Standard Model Of Care Research Articles

Use of Telemedicine in Care of Hematologic Malignancy Patients: Challenges and Opportunities.

Purpose of ReviewFor nearly 20 years, oncology specialty practices have been working to integrate telemedicine technologies into standard patient care models. However, hematology practices have been slower to adopt telemedicine due to traditional care models that rely on interdisciplinary regional care centers and their ability to provide comprehensive and centralized services. Patients have traditionally been able to access high-quality medical care, diagnostics, supportive care, and clinical trials from these regional care centers, but they are required to attend frequent in-person visits to access these services. Rural and underserved patients experience more barriers than their urban counterparts to access the same level of care.Recent FindingsThe COVID-19 pandemic has elevated telemedicine into the forefront of care, highlighting both promise and limitations to incorporating telemedicine into specialty hematology care.SummaryHematologists should consider the benefits of incorporating telemedicine technologies into standard-of-care practices to promote patient-centered care and provide equal access to all patient populations.

Delivering patient-centered care: outcomes of comprehensive geriatric assessment across healthcare settings

Comprehensive geriatric assessment (CGA) is a systematic multidimensional and interdisciplinary evaluation that enables clinicians to recognize age-related impairments and develop a coordinated treatment plan and follow-up suited to the patient's needs. Considering the growing number of older persons requiring care in health systems everywhere and the importance of shifting from a disease-specific care model to a more comprehensive care model, we aimed to present the benefits of CGA for older people in different healthcare settings using a narrative review. This patient-centered model of care has been associated with lower hospital (re)admission, maintenance of function, improved quality of life, less caregiver burden, and higher patient satisfaction with the care provided across different healthcare settings. In some contexts — for example, hospitalized older people —, CGA has already been established as the standard model of care as it was consistently related to reduced mortality. Consistent findings from specific contexts (eg, oncology, orthopaedics) also show the importance of CGA in aiding clinicians make better decisions for older patients. It is noteworthy that further evidence from cost-effectiveness studies is still warranted, particularly in community settings. Another encouraging topic for future research is the role of technology in disseminating CGA-based models of care.

Bridging the gap between attitudes and action: A qualitative exploration of clinician and exercise professional’s perceptions to increase opportunities for exercise counselling and referral in cancer care

ObjectiveThis study aimed to 1) understand factors impacting the implementation of exercise communication and referral, and 2) explore integrated clinical approaches to exercise communication and referral in cancer care. MethodsSeven focus groups (N = 53) were conducted with clinicians and exercise professionals throughout Sydney, Australia. A sub-sample of participants (n = 9) attended a half-day workshop to identifying best practice approaches for moving forward. Data were analysed using thematic content analysis. ResultsTwo themes emerged: 1) Factors impacting the knowledge-to-action gap, inclusive of limited exercise specific knowledge and training opportunities, funding structure, and current referral process, and 2) Recommendations for a consistent and efficient way forward, detailing the need for oncologist-initiated communication, distribution of cancer-exercise resources, and access to exercise professionals with cancer expertise. ConclusionsThis study identified factors (e.g., cancer-exercise specific training, integration of exercise physiologists) influencing exercise counselling and referral. A potential implementation-referral approach accounting for these factors and how to incorporate exercise into a standard model of cancer care, is described. Future testing is required to determine feasibility and practicality of these approaches. Practical ImplicationsA pragmatic model is provided to guide implementation-referral, inclusive of oncologist-initiated communication exchange, relevant resources, and access to exercise professionals with cancer expertise.

