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Abstract Background Care coordination has been identified as one of five focuses of HealthierSG. Family medicine residents are expected to collaborate with other healthcare professionals for complex patients by the end of residency. However, many residents felt that it was challenging to coordinate care effectively among healthcare stakeholders. However, to date, no qualitative studies have explored these challenges. Therefore, this study aimed to understand the challenges encountered by family medicine residents when coordinating care for complex patients. Methods This was a qualitative descriptive study in which semi structured in-depth interviews were conducted and guided by a topic guide. Total population sampling of 15 third-year family medicine residents in the National Healthcare Group Polyclinics was performed. The interviews were performed over Zoom and were transcribed. Thematic analysis was subsequently performed to analyse the transcripts. Coding was performed iteratively by two independent researchers. Disagreements were adjudicated by a third coder. A coding framework was agreed upon. Potential themes were then independently developed based on the coding framework. Results Six themes emerged from the data, namely, interprofessional communications, accessibility, personal knowledge, time constraints, patient factors and caregiver dissent. Conclusion Challenges faced by family medicine residents are multifaceted. While a few are systemic and pertain to the broader healthcare framework, others, such as issues of unfamiliarity with institutional workflows, community resources, and confidentiality, pertain to the microcosm of residency itself. These are reversible areas for improvement. These challenges can be addressed during planning of residency curricula to better equip family medicine residents with coordinating care for complex patients in the future.

Background: Care coordination has been identified as one of five focuses of HealthierSG. Family medicine residents are expected to collaborate with other healthcare professionals for complex patients by the end of residency. However, many residents felt that it was challenging to coordinate care effectively among healthcare stakeholders. However, to date, no qualitative studies have explored these challenges. Therefore, this study aimed to understand the challenges encountered by family medicine residents when coordinating care for complex patients. Methods: This was a qualitative descriptive study in which semi structured in-depth interviews were conducted and guided by a topic guide. Total population sampling of 15 third-year family medicine residents in the National Healthcare Group Polyclinics was performed. The interviews were performed over Zoom and were transcribed. Thematic analysis was subsequently performed to analyse the transcripts. Coding was performed iteratively by two independent researchers. Disagreements were adjudicated by a third coder. A coding framework was agreed upon. Potential themes were then independently developed based on the coding framework. Results: Six themes emerged from the data, namely, interprofessional communications, accessibility, personal knowledge, time constraints, patient factors and caregiver dissent. Conclusion: Challenges faced by family medicine residents are multifaceted. While a few are systemic and pertain to the broader healthcare framework, others, such as issues of unfamiliarity with institutional workflows, community resources, and confidentiality, pertain to the microcosm of residency itself. These are reversible areas for improvement. These challenges can be addressed during planning of residency curricula to better equip family medicine residents with coordinating care for complex patients in the future. [ABSTRACT FROM AUTHOR]

Abstract Purpose To investigate how useful the Intermed-Self Assessment (IMSA) questionnaire and its components were for identifying which patient candidates would benefit most from case management (CM) in general practice. Methods The study was carried out in a group family medicine practice in Lausanne comprising seven GPs and four medical assistants, from February to April 2019. All the patients attending the practice between February and April 2019 were invited to complete the IMSA questionnaire. Additionally, their GPs were asked for their opinions on the potential benefits of each patient being assigned a case manager. Each IMSA item’s value has been assessed as a predictor of GPs’ opinions by using multivariate logistic models. A score including items retained as predictor was built. Results Three hundred and thirty one patients participated in the study (participation rate: 62%). Three items from the 20 item IMSA were sufficient to predict GPs’ opinions about whether their patients could be expected to benefit if assigned a case manager. Those items addressed the patient’s existing chronic diseases (item1), quality of life in relation to existing diseases (item 3), and their social situation (item 9). Using these three items as a score, a cut-off at 4 gave a sensitivity of 70% (ability to correctly identify patients who could benefit from a CM) and specificity of 73% (ability to correctly identify patients who should not benefit from a CM) and concerned about one patient in two. Conclusion Identifying complex patients suitable for case management remains a challenge for primary care professionals. This paper describes a novel approach using a structured process of combining the results of standardized tools such as the one defined in this study, and the experience of the primary care team.

BACKGROUND:A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management. OBJECTIVE:To characterize factors that best identify which complex patients are most suited for intensive care management. DESIGN:We conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) "good candidates" for care management, (2) "not needing" intensive care management, or (3) "needing more" than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups. RESULTS:CMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p

Purpose To investigate how useful the Intermed-Self Assessment (IMSA) questionnaire and its components were for identifying which patient candidates would benefit most from case management (CM) in general practice. Methods The study was carried out in a group family medicine practice in Lausanne comprising seven GPs and four medical assistants, from February to April 2019. All the patients attending the practice between February and April 2019 were invited to complete the IMSA questionnaire. Additionally, their GPs were asked for their opinions on the potential benefits of each patient being assigned a case manager. Each IMSA item's value has been assessed as a predictor of GPs' opinions by using multivariate logistic models. A score including items retained as predictor was built. Results Three hundred and thirty one patients participated in the study (participation rate: 62%). Three items from the 20 item IMSA were sufficient to predict GPs' opinions about whether their patients could be expected to benefit if assigned a case manager. Those items addressed the patient's existing chronic diseases (item1), quality of life in relation to existing diseases (item 3), and their social situation (item 9). Using these three items as a score, a cut-off at 4 gave a sensitivity of 70% (ability to correctly identify patients who could benefit from a CM) and specificity of 73% (ability to correctly identify patients who should not benefit from a CM) and concerned about one patient in two. Conclusion Identifying complex patients suitable for case management remains a challenge for primary care professionals. This paper describes a novel approach using a structured process of combining the results of standardized tools such as the one defined in this study, and the experience of the primary care team. [ABSTRACT FROM AUTHOR]

