The Environment of Care Model: a paradigm shift in comprehensive breast care

OA21.06 Turning Best Supportive Care into Active Care. A Service Development for Patients with Advanced Lung Cancer in NHS Fife, Scotland

The healthcare industry has already been burdened by longstanding trends like aging populations, provider burnout, and patient dissatisfaction. Healthcare burnout has increased significantly during the pandemic. Many factors are putting strain on the industry: expanding healthcare roles, squeeze in reimbursements, competition for patient volume, shifts in the delivery of care, and a shortage of providers and staff. These factors have contributed to the unprecedented challenge forcing healthcare organizations to rethink established norms and operational best practices. While new technologies have promised significant clinical and operational benefits for healthcare organizations, COVID-19 has turned them from nice-to-haves to imperatives. This session will discuss how today’s workforce crisis can be addressed through new models of care such as telehealth.
 Objectives:
 
 Discuss the business process and business applications revolution
 Explain the experience revolution
 Describe the impact of new models of care on the clinical workforce

As healthcare policy moves from the realms of "treating disease" towards supporting "well-being" there is a natural move from traditional hospital services to community care. Chaplaincy and Spiritual Care services are uniquely placed to understand the language and essence of this paradigm shift and are developing new models of spiritual care to support it. However, such a shift is not without its challenges. This article explores the shift from current healthcare practices to the promotion of communitybased care focused on well-being in NHS Scotland. It introduces the new models of spiritual care that are being developed to embrace the change. In conclusion, it highlights the challenges of change that arise from new models of care while at the same time embraces the recognition of spiritual care as an integral dimension of modern healthcare.

BackgroundA new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner (GP) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting. This study evaluates the health and clinical benefits of the new model of care, assesses the acceptability of the model to patients, GPs and other health professionals, and examines the cost-effectiveness of the model.Methods/DesignThe study is an open, non-inferiority randomised controlled trial with data collected at baseline, 6 and 12 months. Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals. Eligible consenting patients are randomised to either a community practice site (intervention) or a hospital site (usual care). In the intervention model, medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist. Quantitative measures include clinical indicators with HbA1c as the primary outcome; patient-reported outcomes include health-related quality of life, mental health and satisfaction with care. Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care. An economic evaluation will also be undertaken.DiscussionThis model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes. The study will provide empirical evidence about the impact of the model of care on health outcomes, patient and clinician satisfaction, as well as any economic impacts.Trial registrationClinical Trials Registry Number:ACTRN12612000380897

BackgroundMany countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key ‘components’, impacts of new models of care, and barriers and facilitators to PCT implementation.MethodsWe undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.ResultsA total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.ConclusionsCountries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

BackgroundPrior to the implementation of a new model of care in long-term care facilities in the Capital District Health Authority, Halifax, Nova Scotia, residents entering long-term care were responsible for finding their own family physician. As a result, care was provided by many family physicians responsible for a few residents leading to care coordination and continuity challenges. In 2009, Capital District Health Authority (CDHA) implemented a new model of long-term care called “Care by Design” which includes: a dedicated family physician per floor, 24/7 on-call physician coverage, implementation of a standardized geriatric assessment tool, and an interdisciplinary team approach to care. In addition, a new Emergency Health Services program was implemented shortly after, in which specially trained paramedics dedicated to long-term care responses are able to address urgent care needs. These changes were implemented to improve primary and emergency care for vulnerable residents. Here we describe a comprehensive mixed methods research study designed to assess the impact of these programs on care delivery and resident outcomes. The results of this research will be important to guide primary care policy for long-term care.ObjectiveWe aim to evaluate the impact of introducing a new model of a dedicated primary care physician and team approach to long-term care facilities in the CDHA using a mixed methods approach. As a mixed methods study, the quantitative and qualitative data findings will inform each other. Quantitatively we will measure a number of indicators of care in CDHA long-term care facilities pre and post-implementation of the new model. In the qualitative phase of the study we will explore the experience under the new model from the perspectives of stakeholders including family doctors, nurses, administration and staff as well as residents and family members. The proposed mixed method study seeks to evaluate and make policy recommendations related to primary care in long-term care facilities with a focus on end-of-life care and dementia.MethodsThis is a mixed methods study with concurrent quantitative and qualitative phases. In the quantitative phase, a retrospective time series study is being conducted. Planned analyses will measure indicators of clinical, system, and health outcomes across three time periods and assess the effect of Care by Design as a whole and its component parts. The qualitative methods explore the experiences of stakeholders (ie, physicians, nurses, paramedics, care assistants, administrators, residents, and family members) through focus groups and in depth individual interviews.ResultsData collection will be completed in fall 2013.ConclusionsThis study will generate a considerable amount of outcome data with applications for care providers, health care systems, and applications for program evaluation and quality improvement. Using the mixed methods design, this study will provide important results for stakeholders, as well as other health systems considering similar programs. In addition, this study will advance methods used to research new multifaceted interdisciplinary health delivery models using multiple and varied data sources and contribute to the discussion on evidence based health policy and program development.