Predictors of response following standardized education and self-management recommendations for low back pain stratified by dominant pain location

BackgroundLow back pain (LBP) is a leading cause of disability globally. Risk-stratification systems (e.g. STarT Back) have been proposed to guide treatment, but with varying success. We investigated factors associated with poor response to standardized LBP education and self-management recommendations stratified by dominant pain location (back or leg). MethodsLBP patients underwent a standardized primary care model of care of education and self-management recommendations. Poor response was defined as an Oswestry Disability Index (ODI) change score <10 units by 6 months. Multivariable logistic regression was used to identify poor response risk factors, stratified by back-dominant and leg-dominant back pain. Baseline factors: age, sex, body mass index, ODI, LBP/leg-pain intensity, LBP/leg-pain duration, STarT Back chronicity-risk, smoking, comorbidity count, and self-efficacy. ResultsThe sample consisted of 767 patients (443 back-dominant, 324 leg-dominant). Mean age was 53 years, and 59% were female. Females accounted for 66% of back-dominant and 50% of leg-dominant patients. Chronicity risk was ‘high’ for 18% of back-dominant and 29% of leg-dominant patients. Poor response was higher in back- (57%) compared to leg-dominant (42%) patients. Adjusted stratified analyses: female sex, moderate or high chronicity-risk, and increasing age were associated with increased risk of poor response, and greater self-efficacy with favourable response, in leg-dominant patients; these were not the cases among back-dominant patients. Increased comorbidity count was associated with poor response in back dominant patients. In both patient groups, higher baseline ODI score was associated with favorable response, and smoking and longer pain duration with poor response. ConclusionsDifferences in the influence of sex and chronicity risk in particular on outcome by dominant pain location suggests that considering these patients as a single group may not be appropriate. Furthermore, findings suggest that stratification by pain dominance may enhance the use of established risk stratification tools such as the STarT Back.

Changing from telephone to videoconference for pre-treatment pharmacist consults in cancer services: Impacts to funding and time efficiency

Introduction: This study examined the reimbursement opportunity and the time efficiency of a standard care model of unscheduled telephone consults compared to scheduled videoconference consults for obtaining pre-treatment medication histories for patients with cancer. Methods: Data related to (a) the available and the claimed activity-based funding for both models and (b) the number of contacts and the duration of each contact to complete the patient’s medication history via either unscheduled telephone or scheduled videoconference consults were collected and compared. Results: Data was collected for 86 telephone and 56 videoconference consults. The actual activity-based funding claimed for telephone consults was $0, even though $86 of activity-based funding was available for each consult. This represented a $0 reimbursement for the staff time spent conducting the telephone consults, and a missed opportunity to claim $86 per consult. Activity-based funding was claimed for all but one videoconference consult with an average of $205 received per consult, when $221 per consult was available. Videoconference consults were an average of 2.3 min shorter than telephone consults. Discussion: When compared to unscheduled telephone consults, the scheduled videoconference consults represented increased reimbursement and equivalent time efficiency for the cancer pharmacist completing pre-treatment medication histories.

The level of quality care nurse practitioners provide compared with their physician colleagues in the primary care setting: A systematic review.

There is an increasing demand for high-quality primary care providers without adequate supply to meet the need. Nurse practitioners (NPs) are uniquely positioned to fill this demand but influence on regulatory practice authority from concerned groups regarding patient safety and quality of care has delayed this as an effective solution. The objective was to address concerns abovt NP-led care by examining evidence regarding patient safety, clinical outcomes, cost, and patient satisfaction that reflect on the ability of NPs to provide high-quality care within the primary care setting and to compare their ability with standard models of care led by physicians. A systematic review was completed using PubMed, CINHAL Complete, and Scopus. Using PRISMA guidelines to critique literature and the John's Hopkins Research Evidence Appraisal tool, articles were analyzed comparing the quality of care between NP and physician providers in the primary care setting. A total of 11 articles met the criteria and reveal that NPs provide equal or better quality of care for all outcomes outcomes when compared with their physician colleagues. Quality patient care provided by NPs in the primary care setting is equal to, and in several cases superior to, that of physicians. Concerns for patient safety and quality care outcomes seem unsupported by data, and state legislatures should continue to grant full practice authority. as an effective source of providing high-quality primary health care.

Community-based model for the delivery of antiretroviral therapy in Cambodia: a quasi-experimental study protocol

BackgroundMulti-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients’ and health facilities’ burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model’s effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia.MethodsWe will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD—a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers’ work burden, the model’s cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective.DiscussionThis study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response.Trial registrationClinicalTrials.gov, NCT04766710. Registered 23 February 2021, Version 1.