BackgroundPhysical frailty and cognitive decline are two major consequences of aging and are often in older individuals, especially in those with multimorbidity. These two disorders are known to usually coexist with each other, increasing the risk of each disorder for poor health outcomes. Mental health disorders, anxiety and depression, are common in older people with multimorbidity, in particular those with functional or sensory deficits, and frailty.PurposeThe aim of this study was to show how physical frailty, cognitive impairments and mental disorders, cluster in the real life setting of older primary care (PC) patients, and how these clusters relate to age, comorbidities, stressful events, and coping strategies. Knowing that, could improve risk stratification of older individuals and guide the action plans.MethodsParticipants were older individuals (≥60, N = 263), attenders of PC, independent of care of others, and not suffering from dementia. For screening participants on physical frailty, cognitive impairment, and mental disorders, we used Fried‘s phenotype model, the Mini-Mental State Examination (MMSE), the Geriatric Anxiety Scale (GAS), and the Geriatric Depression Scale (GDS). For testing participants on coping styles, we used the 14-scale Brief-Coping with Problems Experienced (Brief-COPE) questionnaire. To identify clusters, we used the algorithm fuzzy k-means. To further describe the clusters, we examined differences in age, gender, number of chronic diseases and medications prescribed, some diagnoses of chronic diseases, the number of life events, body mass index, renal function, expressed as the glomerular filtration rate, and coping styles.ResultsThe most appropriate cluster solution was the one with three clusters, that were termed as: functional (FUN; N = 139), with predominant frailty or dysfunctional (DFUN; N = 81), and with predominant cognitive impairments or cognitively impaired (COG-IMP; N = 43). Participants in two pathologic clusters, DFUN and COG-IMP, were in average older and had more somatic diseases, compared to participants in cluster FUN. Significant differences between the clusters were found in diagnoses of osteoporosis, osteoarthritis, anxiety/depression, cerebrovascular disease, and periphery artery disease. Participants in cluster FUN expressed mostly positive reframing coping style. Participants in two pathological clusters were represented with negative coping strategies. Religion and self-blame were coping mechanisms specific only for cluster DFUN; self-distraction only for cluster COG-IMP; and these two latter clusters shared the mechanisms of behavioral disengagement and denial.ConclusionThe research approach presented in this study may help PC providers in risk stratification of older individuals and in getting insights into behavioral and coping strategies of patients with similar comorbidity patterns and functional disorders, which may guide them in preparing prevention and care plans. By providing some insights into the common mechanisms and pathways of clustering frailty, cognitive impairments and mental disorders, this research approach is useful for creating new hypotheses and in accelerating geriatric research.

Background: Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. Methods: This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. Results: The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition–specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. Discussion: We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors. [ABSTRACT FROM AUTHOR]

Background: The long-term efficacy and safety of bioresorbable vascular scaffolds (BVS) in real world clinical practice including Magmaris need to be elucidated to better understand performance of this new and evolutive technology. The aim of this study was to evaluate long-term performance of Magmaris, drug-eluting bioresorbable metallic scaffold, in all-comers patients' population. Methods: We included in this prospective registry first 54 patients (54 ± 11 years; male 46) treated with Magmaris, with at least 30 months of follow-up. Diabetes mellitus and acute coronary syndrome were present in 33 (61%) and 30 (56%) of the patients, respectively. Patients were followed for device- and patient-oriented cardiac events during a median follow-up of 47 months (DOCE–cardiac death, target vessel myocardial infarction, and target lesion revascularization; POCE–all cause death, any myocardial infarction, any revascularization). Results: Event-free survivals for DOCE and POCE were 86.8% and 79.2%, respectively. The rate of DOCE was 7/54 (13%), including in total target vessel myocardial infarction in two patients (4%), target lesion revascularization in six patients (11%), and no cardiac deaths. The rate of POCE was 11/54 (21%), including in total any myocardial infarctions in 3 patients (6%), any revascularization in 11 patients (20%), and no deaths. Definite Magmaris thrombosis occurred in two patients (3.7%), and in-scaffold restenosis developed in five patients (9.3%). Variables associated with DOCE were implantation of ≥2 Magmaris BVS (HR: 5.4; 95%CI: 1.21–24.456; p = 0.027) and total length of Magmaris BVS ≥ 40 mm (HR: 6.4; 95%CI: 1.419–28.855; p = 0.016), whereas previous PCI was the only independent predictor of POCE (HR: 7.4; 95%CI: 2.216–24.613; p = 0.001). Conclusions: The results of the long-term clinical outcome following Magmaris implantation in patients with complex clinical and angiographic features were acceptable and promising. Patients with multi-BVS and longer multi-BVS in lesion implantation were associated with worse clinical outcome. [ABSTRACT FROM AUTHOR]

Background: Most healthcare costs are concentrated in a small proportion of individuals with complex social, medical, behavioral, and clinical needs that are poorly met by a fee-for-service healthcare system. Efforts to reduce cost in the top decile have shown limited effectiveness. Understanding patient subgroups within the top decile is a first step toward designing more effective and targeted interventions. Objective: Segment the top decile based on spending and clinical characteristics and examine the temporal movement of individuals in and out of the top decile. Design: Retrospective claims data analysis. Participants: UnitedHealthcare Medicare Advantage (MA) enrollees (N = 1,504,091) continuously enrolled from 2016 to 2019. Main Measures: Medical (physician, inpatient, outpatient) and pharmacy claims for services submitted for third-party reimbursement under Medicare Advantage, available as International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and National Drug Codes (NDC) claims. Key Results: The top decile was segmented into three distinct subgroups characterized by different drivers of cost: (1) Catastrophic: acute events (acute myocardial infarction and hip/pelvic fracture), (2) persistent: medications, and (3) semi-persistent chronic conditions and frailty indicators. These groups show different patterns of spending across time. Each year, 79% of the catastrophic group dropped out of the top decile. In contrast, 68–70% of the persistent group and 36–37% of the semi-persistent group remained in the top decile year over year. These groups also show different 1-year mortality rates, which are highest among semi-persistent members at 17.5–18.5%, compared to 12% and 13–14% for catastrophic and persistent members, respectively. Conclusions: The top decile consists of subgroups with different needs and spending patterns. Interventions to reduce utilization and expenditures may show more effectiveness if they account for the different characteristics and care needs of these subgroups. [ABSTRACT FROM AUTHOR]

