Using the PEPPA framework to develop the nurse practitioner role in emergency care: Critical reflections

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.

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

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.

Emergency Physicians Seek Their Place in a Pay-for-Value World

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.

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.

To explore which medications Australian nurse practitioners most frequently prescribe. Although nurse practitioners in Australia have prescriptive authority, little is known about which specific medications nurse practitioners are prescribing and how frequently they do so. Descriptive electronic survey. A total of 209 nurse practitioners reported current prescribing practices. Medications reported were categorised according to the Australian Medicines Handbook major drug classifications and frequencies presented. Seventy-eight per cent of respondents reported prescribing medications as part of their Nurse Practitioner practice. In total, participants reported prescribing 234 separate medications from most Australian Medicines Handbook major drug classifications. Medications from the classification anti-infective drugs were most frequently prescribed followed by medications from analgesic, psychotropic, cardiovascular, musculoskeletal, genitourinary and gastrointestinal classifications. The majority of nurse practitioners in Australia prescribe medications in their clinical practice, although the proportion of nurse practitioners prescribing has not changed significantly in the past four years. The medications prescribed are comparable with those most frequently prescribed by all prescribers in Australia and highlight the diversity in scope of practice among nurse practitioners. Findings highlight the importance of Nurse Practitioner's a capacity to prescribe wide variety of medications, especially in practice areas such acute, primary and emergency care. The unique role nurse practitioners in relation to management of patients with infective processes and patients requiring pain relief is highlighted. Insight into current Nurse Practitioner prescribing trends informs future Nurse Practitioner curricular and future continuing education programmes. Findings give unique insight for future service planning, especially service providers considering introducing nurse practitioners to their service. The finding that nurse practitioners prescribing patterns are similar to other non-nurse practitioner prescribers in Australia highlights the potential for service providers to introduce new models of care that are Nurse Practitioner lead.

Introduction/Background: Children's Health Queensland Hospital and Health Service (CHQ) partnered with a general practice organisation to establish and pilot the first known paediatric minor injury and illness clinic (P-MIIC) in Australia. The P-MIIC was built and operated within the Queensland Children’s Hospital (QCH), proximate to the emergency department (ED). The aim of the new model of care was to pilot a response to the state’s growing demand pressures in hospital EDs, by improving waiting times and enhancing the experience for children aged 0-18 and their families seeking high-quality and timely care. Who is it for? The pilot model of care was designed to provide an alternative pathway for families presenting at the ED to be seen by an experienced General Practitioner-led (GP) team. The clinic was physically situated close by the ED, medical imaging, and pathology collection services within the QCH. Children who presented at the ED and were triaged as category 3, 4 or 5 against the Australian Triage Scale were given the option to bypass the ED to be seen by the GP-led team working in the P-MIIC. Who did you involve and engage with? The model of care was overseen by an inter-agency strategic governance committee, consisting of: Hospital and Health Service and Primary Health Network executives, Paediatric and General Practice clinical and practice management leads, Hospital Facilities Management and Arts in Health advisors, Project and research/evaluation leads. In parallel, the QCH Emergency Consumer Group was consulted throughout the pilot development for input and feedback on all aspects of the model of care, communication materials and to raise community awareness of the pilot. What did you do? The clinic was constructed in a former retail space directly above the QCH’s ED, consisting of four consultation rooms, dual treatment space, dirty clean-up room, reception and waiting area, and telehealth consult/meeting room. The clinic pilot operated from June-November 2022. What results did you get? The clinic treated approximately 1000 patients during the pilot period. Interim evaluation findings included that families reported higher levels of positive experience than those whose children were treated exclusively within the ED across 7/12 measures. This was particularly relevant in the domains of waiting time for treatment, confidence and trust in treating clinicians, and post-discharge care arrangements. What is the learning for the international audience? This pilot demonstrated the potential benefits of incorporating a primary care model like P-MIIC in a hospital setting could significantly enhance patient experiences and improve efficiency in the QCH ED. What are the next steps? This pilot will inform the concurrent state-wide co-commissioning of other minor injury and illness or urgent care centres across Queensland and nationally which have been funded by the Federal Government. This pilot serves as an exemplar for audiences considering more intentional collaborations with general practices to pilot dynamic models of care. Formal research outputs in development will detail the pilot’s demonstrated improvements in demand pressures in the QCH ED, wait times and consumer experience for families seeking high-quality and timely care.

