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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]

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

Efforts to improve access to high-quality, effi cient primary care have highlighted the need for team-based care. Most primary care teams are designed to maintain continuity of care between patients and primary care providers (PCPs), because continuity of care can improve some patient outcomes. However, PCPs are interdependent because they care for, or share, patients. PCP interdependence, and its association with continuity of care, is not well described. This study describes a measure of PCP interdependence. We also evaluate the association between patient and panel characteristics, including PCP interdependence. Our results found that the extent of interdependence between PCPs in the same clinic varies widely. A range of patient and panel characteristics affect continuity of care, including patient complexity and PCP interdependence. These results suggest that continuity of care for complex patients is sensitive to panel characteristics, including PCP interdependence and panel size. This information can be used by primary care organizations for evidencebased team design. [ABSTRACT FROM AUTHOR]

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]

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]

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]

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]

Brief intervention (BI) is recommended for all primary care (PC) patients who screen positive for unhealthy alcohol use; however, patients with multiple chronic health conditions who are at high-risk of hospitalization (i.e., "high complexity" patients) may face disparities in receiving BIs in PC. The current study investigated whether high complexity and low complexity patients in the Veterans Health Administration (VHA) differed regarding screening positive for unhealthy alcohol use, alcohol-use severity, and receipt of BI for those with unhealthy alcohol use. Patients were veterans receiving PC services at the VHA in a mid-Atlantic region of the United States. The study extracted VHA administrative and clinical data for a total of 282,242 patients who had ≥1 PC visits between 1/1/2014 and 12/31/2014, during which they were screened for unhealthy alcohol use by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C). The study defined high complexity patients as those within and above the 90th percentile of risk for hospitalization per the VHA's Care Assessment Need Score. Logistic regression models assessed if being a high complexity patient was associated with screening positive for unhealthy alcohol use (AUDIT-C ≥ 5), severity of unhealthy alcohol use in those who screened positive (AUDIT-C score range 5–12), and receipt of BI in those who screened positive. Our sample was 94.5% male, 83% White, 13% Black, 4% other race, and 1.7% Hispanic. A total of 10,813 (3.8%) patients screened positive for unhealthy alcohol use from which we identified 569 (5.3%) high complexity and 10,128 (93.6%) low complexity patients (n = 116 removed due to missing complexity data). Relative to low complexity patients, high complexity patients were less likely to screen positive for unhealthy alcohol use (3.3% vs. 4.1%, AOR = 0.59, p <.001); however, in patients who screened positive, high complexity patients had higher AUDIT-C scores (Mean AUDIT-C = 7.75 vs. 6.87, AOR = 1.46, p <.001) and were less likely to receive a BI (78.0% vs. 92.6%, AOR = 0.42, p <.001). Disparities in BI exist for highly complex patients despite having more severe unhealthy alcohol use. Future research should examine the specific patient- and/or clinic-level factors impeding BI delivery for complex patients. • High complexity patients were less likely to screen positive for unhealthy alcohol use. • In those with unhealthy alcohol use, high complexity patients had more severe use. • BI for unhealthy alcohol use was less likely to occur in high complexity patients. • More research is needed to identify barriers to BI in high complexity patients. [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]

OBJECTIVE: A well-recognized gap exists in assessing and improving the quality of care for medically complex patients. Our objective was to examine evidence for primary care based on the patient-centered medical home model and to identify valid and meaningful quality measures for use in complex pediatric patients. METHODS: We conducted literature searches on Medline and the National Quality Measures Clearinghouse for existing measures, as well as evidence to inform the development of new quality measures. We used a 3-step process to select relevant sources from published literature: (1) the titles were screened by 2 independent reviewers; (2) the abstracts were reviewed for quality-of-care contents or constructs; and (3) full-text articles were obtained and reviewed for measure specification. All materials were reviewed for the Oxford Centre For Evidence-Based Medicine level of evidence and for relevance to primary care of complex pediatric patients. A national expert panel was convened to evaluate and rate the measures by using the Rand/University of California Los Angeles Appropriateness Method. RESULTS: We presented 74 quality measures to the expert panel for review and discussion. The panel rated and accepted 35 measures as valid and feasible for assessing primary care quality in complex pediatric patients. The final set of quality measures was grouped in the following domains: primary care-general (14), patient/family- centered care (8), chronic care (2), coordination of care (9), and transition of care (2). CONCLUSIONS: By using the patient-centered medical home framework of accessible, continuous, family-centered, coordinated, and culturally effective care, a national expert panel selected 35 primary care quality measures for complex pediatric patients. [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]