Abstract Purpose Chronic disease is a global concern. While ample research has aimed to identify the epidemiology of multimorbidity and patient complexity using administrative data, little attention has been paid to the processes of care that treating complex patients entail. Consequently, the concept of patient complexity itself does not directly speak to how challenging it may be to care for a given patient. The purpose of this study was to investigate how primary care providers define, encounter, and manage complex patients, especially those with chronic pain. To our knowledge, this is the first study to move beyond general narrative descriptions of complexity towards an interrogation that is grounded in the work practices of caring for these patients. Methods We undertook an institutional ethnography (IE) in Ontario, Canada. IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that orient experiences. Grounded in the everyday experience of primary care providers, we draw here on 51 interviews that were collected as part of our larger IE study, to interrogate the utility of definitions of patient complexity as medical multimorbidity. Findings Care providers consider patients challenging due to their socio-economic status more so than their medical problems alone. Our data shows that patients’ issues are often bound up with poverty, trauma, and mental health concerns, and are challenging for health care providers in part because the interventions needed exceed the scope of their medical expertise, while social issues render the treatment of potentially straightforward medical problems complicated. This was especially so for patients with chronic pain. Conclusion Defining patient complexity as morbidity alone is inadequate; such models neglect syndromes and conditions that are not included in formal disease classifications. Chronic pain should be included among the chronic conditions that are considered to constitute multimorbidity. In order to provide effective patient-centered care, discussions of patient complexity must also attend to the complex social and economic circumstances in which many patients live and include broader issues of inequity and social justice. This approach would enable policies to better support primary care providers who struggle to manage their patients with complex needs across domains of physiological health, mental health, and the quality of their living conditions, and in so doing improve the care that patients receive.

This article, published in the European Heart Journal Case Reports, presents a case report of a 71-year-old male patient with an extensive aortic arch aneurysm. The patient underwent a type III hybrid arch repair, which involved ascending aortic and total arch replacement with frozen elephant trunk, and subsequent thoracic endovascular aortic repair. The surgical team utilized multimodality neuroimaging, including computed tomographic angiography (CTA) and transcranial Doppler (TCD) monitoring, to guide the procedure and mitigate neurological risks. The surgery was successful, with stable cerebral blood flow and no significant post-operative neurological complications. The case highlights the importance of individualized neuroimaging and targeted cerebral perfusion strategies in complex cardiac surgeries. [Extracted from the article]

Background: Care plans are an evidence-based strategy, encouraged by the Centers for Medicare and Medicaid Services, and are used to manage the care of patients with complex health needs that have been shown to lead to lower hospital costs and improved patient outcomes. Providers participating in payment reform, such as accountable care organizations, may be more likely to adopt care plans to manage complex patients. Objective: To understand how Medicare accountable care organizations (ACOs) use care plans to manage patients with complex clinical needs. Design: A qualitative study using semi-structured interviews with Medicare ACOs. Participants: Thirty-nine interviews were conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff. Approach: Development, structure, use, and management of care plans for complex patients at Medicare ACOs. Key Results: Most (11) of the interviewed ACOs reported using care plans to manage care of complex patients. All care plans include information about patient history, current medical needs, and future care plans. Beyond the core elements, care plans included elements based on the ACO's planned use and level of staff and patient engagement with care planning. Most care plans were developed and maintained by care management (not clinical) staff. Conclusions: ACOs are using care plans for patients with complex needs, but their use of care plans does not always meet the best practices. In many cases, ACO usage of care plans does not align with prescribed best practices: ACOs are adapting use of care plans to better fit the needs of patients and providers. [ABSTRACT FROM AUTHOR]

Abstract Background Evidence supporting the effectiveness of care management programs for complex patients has been inconclusive. However, past reviews have not focused on complexity primarily defined by multimorbidity and healthcare utilization. We conducted a systematic review of care management interventions targeting the following three patient groups: adults with two or more chronic medical conditions, adults with at least one chronic medical condition and concurrent depression, and adults identified based solely on high past or predicted healthcare utilization. Methods Eligible studies were identified from PubMed, published between 06/01/2005 and 05/31/2015, and reported findings from a randomized intervention that tested a comprehensive, care management intervention. Identified interventions were grouped based on the three “complex” categories of interest (described above). Two investigators extracted data using a structured abstraction form and assessed RCT quality. Results We screened 989 article titles for eligibility from which 847 were excluded. After reviewing the remaining 142 abstracts, 83 articles were excluded. We reviewed the full-text of 59 full-text articles and identified 15 unique RCTs for the final analysis. Of these 15 studies, two focused on patients with two or more chronic medical conditions, seven on patients with at least one chronic medical condition and depression, and six on patients with high past or predicted healthcare utilization. Measured outcomes included utilization, chronic disease measures, and patient-reported outcomes. The seven studies targeting patients with at least one chronic medical condition and depression demonstrated significant improvement in depression symptoms (ranging from 9.2 to 48.7% improvement). Of the six studies that focused on high utilizers, two showed small reductions in utilization. The quality of the research methodology in most of the studies (12/15) was rated fair or poor. Conclusions Interventions were more likely to be successful when patients were selected based on having at least one chronic medical condition and concurrent depression, and when patient-reported outcomes were assessed. Future research should focus on the role of mental health in complex care management, finding better methods for identifying patients who would benefit most from care management, and determining which intervention components are needed for which patients.

Introduction: Transitions in care between and within healthcare sectors are a major focus across health jurisdictions. It is a time of vulnerability for both patients and their families. Hip fractures are one of the leading causes of hospitalizations among the older population, with patients averaging 3.5 care setting transitions before reaching their final destination. Thus, hip fracture patients are an ideal population to study for understanding transitions of care for older adults. These patients have high rates of readmissions due to medical complications within 6 months of being discharged from acute care. Of those patients who survive one-year post-injury, only 40% can perform activities of daily living independently, leading to potential social vulnerability. Across health regions, there is substantial variation in system performance on care relating to hip fractures, which requires further understanding of the contextual factors influencing care transitions, patient/informal care experiences, and health and well-being outcomes. Methods: A multiple-case study design was chosen to compare transitions in care for hip fractures in two contrasting health jurisdictions. Regions were selected for variation in patient populations, system performance and geography. Qualitative interviews were conducted with patients, their informal care providers (e.g. family/friends), clinicians and decision-makers in both jurisdictions. When possible, patients and caregivers were followed through their care journey by sequential interviews. By interviewing a variety of key stakeholders, the intention was to develop a holistic understanding of care transitions for complex patients and system-level factors contributing to this journey. Results: Data collection is ongoing. We anticipate interviewing 56 individuals (16 patients, 16 family members, 12 clinicians and 12 decision-makers). Preliminary results suggest three main themes: 1) patient, caregiver and healthcare provider uncertainty; 2) urgency to improve transitions; and 3) transitions as a component of the larger care experience. Discussion: Consequences of poor transitions include delays, adverse medication events, dissatisfaction among patients and families as well as high patient readmission rates and emergency department visits following acute care discharge. Findings from this work will identify context specific solutions at the individual, community and system levels to optimize transitions for patients with hip fractures and for those that provide care. Conclusion (w/ key findings): Barriers and enabling factors that influence optimal care transitions are specific to local health system contexts; however, the experiences of key stakeholders across the two jurisdictions were remarkably similar. There remains much room for improvement in care transitions for complex patient populations and their caregivers. Lessons Learned: A community-engagement and integrated knowledge translation approach takes effort and time, but ensures the research is of value to key system users. Limitations: This study compares only two health care jurisdictions in Ontario, with interviewees recruited primarily from one hospital in each jurisdiction, and interviews conducted in English and French alone. It is possible that experiences with transitions may be different across different health regions, in different hospitals in the study regions, and among non-English or French speaking participants. Suggestions for Future Research: Future research can expand to different health regions and include patients and caregivers who speak different languages.

