learning, leads to continuity, reduces costs and improves the quality of care. Telepsychiatry, in the form of video conferencing, has been well received by patients (n=27) and general practitioners (n=3) as a method reducing waiting time and bridging the distance between patients and specialized psychiatric care.

Promoting the Shared-Care Model for Adolescent and Young Adults With Cancer: Optimizing Referrals and Care Coordination With Primary Care Providers.

The "shared-care model" for patients with cancer involves care coordination between primary care providers (PCPs) and oncologists, with the goal of optimizing survivorship care. However, a high proportion of adolescent and young adult (AYA) cancer survivors do not have a PCP. Study objectives were to increase the percentage of AYAs with a PCP documented in the electronic medical record (EMR) via the use of a best practice advisory (BPA) or "stopgap" intervention; to increase communication between providers by the number of routed clinic notes; and to assess oncology providers' attitudes/beliefs about the model and intervention. Data were collected for the 6 months before implementation of the BPA to determine the percentage of AYAs with a PCP and the number of notes routed to providers (time point 1 [T1]). The same data were collected at time point 2 (T2) after the BPA had been implemented for 6 months. Oncology providers participated in an education video module and an online survey at T1 and a survey at T2. At T1, 47.1% of 756 AYAs had a documented PCP in the EMR. At T2, the percentage increased to 55.1% (P<.002). The number of routed notes did not change significantly from T1 to T2. Providers that completed the intervention survey agreed/strongly agreed that the shared-care model is a desirable model of care (T1 = 86%; T2 = 93%) and that a BPA is useful for facilitating PCP referrals (T1 = 76%; T2 = 39%). This BPA is feasible for increasing the percentage of AYAs with a PCP documented in the EMR and could potentially lead to increased PCP referral and communication among providers for the benefit of long-term survivorship care. Providers generally agree with the shared-care model; however, the BPA implementation requires modification.

Pioneering outcomes based innovation in general practice

Introduction: There is increasing interest in the role of general practice as a vehicle of integration. This relates to its potential for direct delivery of an enhanced range of services, its role in the co-ordination of care for those with multiple morbidity and in its relationships with other services and organisations who work in primary and community care. A key issue in realising these aspirations is how to motivate and enable practices to take on these enhanced responsibilities and be willing to work differently with other professionals and services.In England there has been a reliance on financial rewards to ensure that general practice responds to new ways of working and provides the required breadth of services. The nature of these rewards, and the improvements that they relate to, have been set by central government policy makers and local purchasers of primary care. Whilst this approach has led to some positive improvements, there has been inconsistency in the level and quality achieved, and the tight specification of the process to be followed has been seen to restrict opportunity for other innovations. There are also concerns that it has resulted in many general practitioners being deterred from identifying and developing their own creative responses to local needs.Change in practice: This project was introduced within a clinical commissioning group (CCGs) responsible for an urban population of 300,000. CCGs are membership organisations which commission primary and acute health care services for the patient population registered with their member practices. The ‘pioneer project’ aimed to introduce a new purchasing approach which would motivate and liberate general practices to develop and adopt new integrated models of care through providing a more ‘enabling environment’. The key elements of this approach were -- Requiring practices to work in groupings rather than as single practices- Providing funding up front rather than in arrears on completion of required activity or quality- Determining success by achievement of outcomes rather than by implementing process- Embedding a culture of joint learning and reflection between the practices and with the commissionerKey stakeholders were the staff working within the general practices, the commissioners, provider of community nursing services, acute hospitals and the adult social work division within the local authority. The university were funded to undertake an 18 month mixed methods action research project which would provide emerging data for discussion and a final summative assessment of what was achieved.Key findings: The evaluation will be completed in December 2015. Emerging findings are:- All groupings of practices have been able to provide enhanced diagnostics and treatment for key conditions such as diabetes. This has enabled diversion of these activities from acute to primary care and provided care closer to patients’ homes.- The groupings have provided a firm base from which general practice can consider an enhanced depth and breadth of services, and have also resulted in a raising of quality within members of the groupings.- The majority of groupings have developed new ways of working which respond to the needs of their local populations – these include the development of innovative model of shared care between acute and primary care regarding people with diabetes from south asian communities, the introduction of new joint protocols with accident and emergency, and community link workers to connect people with complex social needs with appropriate support from statutory and voluntary sector servicesHighlights of learning- The practice leads confirmed that the previous arrangements had stifled innovation and led to them not feeling able or motivated to suggest or lead more radical improvements. Adjusting to the new expectations and freedoms involved a significant paradigm shift for them (and the commissioner)- Learning sets which brought together the pilot leads and commissioner were seen as key opportunities to share practice and challenges, albeit it with considerable opportunities for further strengthening of this reflective approach- There was greater success in engaging with key services in the acute sector through engaging with key professionals – community health and adult social care were harder to influence due to lack of personal connection and alternative initiatives being pursued- Conceptualisation of outcomes within the commissioner has changed over time and been subject to internal tensions.Conclusion:- The pioneer project facilitated a more collaborative relationship between purchaser and general practice which encouraged and facilitated greater clinical leadership. For these groups of practices funding was an enabler rather than an incentive, providing ‘capacity and flexibility’ rather than ‘motivation and reward’.- The final data gathering will seek to establish improvements in outcomes and quality, and the extent to which changes have been sustained when the project phase is completed.