Assessment of Variation in Care Following Hospital Discharge for Children with Acute Asthma.

PurposeTo evaluate potential variation in care management pathways following hospital discharge for children with asthma in New South Wales, Australia.MethodsA cross-sectional web-based survey was conducted in emergency departments (EDs) and paediatric units of public hospitals with more than five paediatric beds within New South Wales, Australia, between July 2018 and March 2019. Nursing and medical staff in EDs and paediatric units who had cared for children aged under 18 years with asthma in the preceding 12 months were invited to participate in this study. Outcome measures included use of clinical practice guidelines and asthma action plan (AAP); advice on post-hospitalization follow-up; provision of asthma education for parents/carers; availability of community-based asthma services; communication with schools/childcare services.ResultsA total of 502 participants (236 nursing and 266 medical staff, response rate=22%) from 37 hospitals were included. Overall, the use of AAP was not universal (median=90%; IQR=81–96%) with significant difference across local health districts (LHDs) (88.6%, 95% CI=85.4–91.3) and between EDs and paediatric wards (p=9.4×10−9); and a range of asthma clinical practice guidelines were used. Post-hospitalization follow-up within 2–3 days was recommended by 70% of the respondents, but only 8% reported that hospitals had a system in place to ensure follow-up compliance. Formal asthma education sessions (27% respondents) were seldom provided to parents/carers during hospital stays, especially in EDs (14% respondents). Less than 50% of the respondents were aware of any asthma community services for children and only 4% reported that schools/childcare services were notified about the child’s hospital admission for an asthma flare up.ConclusionThere are marked variations in the post-hospitalization asthma care and community management for children in NSW. An integrated standardized model of care may improve health outcomes in children with asthma.

Care plus study: a multi-site implementation of early palliative care in routine practice to improve health outcomes and reduce hospital admissions for people with advanced cancer: a study protocol

BackgroundCurrent international consensus is that ‘early’ referral to palliative care services improves cancer patient and family carer outcomes. In practice, however, these referrals are not routine. An approach which directly addresses identified barriers to early integration of palliative care is required. This protocol details a trial of a standardized model of early palliative care (Care Plus) introduced at key defined, disease-specific times or transition points in the illness for people with cancer. Introduced as a ‘whole of system’ practice change for identified advanced cancers, the key outcomes of interest are population health service use change.The aims of the study are to examine the effect of Care Plus implementation on (1) acute hospitalisation days in the last 3 months of life; (2) timeliness of access to palliative care; (3) quality and (4) costs of end of life care; and (5) the acceptability of services for people with advanced cancer.MethodsMulti-site stepped wedge implementation trial testing usual care (control) versus Care Plus (practice change). The design stipulates ‘control’ periods when usual care is observed, and the process of implementing Care Plus which includes phases of planning, engagement, practice change and evaluation. During the practice change phase, all patients with targeted advanced cancers reaching the transition point will, by default, receive Care Plus.Health service utilization and unit costs before and after implementation will be collated from hospital records, and state and national health service administrative datasets. Qualitative data from patients, consumers and clinicians before and after practice change will be gathered through interviews and focus groups.DiscussionThe study outcomes will detail the impact and acceptability of the standardized integration of palliative care as a practice change, including recommendations for ongoing sustainability and broader implementation.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN 12619001703190. Registered 04 December 2019.

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study.