Introduction: Integrated care models are becoming more frequent in various health systems to provide quality coordinated care, with the aim of improving patient outcomes and costs. Many patients under an integrated care model present with complex health and social needs requiring more sophisticated care coordination. For example, in Ontario, Canada 75% of patients with complex health and social needs see six or more physicians and are taking an average of 13 medications. These patients would likely benefit from medication optimization, an area of expertise of community pharmacists. In Ontario, these patients often receive care through an integration of care approach called Health Links; however, pharmacists are generally not included in Health Links, representing a potential gap in care for these complex patients. The study objectives were to 1) explore stakeholder perceptions of formally ‘linking’ community pharmacy into the Health Links model and 2) identify barriers and facilitators to such a ‘linkage’. Methods: In-depth narrative qualitative interviews were conducted with pharmacists, clinicians and decision-makers following a semi-structured guide. Interviews were conducted by telephone and averaged 30 minutes in length. Descriptive thematic analysis of the interview transcripts was conducted. Results: Four key themes were identified in relation to community pharmacists’ inclusion in an integrated care model: perceived value contribution; perceptions of current and idealized roles; tensions surrounding collaboration; and implementation strategies. Discussion: The Health Links integrated care model involves primary, community and hospital care partnerships but often omits community pharmacists. A frequently discussed barrier to integrating community pharmacists into such a model was the perceived business-professional/clinical conflict of interest even though similar conflicts exist for other health care professions (e.g. fee-for-service physicians). Despite this tension, community pharmacists’ expertise and frequent contact with patients were identified as valuable to the Health Links approach. Building strong interprofessional relationships and educating clinicians on pharmacists’ professional scope of practice will help alleviate this tension and contribute to successful collaboration. Conclusion (w/ key findings): To optimize delivery of health care and improve patient health outcomes, collaboration, potentially through an integrated care model, should include community pharmacists. Their medication-related expertise and frequent contact with patients makes them an under-utilized healthcare profession. Lessons Learned: Clinicians respond well to direct questions about sensitive subjects such as perceived professional conflicts of interest. Clinicians have differing views about the value of embedding community pharmacy within an integration of care model. Limitations: Interviews were conducted with individuals within one province of Canada. Also, a snowballing technique whereby participants were asked to suggest other individuals who may be interested and a good candidate for the study was used for participant recruitment. This technique may have selected for like-minded individuals; however, additionl purposeful sampling was also conducted to increase participant diversity and interviews were conducted until thematic saturation was reached. Suggestions for Future Research: Future research can involve other Canadian provinces and different integrated care models to understand if similar barriers and facilitators exist. Pilot studies of integrated care models that include community pharmacists should be conducted to assess real-world feasibility of such a model.

Introduction: Robotic hysterectomy may offer advantages for complex cases over the conventional laparoscopic approach. Objective: To assess the association of surgical approach (robotic vs conventional) with blood loss, risks of readmission, reoperation, complications, and average operative time. Methods: In a retrospective cohort study, we used the electronic medical records of Kaiser Permanente Northern California, 2011 to 2015, to estimate outcomes of robotic and conventional laparoscopic hysterectomy among women with complex or noncomplex benign disease. Mixed-effects regression models accounted for patient characteristics and surgeon volume. Results: The study included 560 robotic and 6785 conventional laparoscopic cases. Overall, 1836 patients (25%) met criteria for being complex. The average operative time was 152 minutes for robotic hysterectomy and 157 minutes for conventional laparoscopic hysterectomy (p < 0.0001). Complex surgical cases averaged 190 minutes and noncomplex cases averaged 144 minutes. The difference in operative time for high-volume surgeons treating complex patients with robotic hysterectomy vs conventional hysterectomy was 21 minutes faster (p < 0.05). After adjustment, the risk of blood loss at least 51 mL was lower for robotic surgery than for conventional surgery for complex and noncomplex patients. Other than risk of urinary tract complications, we observed no differences in the risks of complications or risk of reoperation between robotic and conventional laparoscopy for complex and noncomplex patients. Conclusion: For women with complex disease, the robotic approach, when used by a higher-volume surgeon, may be associated with shorter operative time and slightly less blood loss, but not with lower risk of complications. [ABSTRACT FROM AUTHOR]

Background Nursing home staff manage increasingly complex patients yet struggle to access education programmes due to geographical logistical barriers. The aim of this study is to measure the impact on emergency hospital transfers a novel teleconference-delivered palliative care education programme (ECHO) has on patient transfers from nursing homes to emergency departments. Methods Ten interactive sessions were provided to staff from 20 nursing homes, using teleconferencing technology through the "Project ECHO" model. "Transfer forms" were completed by participating staff 6 months before echo, and 6 months from commencement of echo outlining details of emergency hospital transfers. Participating sites must attend 4 or more of 10 sessions for study inclusion. Results Of 20 nursing homes, 15 attended sufficient sessions, and they submitted data regarding 260 emergency transfers over a 12-month period. There was no significant difference in the number of transfers pre vs post ECHO (137 of 260 vs 123 of 260, p=0.62). There was no significant difference in likelihood of hospital admission, length of stay, or number of weekend transfers to hospital (p=0.26, 0.68 and 0.6 respectively). Post-echo, patients were less likely to have pain documented as the primary symptom (11 of 137 vs 1 of 123, p=0.006), and it was more likely that transfer wishes were documented in advance (62 of 137 (45%) vs 82 of 123 (67%), p<0.001). Increase in transfer wishes documentation was explained primarily by an increase in a "for transfer" decision (27 of 62 vs 67 of 82) p=<0.001). Conclusion This teleconference, ECHO-delivered palliative education programme did not affect overall rates of emergency hospital transfers from nursing homes. However, it did significantly lower rates of transfers reporting pain as the primary symptom, tentatively suggesting a possible impact on "reversible" hospital transfers. ECHO significantly increased likelihood of transfer status discussion, while most "extra" discussions resulted in a "for transfer" decision. [ABSTRACT FROM AUTHOR]