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

This study sought to explore the views and experiences of women and midwives participating in the Pre And Postnatal Outpatients Collaborative Service (PAPOOSE) model of care at a hospital in Sydney, NSW. The study was guided by two research questions: What are the experiences of women receiving their antenatal and postnatal care through the PAPOOSE model of care; and what are the views of the PAPOOSE midwives about the MAPS model of care? In this qualitative study informed by feminist standpoint theory, in-depth interviews were conducted via Zoom with ten women who received their antenatal and postnatal care through PAPOOSE. In addition, two focus groups were undertaken with ten midwives and two midwifery students providing care. The transcripts from the interviews and focus group discussions were analysed through reflexive thematic analysis. Four themes were constructed from the women’s data: ‘Looking for the right model of care’; ‘Enjoying antenatal and postnatal continuity of care’; ‘Missing the known midwife during labour and birth’; and ‘There’s room for improvement’. In the case of the midwives, four themes were constructed: “It’s my slice of heaven”; “It’s great for the women to have that continuity”; ‘Finding our place as a new model of care’; and ‘There’s room for improvement’. These themes reflected the perspectives of women and midwives and showed that although the relational aspects of the PAPOOSE model were valued overall by all participants, each group had distinct concerns about different aspects of the model of care. Both women and midwives had suggestions for how the PAPOOSE model of care could be improved. Although MAPS models show potential for increasing women’s access to MCOC in Australia, this study revealed a need for the models to be more woman-centred. Midwifery students have shown great potential for enhancing continuity of care within the context of MAPS. Findings from this research and ongoing feedback from women and midwives need to be incorporated into the continuous refinement of MAPS models. More research is needed to evaluate maternal and neonatal clinical outcomes of MAPS models, as well as the experiences of women and midwives participating in these models of care.

The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process. One of the challenges of nursing today is to meet the health-care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided. This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence-base for an evolving model of care. The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self-care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients. The participatory action research process resulted in improved heath-care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient-centred care relationship based on Orem's self-care model. This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting. This study is significant because of its evidence-base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the 'grass roots' level. Therefore, being involved in the decision-making process provided an incentive to actively implement change.

<h3>Context</h3> Practice facilitation has been shown to improve practice implementation of new evidence-based models of care and clinical quality measures and other patient-related outcomes, but its impact on cost of care has rarely been evaluated. <h3>Objective</h3> This project analyzed the impact on Medicaid costs and utilization of practice facilitation supporting primary care practices in implementing care expectations based on Bodenheimer’s Building Blocks of High Performing Primary Care. <h3>Study Design and Analysis</h3> A two-step hurdle model was used to estimate the impact of project participation for all cost and utilization outcomes, and a contemporaneous comparison group counterfactual analysis was used to calculate a point estimate and confidence intervals for differences in predicted outcomes with and without exposure to the intervention. <h3>Population Studied</h3> Colorado primary care practices participating in the Innovation Support Project (N=122) and their Medicaid patients. <h3>Intervention</h3> Practice facilitation support (generally monthly meetings with email or phone contacts between visits) was provided to the practices over one to three years. The support focused on implementation of care expectations based on the Building Blocks, developed in collaboration with state agencies and health plans. <h3>Outcome Measures</h3> Cost and utilization data for Colorado Medicaid members were analyzed for 3 years before, 3 years during, and 1 year after the project (N=362,546 members exposed to care in practices participating in the project and 1,520,358 members never exposed to care in participating practices). Measures included total cost of care, primary care costs, prescription costs, primary care visits, emergency department visits, and capitated (non-primary care) behavioral health visits. <h3>Results</h3> Members exposed to care in participating practices had significantly lower total cost of care ($9.78 per member per month (PMPM)), prescription cost ($4.11 PMPM), emergency department visits (4 fewer visits per 1,000 members in each month, and capitated behavioral health visits (8 fewer visits per 1,000 members in each month). Primary care visits were 1.4 fewer per 1,000 members per month, but total primary care costs were $0.79 PMPM higher (p&lt;.05). <h3>Conclusions</h3> Practice facilitation to support practices in implementing new models of care can result in decreased health care costs and utilization. This impact is sustained beyond the end of the actual practice support.

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.&#x0D; Objectives:&#x0D; &#x0D; Discuss the business process and business applications revolution&#x0D; Explain the experience revolution&#x0D; Describe the impact of new models of care on the clinical workforce&#x0D;