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations. This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended. Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care. This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Implementation of advanced practice nursing for minor orthopedic injuries in the emergency care context: A non-inferiority study

AimsTo evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models. DesignA non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use. MethodsPatients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019. ResultsIn total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06–1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21–0.97). ConclusionAdvanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Daily Hand-Off of Chronic Stroke Neurorehabilitation Patients to Expert Clinicians, With Resulting Significant Coordination Improvement: Care Model Development and Implementation

Background: New models of care delivery are necessary to meet workforce needs while delivering expert care in neurorehabilitation. Therefore, we sought to develop and assess the implementation of a new model of care for neurorehabilitation using a 5-member team of therapists (5-Team Model) for the treatment of individuals with chronic stroke, rather than a conventional single-therapist model. Methods: A mixed methods approach was employed; continuous quality improvement methods and quasi-experimental pre-test/post-test methods were used to assess the effectiveness of the new model. Six chronic stroke patients participated in an upper limb neurorehabilitation motor learning protocol 5 days/week, 5 hours/day (60 sessions; 300 hours); treatment was administered using the 5-Team Model approach to treatment. Results: Mean improvement on the Fugl Meyer (FM) was 11.5 points. All six participants demonstrated improvement on Fugl Meyer that was within or beyond the minimal clinically important difference (MCID) range of 4.25-7.25 points for chronic stroke. Results indicated that the 5-Team Model was effective in implementing care. Conclusions: The 5-Team Model for neurorehabilitation was successfully implemented, with patient hand-off every day to a different therapist; it produced clinically significant improvement on a measure of coordination (FM) which is comparable to or better than prior reports from a standard care model. This new model of care met the needs of the research team workforce for flexibility, while maintaining the level of quality of care. Successful implementation required addressing a series of hindering factors in an iterative manner and enhancing promoting factors. These elements included the context within which the change was implemented, the methods used in implementing the change, the evidence that the change was successful, and communication that the change was successful. The context requirements included existing framework and participating model members who were willing to exert the required effort for success, model champions. This high level of enthusiastic participation along with strong leadership contributed to long-term success, sustainability.

A Decision Aid for midwifery continuity of care: Development and pilot acceptability testing

BackgroundMany maternity services in Australia offer women a variety of models of care including midwife led models. Childbearing women, however, need to understand the differences between these models if they are to make an informed decision about their choice of care. Decision Aids (DA) help people decide when there is not a single best option and the best decision will be based upon the values of the decision maker. There is no current tool that focuses on the choice of midwife led vs other models of maternity care. AimThis research aimed to develop, and pilot test a Decision Aid focusing on the choice between midwife led and standard models of maternity care. MethodsThe DA was developed using the International Patient Decision Aid Standards and pilot tested for acceptability with a group of clinicians who provide antenatal care in one jurisdiction in Australia. A posttest only study was conducted assessing knowledge, acceptability and decisional conflict, with a group of women of childbearing age living in the jurisdiction. FindingsA DA was developed and pilot acceptability testing with 14 women and 13 clinicians of Australian Capital Territory (ACT) health demonstrated its acceptability and highlighting areas for further development. DiscussionSome revisions may be needed to address issues of balance and bias toward midwife-led care identified by some recipients. ConclusionPilot acceptability testing with women and staff of ACT health provides a steppingstone to further research, development and evaluation of this DA.

Breaking Silos: The Team-Based Approach to Coronavirus Disease 2019 Pandemic Staffing.

Breaking Silos: The Team-Based Approach to Coronavirus Disease 2019 Pandemic Staffing.

Preserving Multidisciplinary Care Model and Patient Safety During Reopening of Ambulatory Cystic Fibrosis Clinic for Nonurgent Care: A Hybrid Telehealth Model.

Introduction: The University of Virginia's (UVA's) adult cystic fibrosis (CF) program implemented a rapid and successful transition to telemedicine care mid-March of 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic. In May 2020, the adult UVA CF program redesigned the care model to adjust to the reopening of ambulatory operations and introduced hybrid clinics. The goal remained to minimize person-to-person contacts for patients and care team members (CTMs) while ensuring patient access to quarterly, coproduced, synchronous, multidisciplinary CF care, similar to pre-COVID-19 era regular CF care. Methods: Using quality improvement tools, the UVA adult CF program created a standardized hybrid model of care for in-clinic visits, which included combined components of in-person and synchronous virtual interactions with members of the multidisciplinary team. Results: A total of 16 hybrid visits occurred between May 14 and June 11, 2020. All hybrid visits were multidisciplinary and fulfilled patient requests to see CTMs. All patients seen by hybrid encounter participated in coproduced agenda setting, underwent spirometry, and obtained blood work; 75% provided sputum for surveillance culture. Each hybrid visit type was attended by an average of four CTMs and amounted to 63 separate interactions. Of these interactions, 28 were completed virtually, reducing in-person contacts and personal protection equipment utilization by 44% compared with a fully in-person model of care. Conclusions: Combining in-person and telehealth components in a multidisciplinary CF care model reduces patient and staff interactions and personal protective equipment utilization. The hybrid model of in-person/remote combined care enables reliable access to biological data to support medical decision making while mitigating the risks of person-to-person contact for patients and staff.