Background Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or 'HUDDLE' was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital. Methods The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services.We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications. Results There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days). Conclusion Rather than using a negative view of older adults as potential 'bed blockers', the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient's hospital journey. [ABSTRACT FROM AUTHOR]

Introduction: Complex patients are frequently high-users of health care resources. Case management has been demonstrated to be an effective and efficient approach for this demographic. Case Presentation: A 36-year old, medically complex male patient was referred to an interprofessional primary care team to optimize health status. Team involvement included a case manager, nurse practitioner, pharmacist, social worker, team assistant and chiropractor. Interventions involved medication management, smoking cessation, mindfulness skills and musculoskeletal treatment. Summary: Complex patients are increasingly managed by teams. To continue, these teams will have to demonstrate positive outcomes and cost-effectiveness. Chiropractors have skills that can enhance team-based patient care. [ABSTRACT FROM AUTHOR]

Abstract Telecare is increasingly recognized as an essential tool for a contemporary twenty-first century health care system even though the evidence is still emerging on its effectiveness. The need to find delivery models like telecare that improve both the convenience and value of care is universal, but particularly pressing for countries like the U.S. and Israel who are facing rising costs related to the needs of individuals with multiple complex conditions. This commentary provides highlights of the current state of practice and policy for telecare and the challenges that remain ahead as it is adopted into the mainstream.

Purpose: Time during primary care visits is limited. We tested the hypothesis that a waiting room health information technology (IT) tool to help patients identify and voice their top visit priorities would lead to better visit interactions and improved quality of care.Methods: We designed a waiting room tool, the Visit Planner, to guide adult patients through the process of identifying their top priorities for their visit and effectively expressing these priorities to their clinician. We tested this tool in a cluster-randomized controlled trial with usual care as the control. Eligible patients had at least 1 clinical care gap (eg, overdue for cancer screening, suboptimal chronic disease risk factor control, or medication nonadherence).Results: The study (conducted March 31, 2016 through December 31, 2017) included 750 English- or Spanish-speaking patients. Compared with usual care patients, intervention patients more often reported "definitely" preparing questions for their doctor (59.5% vs 45.1%, P <.001) and "definitely" expressing their top concerns at the beginning of the visit (91.3% vs 83.3%, P = .005). Patients in both arms reported high levels of satisfaction with their care (86.8% vs 89.9%, P = .20). With 6 months of follow-up, prevalence of clinical care gaps was reduced by a similar amount in each study arm.Conclusions: A simple waiting room-based tool significantly improved visit communication. Patients using the Visit Planner were more prepared and more likely to begin the visit by communicating their top priorities. These changes did not, however, lead to further reduction in aggregate clinical care gaps beyond the improvements seen in the usual care arm. [ABSTRACT FROM AUTHOR]

Background: A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management.Objective: To characterize factors that best identify which complex patients are most suited for intensive care management.Design: We conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) "good candidates" for care management, (2) "not needing" intensive care management, or (3) "needing more" than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups.Results: CMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p < 0.001), prescribed more medications (p = 0.02) and had more prior year outpatient visits (p = 0.04), while the number of prior year hospital and emergency room admissions were greater than not needing but less than needing more (p < 0.001). A logistic regression model using available electronic record data predicted good candidate designation with a c statistic of 0.75. Several qualitative themes emerged that helped define appropriateness for referral, including availability of social support, patient motivation, non-medical transitions, recent trajectory of medical condition, and psychiatric or substance use issues.Conclusion: Many apparently complex patients are not good candidates for intensive care management. Current electronic medical records do not capture several of the most salient characteristics that determine appropriateness for care management. Our findings suggest that systematic collection of social support, patient motivation, and recent non-medically related life change information may help identify which complex patients are most likely to benefit from care management. [ABSTRACT FROM AUTHOR]

Background: Evidence supporting the effectiveness of care management programs for complex patients has been inconclusive. However, past reviews have not focused on complexity primarily defined by multimorbidity and healthcare utilization. We conducted a systematic review of care management interventions targeting the following three patient groups: adults with two or more chronic medical conditions, adults with at least one chronic medical condition and concurrent depression, and adults identified based solely on high past or predicted healthcare utilization.Methods: Eligible studies were identified from PubMed, published between 06/01/2005 and 05/31/2015, and reported findings from a randomized intervention that tested a comprehensive, care management intervention. Identified interventions were grouped based on the three "complex" categories of interest (described above). Two investigators extracted data using a structured abstraction form and assessed RCT quality.Results: We screened 989 article titles for eligibility from which 847 were excluded. After reviewing the remaining 142 abstracts, 83 articles were excluded. We reviewed the full-text of 59 full-text articles and identified 15 unique RCTs for the final analysis. Of these 15 studies, two focused on patients with two or more chronic medical conditions, seven on patients with at least one chronic medical condition and depression, and six on patients with high past or predicted healthcare utilization. Measured outcomes included utilization, chronic disease measures, and patient-reported outcomes. The seven studies targeting patients with at least one chronic medical condition and depression demonstrated significant improvement in depression symptoms (ranging from 9.2 to 48.7% improvement). Of the six studies that focused on high utilizers, two showed small reductions in utilization. The quality of the research methodology in most of the studies (12/15) was rated fair or poor.Conclusions: Interventions were more likely to be successful when patients were selected based on having at least one chronic medical condition and concurrent depression, and when patient-reported outcomes were assessed. Future research should focus on the role of mental health in complex care management, finding better methods for identifying patients who would benefit most from care management, and determining which intervention components are needed for which patients. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic conditions and multiple comorbidities represent a growing challenge for health care globally. Improved coordination of care is considered essential for providing more effective and cost-efficient care for these patients with complex needs. Osteoarthritis is one of the most common and debilitating chronic conditions, is the most frequent cause of chronic pain yet osteoarthritis care is often poorly-coordinated. Primary care is usually the first contact for patients requiring relief from chronic pain. Our previous work suggests discordance between the policy goals of improving patient care and the experience of osteoarthritis patients. We plan to investigate the empirical context of the primary care setting by focusing on primary physicians' conceptualizations and performance of their work in treating complex patients with chronic pain. This will allow for an exploration of how primary health care is - or could be - integrated with other services that play an important role in health care delivery.Methods: Our study is an Institutional Ethnography of pain management in family medicine, to be carried out in three phases over 3 years from 2014/15 to 2018. Over the first year we will undertake approximately 80 key informant interviews with primary care physicians, other health care providers, policymakers and clinical experts. In the second year we will focus on mobilizing our networks from year one to assist in the collection of key texts which shape the current context of care. These texts will be analyzed by the research team. In the final year of the study we will focus on synthesizing our findings in order to map the social relations informing care. As is standard and optimal in qualitative research, analysis will be concurrent with data collection.Discussion: Our study will allow us to identify how the work of coordinating care across multiple settings is accomplished, in practice as well as discursively and textually. Ultimately, we will identify links between everyday experience of care for patients with chronic pain, and broader discourses related to health care system inefficiencies, integration and patient-centred care. An expected outcome of this study will be the development of new, or augmentation of existing, models of care, that are based in the local realities of primary care practice. [ABSTRACT FROM AUTHOR]