Introduction Interprofessional interventions improve the ability of health professionals to work in teams, communicate effectively, respect and appreciate each other, and develop shared patient-centric values. While these interventions can change attitudes and beliefs about interprofessional collaboration, the relationship between interprofessional collaboration and patient health outcomes remains poorly understood, particularly for socioeconomically disadvantaged populations. This study sought to explore the relationship between interprofessional collaboration and patient health outcomes in urban disadvantaged settings. Methods Constructivist grounded theory methodology was used to perform 4 focus groups and 19 individual interviews with health professionals working in these settings in the United States. Emergent themes were developed into a conceptual model that captures their views on the link between interprofessional collaboration and patient health outcomes in these settings. Results 114 qualitative themes were identified and collapsed into 10 theoretical categories (interprofessionalism, building trust, coordination, facilitating sharing, patient care, enhancing reciprocity, common goals, effecting change, healthcare system disparities, and patient individual, group or population disparities), all of which were then merged into two theoretical concepts that explain all of the data (social capital and disparities). Conclusion Interprofessional collaboration works via better coordination and optimization of patient care, which explains how better patient health outcomes may be achieved. However, it is social capital and its cognitive elements of trust, sharing and reciprocity that underlie this phenomenon and explain why better health outcomes may be possible via interprofessional collaboration. Additional research studies exploring patient perspectives and the structural elements of social capital in this context are warranted.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through to the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. The objective of this study was to compare the new model of care with standard maternity care. In a randomized controlled trial, 1000 women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to receive continuity of midwifery care (team care) from a group of seven midwives in collaboration with obstetric staff, or care from a variety of midwives and obstetric staff (standard care). The primary outcome measures were procedures in labor, maternal outcomes, neonatal outcomes, and length of hospital stay. Women assigned to the team care group experienced less augmentation of labor, less electronic fetal monitoring, less use of narcotic and epidural analgesia, and fewer episiotomies but more unsutured tears. Team care women stayed in hospital 7 hours less than women in standard care. More babies of standard care mothers were admitted to the special care nurseries for more than 5 days because of preterm birth, and more babies of team care mothers were admitted to the nurseries for more than 5 days with intrauterine growth retardation. No differences occurred in perinatal mortality between the two groups. Continuity of midwifery care was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal and perinatal safety. Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service.

Introduction Advances in telehealth and technology have created opportunities for a more comprehensive care approach for patients with OSA. However, it is unclear if these comprehensive care models translate to improved treatment adherence and patient satisfaction compared to their traditional sleep clinic counterparts. This study aims to evaluate self-reported patient experience and treatment outcome data between a traditional sleep care approach and a clinically integrated, comprehensive sleep care program. Methods To better understand the patient experience within these models of care, this study compares outcomes between a traditional sleep care approach and a clinically integrated, comprehensive sleep care program. The study analyzed survey responses from 206 patients with sleep apnea (n=102, traditional care model and n=104, comprehensive care model) with items evaluating patient satisfaction, CPAP adoption and adherence, and quality of life, with descriptive statistics, chi-square analyses, and t-tests conducted to compare outcomes between the two groups. Results A significantly higher proportion of patients (p&amp;lt;.05) in the comprehensive model (85%) were satisfied at all measured points along the patient’s journey compared to the traditional care model (51%). Notably, significantly more patients in the comprehensive model were very satisfied with the ease of navigating the testing process (83% vs. 38%, p&amp;lt;.05), time between diagnosis and CPAP adoption (91% vs. 49%, p&amp;lt;.05), and availability and level of ongoing CPAP support (79% vs. 39%, p&amp;lt;.05). Comprehensive care patients experienced significantly fewer work disruptions due to sleep apnea, with 7% missing work in the past 3 months compared to 58% in the traditional model (p&amp;lt;.05). Conclusion The findings underscore the advantages of a comprehensive care model that improves patient satisfaction, streamlines the sleep apnea treatment journey, and enhances quality of life. These results, paired with prior evidence from the same model, highlight the benefits of removing obstacles to care, which increases patient satisfaction, improves adherence to therapy, and reduces overall healthcare costs, warranting further investigation into these relationships. Support (if any) Funding for this study was provided by Nox Health, Inc. Data gathering and analysis performed by CE Outcomes, Inc.