Lung cancer recurrence and mortality outcomes over a 10-year period using a multidisciplinary team approach

BackgroundLongitudinal data are limited regarding the impact of a multidisciplinary team (MDT) approach on patient outcomes among those diagnosed with lung cancer. The purpose of this study is to 1) compare 1- and 3-year recurrence and mortality rates among patients receiving a MDT vs. standard model of care; and 2) assess trends in these proportions over a 10-year period. MethodsThis investigation included 2044 lung cancer cases reported to the Stony Brook Cancer Registry between 2006 and 2015. Patients were stratified into 2 groups, those participating in Stony Brook’s Lung Cancer Evaluation Center’s (LCEC) MDT Program (n = 1179) and those receiving a standard model of care (n = 865). 1- and 3-year stage-stratified recurrence and mortality rates are reported. Logistic regression analyses are performed and linear by linear associations are used to assess trends over time. ResultsA higher proportion of patients in the MDT program (LCEC) remained disease-free at 1-year compared those receiving standard care (80.0 % vs 62.3 %, p < 0.01). There were no significant changes in mortality over the 10-year observation period in either group, however the rates were significantly lower among LCEC vs non-LCEC cases after adjusting for possible confounders (OR = 0.68 (0.51,0.90) at 1-year; OR = 0.50 (0.36, 0.70) at 3-years). Recurrence was also lower at 3-years in the MDT group (OR = 0.51 (0.32, 0.79)). ConclusionsThis study suggests that a comprehensive MDT program for lung cancer yields improved patient outcomes compared to the standard model of care and this approach may help to decrease rates of disease recurrence and mortality.

Lags in the provision of obstetric services to indigenous women and their implications for universal access to health care in Mexico

Through quantitative and qualitative methods, in this article the authors describe the perspectives of indigenous women who received antenatal and childbirth medical care within a care model that incorporates a non-governmental organisation (NGO), Partners in Health. They discuss whether the NGO model better resolves the care-seeking process, including access to health care, compared with a standard model of care in government-subsidised health care units (setting of health services networks). Universal health coverage advocates access for the most disadvantaged and vulnerable populations as a priority. However, the issue of access includes problems related to the effect of certain structural social determinants that limit different aspects of the obstetric care process. The findings of this study show the need to modify the structure of organisational values in order to place users at the centre of medical care and ensure respect for their rights. The participation of agents outside the public system, such as NGOs, can be of great value for moving in this direction. Women’s participation is also necessary for learning how they are being cared for and the extent to which they are satisfied with obstetric services. This research experience can be used for other countries with similar conditions.

Midwives’ views of caseload midwifery – comparing the caseload and non-caseload midwives’ opinions. A cross-sectional survey of Australian midwives.

BackgroundMidwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling. AimTo compare views of caseload midwifery – those working in caseload models and those in standard care models in hospitals with and without caseload. MethodsA national cross-sectional survey of midwives working in Australian public hospitals providing birthing services. FindingsResponses were received from 542/3850 (14%) midwives from 111 hospitals – 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload. ConclusionsThere was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives’ views.

A Health System Response to COVID-19 in Long-Term Care and Post-Acute Care: A Three-Phase Approach.