An introduction: (comprising context and problem statement) The high prevalence of patients with complex needs is an increasingly worrying reality in health systems. The most characteristic features of the current healthcare model are the fragmentation of care levels, the lack of coordination, integration and continuity in patient care, leading to problems of inappropriate use of human and economic resources and health services. The problem requires a coordinated response comprising all stakeholders involved. Short description of practice change implemented: The European Carewell project http://www.carewell-project.eu/home.html aims the design and implementation of new organizational models of integrated cost-effective care, addressing multimorbid patients, in order to improve care and healthcare through: 1) the coordination and communication among health professionals, and 2) the patient-centered care based on empowerment of the patient (and their caregiver) and the monitoring of their health status. The project uses ICTs as enablers for the implementation of such interventions. Aim and theory of change: The main objective of Carewell is the design, implementation and evaluation of the impact of an integrated healthcare model for multimorbid patients, in terms of quality of care, efficiency and satisfaction of professionals and patients Targeted population and stakeholders: The target population was elderly (= 65) patients having at least two of the chronic diseases included in the Charlson comorbidity index and being one of them CHF, EPOC or diabetes mellitus. In the Basque Country a population of around 6200 patients have benefited from the new integrated care pathway whereas only 200 patients (104 intervention and 100 controls) have been included in the evaluation. These patients have been followed up for a minimum of 9 months. There are 13 integrated care organizations (ICOs, primary and secondary care) in the Basque Country. 6 out of the existing 13 have been involved in the project. A multi-disciplinary, collaborative and inter-organizational team, which consisted in 130 health professionals and 58 social workers from distinct ICOs, was created to define and deploy the new care pathway. Timeline: The project started in February 2014 and phases completed are: - Definition of the new integrated care pathway: February-December 2014 - Preparation of the piloting (professional engagement and training): January-April 2015 - Piloting: May 2015-September 2016 - Evaluation: October-December 2016 Highlights: (innovation, Impact and outcomes) Innovation: A new organization model for the care of multimorbid patients has been defined, developed and deployed. Several elements have been identified as key factors: integrated care pathways agreed by all stakeholders, decision support tools, ICT services, training of professionals, development of an structured empowerment program for patients and caregivers (Kronik-ON) and a new mathematical model to predic sue of resources in midlong term ("Predictive Modeling"). Impact: In the Basque Country the new organizational model has had an impact on the provision of services to multimorbid patients. Through the prevention and promotion of health, as well as the empowerment of patients, it has promoted a transition from specialized and hospital care to primary care. Outcomes: Clinical effectiveness, economic analysis and the patient's and professionals' perspectives have been assessed by quantitative and qualitative approaches. Satisfaction of both professionals and patients/caregivers has been demonstrated, whereas the profile of the use of services has moved from secondary care to primary. In fact, then number of hospitalizations and ED visits has decreased and the GP contacts have augmented. Comments on sustainability: The intervention in the Basque Country has used the human and technological resources currently available in Osakidetza (Basque Health Public System), which favors and facilitates any subsequent deployment. Predictive analysis has confirmed that intervention is cost effective. Comments on transferability: The results of the evaluation of the new organizational model have been positive, which has led to its imminent extension to other ICOs of Osakidetza. Conclusions (comprising key findings) and lessons learned: -A detailed methodology for the design of the intervention is crucial -Multidisciplinary teams should represent all stakeholders in order to consider their perspective in the definition of new care pathways.-New pathways must be integrated into the daily practice. -the service must be flexible to be adopted in new contexts -New roles are necessary which requires reorganization of tasks -Training of professionals is crucial to promote the development of new skills -Technology is essential for facilitating coordination among health professionals -Involvement of top managers of the organizations enhances the engagement of healthcare professionals, favoring the implementation of new procedures -Primary Care is responsible for proactive control of the patients -Nursing role is essential in the empowerment of the patient/caregiver Discussions: It is fundamental to align the project objectives with the strategic plan of the central organization to ensure that the deployment of the intervention is a priority. However, top-down support is not enough, meso-level managers and front-line professionals have to believe in the project, so both interests converge. Continuous improvement methodologies are of great relevance identify weaknesses in a regular basis and apply new solutions. To do so, it is mandatory to establish a consolidate monitoring and assessment procedures. [ABSTRACT FROM AUTHOR]

Fernández-Álvarez 's Integrative Psychotherapy Model (IP Model) is designed to be applied to complex and difficult clinical patients. Scherb (2014) and her professional team aptly applied the IP Model to one such client, "Sonia," who received a successful, multilevel, integrated treatment for 10 years. Scherb's case illustrates the IP Model by analyzing links among the conceptualization, psychopathology, diagnosis, treatment plan, and specific interventions in the case. Her case study reflects the consistency and versatility of the IP Model to account for the complexity of a case in a systematic manner, and provides specific clinical indicators for evaluating the process and outcome in a complex and difficult case such as Sonia's. [ABSTRACT FROM AUTHOR]