Significantly Inferior Overall and Event Free Survival in Pediatric Oncology Patients with Symptomatic Venous Thrombotic Events As Compared to Those without Symptomatic Venous Thrombotic Events: A Population Based Study from Maritimes, Canada

Background: Symptomatic venous thrombotic events (sVTE) are a well-recognized complication in pediatric oncology patients. Although data exists on incidence, risk factors and outcome of sVTE, the association of sVTE with survival outcome in pediatric oncology patients has not been previously assessed. The present study was designed to assess the survival outcome in pediatric oncology patients who developed sVTE as compared to those who did not develop sVTE.Aims: To assess the overall survival (OS) and event free survival (EFS) in pediatric oncology patients with and without sVTE.Methods: The Maritimes constitutes the 3 Canadian Provinces of Nova Scotia, New Brunswick and Prince Edward Island (total population = 1.8 million). All pediatric oncology patients from the Maritimes are treated at IWK Health Centre (IWK) in a shared care model with regional provincial hospitals. This provides a population-based cohort. Institutional ethics board approval for this retrospective study was obtained.A database of all pediatric oncology patients treated at the IWK Health Centre from 2000-2015 was created by amalgamating data from (i) pediatric oncology hospital database (ii) Provincial Cancer in Young People registry (iii) pharmacy database and (iv) hospital health records. All pediatric oncology patients who developed sVTE were identified using the above databases. Data from all databases was cross-verified for accuracy and then pooled.Data on patient demographics, diagnosis, date of diagnosis, date of last follow up, date of first relapse, and date of death were extracted. Status of every patient on or up to 31 December 2015 was reviewed.SPSS version 22 was used for statistical analysis. Survival outcome was assessed using the Kaplan Meier method. Survival was reported in complete months.sVTE was defined as radiologically documented VTE with at least one sign/symptom directly associated with VTE. First relapse or death were classified as events for calculation of EFS. Both OS and EFS were calculated from diagnosis of cancer.Results: Forty-seven (5.02±0.01%) of the 936 patients had sVTE. The mean age at diagnosis for sVTE patients was 10.1 years. The gender ratio was male:female= 1.8:1 in patients with sVTE. Central veins were the most common location for sVTE (72.3%, n=34). The underlying cancer diagnosis in patients with sVTE were leukemia (36.2%, n=17), lymphoma (19.1%, n=9), sarcoma (19.1%, n=9), brain tumor (2.1%, n=1) and others (23.4%,n=11).The OS of patients with sVTE was significantly inferior (p<0.001 by log rank test) as compared to those without sVTE (Figure 1). The estimated mean OS of patients with and without sVTE were 133.1 ±33.6 and 163.7 ±4.8 months respectively (p<0.001). The estimated 5 year OS for patients who developed sVTE was significantly inferior (p=0.007 by log rank test) as compared to those without VTE.Of the 47 patients with sVTE, 17 (36.2%) died. In comparison, among patients without sVTE, 133 (15%) died (p=0.001).The EFS of patients with sVTE was significantly inferior (p<0.001 by log rank test) as compared those without sVTE (Figure 2). The estimated mean EFS of patients with and without sVTE were 112.7 ±31 and 148.7 ±5.9 months respectively (p<0.001).Conclusion: In a large population-based cohort, we demonstrate that the survival outcome of pediatric oncology patients with sVTE is inferior as compared to those without sVTE. A plausible explanation is that patients at higher risk for death: poor prognosis/advanced cancers and those with more intense multimodality therapy are more likely to be diagnosed with sVTE. Validation of these findings is necessary, as is a better understanding of the drivers for this association of sVTE with early death and the possible role of thromboprophylaxis in optimizing outcomes. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Venous thromboembolism and stroke in pregnancy.

Pregnancy and the postpartum period substantially increase the risk for thrombotic events. Although the absolute risk for thrombosis is low, these events comprise a significant portion of maternal morbidity and mortality. The vast majority of such events are venous, although the risk for ischemic stroke also appears to be increased in pregnancy. This review will explore the overlapping and unique risk factors for venous and arterial thrombosis in pregnancy. Diagnosis and prevention will be discussed, and treatment will be briefly touched on. The benefit of using a multidisciplinary model in caring for pregnant women who have had a thrombotic event or who are at increased risk for thrombosis is a major focus of the review. Using the experience of our own Hematology and Obstetrics/Maternal Fetal Medicine shared care model, we discuss specific examples of when the use of such an approach is particularly valuable.

Developmental Behavioral Pediatrician Support of the Medical Home for Children with Autism Spectrum Disorders.

To identify challenges primary care providers (PCPs) experience providing a Medical Home for children with autism spectrum disorders (ASDs) and to describe the role developmental behavioral pediatricians (DBPs) play in the Medical Home Neighborhood. The authors used purposeful sampling to recruit 25 PCPs from around Colorado to participate in 4 focus groups. Member checking was performed at the end of each group. Sampling continued until themes repeated and saturation was achieved. Focus groups were transcribed verbatim, and transcripts were analyzed using content analysis; an outside reviewer audited the data. Qualitative analysis yielded 30 codes that fell into 7 themes: provider education, shared model of care, initial diagnostic evaluation by the DBP, communication, office factors, cost and coverage, and access. PCPs identified knowledge gaps that led to decreased comfort and desired ongoing education and a centralized resource for providers. They envisioned a shared care model with ongoing specialist collaboration and improved communication within the care team. A specific role desired of the DBP was to provide the initial diagnostic evaluation and treatment plan with specific resources. Office factors, high cost and variable coverage, and poor access to services were barriers to providing a Medical Home for children with ASD. Working to remove barriers to shared care as well as providing continued educational opportunities will help improve access to a Medical Home Neighborhood for children with ASD. Advocacy is needed to help remove barriers related to cost, coverage, and access to services.

Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study.

BackgroundMany patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness.ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention.MethodsThis will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients.DiscussionThis study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study.Trial registrationANZCTR ACTRN12616000206426