In this article, we describe and critically reflect on how the PEPPA framework, a Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing, was used to develop a new model of care including the nurse practitioner (NP) role in an emergency department in Norway, where the role is in its infancy. While there is limited earlier research on the applicability of the PEPPA framework, it was here found to be useful. Supported by the framework, we mapped the current model of care, identified stakeholders and participants, determined the need for a new model of care, identified priority problems and goals, and defined the new model of care and the NP role. The PEPPA framework is recommended to develop new models of care including the NP role. Nonetheless, the process has not been straightforward. It is noted that to communicate and establish the new role in a setting as demanding as an emergency department takes time. Support from the management team is essential to succeed in developing and establishing new models of care and new nursing roles, such as the nurse practitioner role.

Pediatric Oncology Clinic Care Model: How to Care for Patients to Achieve Better Continuity of Care in a Medium Sized Program

Although effective interprofessional collaboration is a key component of patient safety and quality improvement initiatives, little is known about the nature of collaboration in ICU settings. Through ethnographic research, this study will explore interprofessional care in 8 ICUs (6 based in the United States and 2 based in Canada), develop an empirically based readiness/diagnostic tool to assess the quality of team-based care delivery, and develop interventions to strengthen team-based care and patient family involvement. Our study has 3 iterative phases and will involve: a scoping review of the literature on team dynamics in the ICU, an ethnographic study (observation, shadowing, interviews) across 8 sites over 2 years and the collection of clinical outcomes data to inform the development of a “diagnostics” tool for interprofessional collaboration and family member involvement in ICU care, as well as interprofessional intervention development. The importance of ethnographic and other forms of qualitative research for the improvement of health care delivery has already been recognized. This study’s comparative design and the richness of its data have the potential to generate a multidimensional understanding of the processes of interprofessional collaboration and patient family member involvement. The creation of generally applicable, empirically grounded tools also has the potential to enhance these processes.

Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.

Background: Children and young people’s (CYP) health outcomes in England are variable and often poor. Health systems throughout high income countries are struggling to adapt to epidemiological transitions, social change, rising demand, and budget cuts. There was a 58% rise in CYP attending EDs between 2007 and 2016, projected to rise 50-60% more by 2030. CYP from the most deprived backgrounds are 60-70% more likely to go to A&E than the least deprived. The majority of ED attendances by CYP are manageable in primary care or integrated models, yet 85% of ED attendances are for minor illnesses, increasing 5% annually. The Children and Young People’s Health Partnership (CYPHP) is a health system strengthening initiative implementing and evaluating a new model of care. Methods: Health system strengthening using the WHO building blocks model included service design by analysis of population need, systematic literature reviews, and extensive patient and public involvement. An evidence-based implementation plan was agreed for a child population of 90,000 in London, and we are evaluating using a cluster randomised control trial (cRCT) design with nested process evaluation and qualitative studies to assess CYP health and wellbeing, healthcare quality, patterns of healthcare use, and cost effectiveness. Results: CYPHP’s comprehensive care includes health promotion and supported self-management, proactive case-finding, biopsychosocial assessment and self-referral via a patient portal, with care delivered by a multidisciplinary team. Services are integrated vertically and horizontally incorporating physical and mental healthcare. Implementation has taken two years longer than anticipated due to technical and cultural challenges of health system strengthening. Early results indicate a reduction of 72 ED contacts per 100 children with asthma, 30 for children with epilepsy, and 15 for children with constipation. We estimate cost savings per 100 asthma patients to be over £15,000, for epilepsy over £6,000, and for constipation over £3,000. Of the first 200 patients, most were from socially deprived areas and 68% were from black and minority ethnic groups. Families report more confidence in managing their child’s condition. Discussion: As a clinical academic partnership, CYPHP combines pragmatic quality improvement and rigorous health services research. CYPHP demonstrates that health system strengthening in high income countries is feasible and effective for implementing and testing new models of care to improve child health. Conclusions: Early results suggest encouraging impact on patterns of healthcare use and potential cost savings. CYPHP’s population health approach provides care for those with greatest health and social need. Lessons learned: Rigorous health services and systems research is feasible in large scale system change in the NHS. Health system strengthening is a new concept in high income countries. It is slow and difficult, but important for effective implementation of new models of care. Fully integrated comprehensive models of care for children may improve health and healthcare outcomes. Limitations: Results are preliminary and reflect early implementation. Suggestions for future research: Rigorously designed health services research for ongoing large-scale health systems changes are an important source of new knowledge. There are few examples of such opportunistic research, representing new avenues for opportunity.