Context: Osona is a Catalonian county with almost 157.000 inhabitants, of which 2.9% are 85 years old or over, and it behaves like a micro health system in the Catalan territory. Local health providers made a strategic alliance more than ten years ago (virtual integration), and launched a range of tools and strategies that seek to create a more integrated and personcentred care of patients with complex health care needs, based government guidelines for Programs of Prevention and Care of Chronic Patients (PPAC) and Social and Health Interaction (PIAISS). One of the main strategies was the development of complex care pathways and the involvement of the social system in its development. Often patients with complex health care needs require the intervention of multiple suppliers and each design their own action plan, therefore the challenge is to achieve shared care for this group. We propose a tool to address the difficulties this entails, called the case conference. That aims for each patient to have a single treatment plan co-designed with the patient and all the suppliers involved now or in the future. The aim of the communication is to describe the process of the implementation of the case conference in our environment. Development of the project - Phase 1: The first step was a trial in two Primary care centres, which showed the need for joint training of the professionals involved and created a rigorous methodology to facilitate the management of the duration of the session. The assessments of the patients were very extensive but superficial and fragmented without an overall view of the situation. The need for a common language and organizational culture were also detected, and everyone agreed that there should be learning processes to work this way and that high level of readiness is required. It confirms the relevance of specialized care in method and content. The level of professional satisfaction was very high and we were asked not to stop the trial. - Phase 2 includes the development of a regional consensus document for the case conference to be extended throughout the county taking advantage of previous experience and with the support of PPAC, which proposes a target of 50 territorial cases. - The Third phase entails using case conference with different primary care centres and creating a framework for its evaluation, and planning how to scale up the experience for a number of patients. Case conference methodology: 1. Teams involved: - The nurse, the doctor and the reference social worker of the primary care team. In some cases also the nurse case manager. Their contributions give a longitudinal understanding of the situation. The ability for decision-making is assessed whenever possible. - The doctor and the nurse of the specialized geriatric care team, who bring expertise in the diagnosis of the situation and forward planning. 2. Criteria for selecting patients. Candidates have to meet the following criteria: - Patients with complex health care needs according to the PPAC criteria of complexity. - High probability of different service providers acting simultaneously. - When a shared plan will provide value for the patient because the process of decision-making raises different options 3. Development of the case conference. It consists of building a virtual team that put together their evaluations to make a single shared plan for the patient so it requires a process of preparation by the teams involved. The geriatric assessment is used as a reference and the role of the coordinator of the case conference is key because they moderate the interventions and guarantee the method. The professionals who make the validation process of the proposals with the patient and his family are chosen at the end of the session and also the information to record on the shared information system. At the beginning the case conference will be done in person and in the future possibly by means of communication technology. Evaluation framework: There is a descriptive part that includes patient characteristics, changes in personalized plans and proposals regarding advanced care planning. The experience of professionals will be assessed qualitatively. Conclusions: Initial results are very encouraging in the sense that it is a very powerful tool to promote integrated care. The preparation time and duration of the sessions are the main difficulties to make it scalable to a large number of patients. [ABSTRACT FROM AUTHOR]

Background Ceftazidime–avibactam (CZA) is a novel cephalosporin/β-lactamase inhibitor with activity against carbapenem-resistant Enterobacteriaceae (CRE) and multidrug-resistant (MDR) Pseudomonas aeruginosa (PA). Real-world experience with CZA for CRE infections is accumulating but data on its use for MDR PA infections remains limited. Methods Retrospective, multicenter cohort study describing the clinical characteristics and outcomes of patients treated with CZA (≥ 72 hours) for MDR PA infections between 2015 and 2018. Results Fifty-one patients were included. The median (IQR) age was 61 (43, 71) years. Most patients had MDR risk factors including recent hospitalization (74.5%), recent antimicrobial exposure (84.3%), and/or previous infection or colonization with an MDR pathogen (58.8%). The median Charlson Comorbidity score was 4 (2, 6) and the median APACHE II score was 20 (12, 29). Infections were predominantly (68.6%) hospital-acquired and 52.9% of patients were in the ICU at infection onset. The common sources were respiratory tract (60.8%), osteoarticular (11.8%) and skin and soft tissue (11.8%). Two patients had positive blood cultures. PA antibiotic susceptibilities were as follows: ceftazidime 52.6% (n = 51), CZA 92.0% (n = 25), ciprofloxacin 10% (n = 30), meropenem 19.6% (n = 46), piperacillin–tazobactam 30.4% (n = 4) and tobramycin 72.9% (n = 48). Most (60.8%) infections were polymicrobial including 15 (29.4) CRE co-infections. CZA was started 97 (50, 170) hours after culture collection and continued for 9 (7, 14) days. Only 8 patients (15.7%) received active antibiotic therapy before CZA. Combination CZA therapy was used 35.3%, most often an aminoglycoside (8/18, 44.4%). Clinical cure or improvement was achieved in 40 patients (78.4%), and 42 (82.4%) were discharged alive. Among patients with repeat cultures (n = 11), CZA resistance development was not detected. Three patients (5.9%) experienced infection recurrence within 30 days of completing therapy. Conclusion The use of CZA was associated with high rates of favorable outcomes in complex patients with MDR PA infections. Future studies evaluating long-term outcomes and comparative studies are needed to more precisely define the role of CZA for MDR PA infections. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Introduction: Transitions in care between and within healthcare sectors are a major focus across health jurisdictions. It is a time of vulnerability for both patients and their families. Hip fractures are one of the leading causes of hospitalizations among the older population, with patients averaging 3.5 care setting transitions before reaching their final destination. Thus, hip fracture patients are an ideal population to study for understanding transitions of care for older adults. These patients have high rates of readmissions due to medical complications within 6 months of being discharged from acute care. Of those patients who survive one-year post-injury, only 40% can perform activities of daily living independently, leading to potential social vulnerability. Across health regions, there is substantial variation in system performance on care relating to hip fractures, which requires further understanding of the contextual factors influencing care transitions, patient/informal care experiences, and health and well-being outcomes. Methods: A multiple-case study design was chosen to compare transitions in care for hip fractures in two contrasting health jurisdictions. Regions were selected for variation in patient populations, system performance and geography. Qualitative interviews were conducted with patients, their informal care providers (e.g. family/friends), clinicians and decision-makers in both jurisdictions. When possible, patients and caregivers were followed through their care journey by sequential interviews. By interviewing a variety of key stakeholders, the intention was to develop a holistic understanding of care transitions for complex patients and system-level factors contributing to this journey. Results: Data collection is ongoing. We anticipate interviewing 56 individuals (16 patients, 16 family members, 12 clinicians and 12 decision-makers). Preliminary results suggest three main themes: 1) patient, caregiver and healthcare provider uncertainty; 2) urgency to improve transitions; and 3) transitions as a component of the larger care experience. Discussion: Consequences of poor transitions include delays, adverse medication events, dissatisfaction among patients and families as well as high patient readmission rates and emergency department visits following acute care discharge. Findings from this work will identify context specific solutions at the individual, community and system levels to optimize transitions for patients with hip fractures and for those that provide care. Conclusion (w/key findings): Barriers and enabling factors that influence optimal care transitions are specific to local health system contexts; however, the experiences of key stakeholders across the two jurisdictions were remarkably similar. There remains much room for improvement in care transitions for complex patient populations and their caregivers. Lessons learned: A community-engagement and integrated knowledge translation approach takes effort and time, but ensures the research is of value to key system users. Limitations: This study compares only two health care jurisdictions in Ontario, with interviewees recruited primarily from one hospital in each jurisdiction, and interviews conducted in English and French alone. It is possible that experiences with transitions may be different across different health regions, in different hospitals in the study regions, and among non-English or French speaking participants. Suggestions for future research: Future research can expand to different health regions and include patients and caregivers who speak different languages. [ABSTRACT FROM AUTHOR]