BACKGROUNDThe Seattle, WA, area was ground zero for coronavirus disease 2019 (COVID‐19). Its initial emergence in a skilled nursing facility (SNF) not only highlighted the vulnerability of its patients and residents, but also the limited clinical support that led to national headlines. Furthermore, the coronavirus pandemic heightened the need for improved collaboration among healthcare organizations and local and state public health.METHODSThe University of Washington Medicine's (UWM's) Post‐Acute Care (PAC) Network developed and implemented a three‐phase approach within its pre‐existing network of SNFs to help slow the spread of the disease, support local area SNFs from becoming overwhelmed when inundated with COVID‐19 cases or persons under investigation, and help decrease the burden on area hospitals, clinics, and emergency medical services.RESULTSSupport of local area SNFs consisted of the following phases that were implemented at various times as COVID‐19 impacted each facility at different times. Initial Phase: This phase was designed to (1) optimize communication, (2) review infection control practices, and (3) create a centralized process to track and test the target population. Delayed Phase: The goals of the Delayed Phase were to slow the spread of the disease once it is present in the SNF by providing consistent education and reinforcing infection prevention and control practices to all staff. Surge Phase: This phase aimed to prepare facilities in response to an outbreak by deploying a "Drop Team" within 24 hours to the facility to expeditiously test patients and exposed employees, triage symptomatic patients, and coordinate care and supplies with local public health authorities.CONCLUSIONSThe COVID‐19 Three‐Phase Response Plan provides a standardized model of care that may be implemented by other health systems and SNFs to help prepare and respond to COVID‐19. J Am Geriatr Soc 68:1155–1161, 2020.

Cost analysis comparing a digitally delivered first-line osteoarthritis self-management program with a face-to-face program

Purpose: To perform a costing analysis, comparing costs for the structured and evidence-based Swedish face-to-face osteoarthritis self-management program, with a digitally delivered program, Joint Academy®, based on the face-to-face program. The face-to-face standard treatment model of care meets the Swedish national guidelines of first-line care of OA management. The aim of the costing analysis was to estimate the cost of one episode of care in the respective treatment models (the unit cost). This is defined as the cost of one full treatment episode of standardized care of patients with osteoarthritis. Both models of care are individually tailored treatments of at least three months duration. In the standard model, patients receive on average 15 one hour, physiotherapist-led sessions in addition to three information/education sessions. The digital model of care involves a set of contacts with a physiotherapist and exercise- and education sessions carried out on the patient’s own accord. On average, patients perform rehabilitation sessions 5-6 times per week, each lasting up to ten minutes. In addition to the training sessions, time for transportation, preparation and follow-up, and administration was measured. Methods: The costing analysis adopted a societal perspective where all relevant resources are included, both on the provider/clinic side and on the patient side as well as in any other sector. The analysis involved three main steps: (i) identification of cost items; (ii) quantification of resource use; and (iii) valuation of each cost item. Items were identified and quantified by consulting providers with multiple years of experience of either program. Both on the primary care side and on the patient side most resources were in the form of time. Depending on whose time is used and when activities are carried out, time was valued according to the human capital approach. In the absence of validated data on some measurements, conservative estimates were used to avoid over- or under-estimation of resource use. To ensure fair comparisons, the analysis did not include estimates of the cost of rents and research and development of either of the models. Results: The cost of an episode of care in the digitally delivered management model was around 2 700 SEK (USD281; 257 euro) compared with around 11 500 SEK (USD1 200; 1 100 euro) in the face-to-face model of OA management. Hence, the costing analysis showed that the digital care model is around 75% less costly than a traditional face-to-face model. Around 55% of the cost difference is found on the clinic/provider side and the remaining difference is found on the patient side. Conclusions: A digitally delivered first-line osteoarthritis self-management program uses less resources compared with standard, primary care-based treatment in Sweden. Cost advantages can be found both to payers for care and for users. It remains to be shown if the higher cost for the traditional face-to-face osteoarthritis treatment program for knee osteoarthritis provides additional benefits compared to a digitally delivered program. While direct comparison studies are lacking, early published outcomes do not provide evidence of marked differences in outcomes between the two programs.