Introduction: Integrated care models are becoming more frequent in various health systems to provide quality coordinated care, with the aim of improving patient outcomes and costs. Many patients under an integrated care model present with complex health and social needs requiring more sophisticated care coordination. For example, in Ontario, Canada 75% of patients with complex health and social needs see six or more physicians and are taking an average of 13 medications. These patients would likely benefit from medication optimization, an area of expertise of community pharmacists. In Ontario, these patients often receive care through an integration of care approach called Health Links; however, pharmacists are generally not included in Health Links, representing a potential gap in care for these complex patients. The study objectives were to 1) explore stakeholder perceptions of formally 'linking' community pharmacy into the Health Links model and 2) identify barriers and facilitators to such a 'linkage'. Methods: In-depth narrative qualitative interviews were conducted with pharmacists, clinicians and decision-makers following a semi-structured guide. Interviews were conducted by telephone and averaged 30 minutes in length. Descriptive thematic analysis of the interview transcripts was conducted. Results: Four key themes were identified in relation to community pharmacists' inclusion in an integrated care model: perceived value contribution; perceptions of current and idealized roles; tensions surrounding collaboration; and implementation strategies. Discussion: The Health Links integrated care model involves primary, community and hospital care partnerships but often omits community pharmacists. A frequently discussed barrier to integrating community pharmacists into such a model was the perceived business-professional/clinical conflict of interest even though similar conflicts exist for other health care professions (e.g. feefor- service physicians). Despite this tension, community pharmacists' expertise and frequent contact with patients were identified as valuable to the Health Links approach. Building strong interprofessional relationships and educating clinicians on pharmacists' professional scope of practice will help alleviate this tension and contribute to successful collaboration. Conclusion (w/key findings): To optimize delivery of health care and improve patient health outcomes, collaboration, potentially through an integrated care model, should include community pharmacists. Their medication-related expertise and frequent contact with patients makes them an under-utilized healthcare profession. Lessons learned: Clinicians respond well to direct questions about sensitive subjects such as perceived professional conflicts of interest. Clinicians have differing views about the value of embedding community pharmacy within an integration of care model. Limitations: Interviews were conducted with individuals within one province of Canada. Also, a snowballing technique whereby participants were asked to suggest other individuals who may be interested and a good candidate for the study was used for participant recruitment. This technique may have selected for like-minded individuals; however, additionl purposeful sampling was also conducted to increase participant diversity and interviews were conducted until thematic saturation was reached. Suggestions for future research: Future research can involve other Canadian provinces and different integrated care models to understand if similar barriers and facilitators exist. Pilot studies of integrated care models that include community pharmacists should be conducted to assess realworld feasibility of such a model. [ABSTRACT FROM AUTHOR]

Introduction and policy context: In the Valencian Region social services and the healthcare system are not connected. Also there is not any normative jointly regulating resources, services or aid benefits that would mean an integrated care IC portfolio. Primary care PC centres are the closest and most trustworthy care facility for patients in the Spanish context. Also, PC is one of the most suitable resources to address needs of complex patients, as elderly and/or those with chronic conditions, through an IC approach, but there are some barriers that block its real and effective deployment. Objective and target population: Authors have studied the viability, implementation and development of stratification tools at PC as a promoter of IC within the Valencian Healthcare System VHS. On the basis of their work and close interaction with PC multidisciplinary staff and patients, some gaps were detected. So, this paper presents three main policy recommendations that the VHS - and other healthcare systems with similar characteristics - may take into consideration to facilitate the introduction of an IC approach. Highlights and transferability: Implementation of systematized, automatized and computerized stratification strategies at the VHS by including predictive algorithms within electronic health records EHR. Early identification of patients at risk through stratification tools provides useful information to carrying out appropriate preventive and intervention actions aimed at reducing the probability of adverse events at short or medium term. Design of a unique portfolio with health and social care services specifically addressed to complex patients. The connection between health and social care systems is possible by establishing agreements on specific administrative activities between decision-makers from each system. On the basis of this regulation, common action plans and guidelines should be launched including healthcare resources and social services at local level. Multidisciplinary case-management teams at PC centres are a relevant pillar to manage and take decisions regarding complex patients. Moreover, specific training for staff and new functions at EHR should be implemented in order to assure effective coordination and communication flows between these professionals. Strengthening of the role of EHR in the VHS by promoting their correct use by care professionals and raising awareness of electronic records research. Firstly, a unique electronic clinical history system should be available at Spanish level or, at least, interoperability between the different EHR used in each Autonomous Community must be introduced. Moreover, the VHS should promote using electronic records to carry out live, dynamic and smart monitoring of population health and to develop small/large scale predictions of patients' health outcomes and needs. Conclusions: PC multidisciplinary teams have a fundamental role in the approach of chronic conditions and older people since an IC perspective. New work cultures must be fostered to facilitate the coordination between professionals and the introduction of new technological infrastructures through EHR for an effective exploitation of data available in. Stratification and predictive systems are only an example of the potentiality of electronic records to plan preventive actions, interventions and policies in order to respond challenges that complex population mean. [ABSTRACT FROM AUTHOR]

Background: Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs., Objective: This study aims to evaluate the feasibility and patients' perceived usefulness of a multi-condition TM platform in a nurse-led model of care., Methods: A pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor., Results: In total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs., Conclusions: Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team., (©Kayleigh Gordon, Katie N Dainty, Carolyn Steele Gray, Jane DeLacy, Amika Shah, Myles Resnick, Emily Seto. Originally published in JMIR Nursing Informatics (https://nursing.jmir.org), 29.09.2020.)