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BackgroundMethodsResultsConclusionsComplex patients require multidisciplinary input for optimal care, but this can lead to fragmented care. This project aimed to improve multidisciplinary communication, care coordination, and patient satisfaction in primary care clinics.Multidisciplinary team meetings focused on discussing complex patients over six months. Pre- and post-intervention surveys assessed changes in communication and satisfaction among healthcare providers and staff. Patient surveys evaluated their satisfaction with care. The generated action items at multidisciplinary meetings, such as new referrals, were categorized to evaluate the impact on care coordination.Post-intervention surveys showed positive responses regarding improved teamwork, communication, and patient care, but ongoing challenges in the selection of patients and team meeting participants. On average, there were 2.3 new referrals per patient, indicating enhanced care coordination.Multidisciplinary team meetings showed promise in enhancing communication, care coordination, and staff satisfaction. Ongoing refinement and assessment are necessary to optimize their feasibility and effectiveness over a longer time period. [ABSTRACT FROM AUTHOR]

Patient-centered, interprofessional occupational therapy is feasible in complex patients in the early phase of rehabilitation, and it contributes to meet needs in the domains of self-care, productivity, and leisure, promoting social role. We planned this single-center single-blind two-arm parallel individual patient randomized controlled trial, to verify the superiority of interprofessional experimental occupational therapy (EOT) compared to standard rehabilitation (SR) in producing higher levels of patients' social participation assessed by the Reintegration to Normal Living Index. EOT is a patient-centered, hospital/home-based rehabilitation intervention based on the Canadian Model of Occupational Performance and Engagement. This appropriately powered study will provide evidence regarding the effectiveness of EOT on the recovery of social participation in the critical transition of complex patients from hospital to the home setting. [ABSTRACT FROM AUTHOR]

The Hugo™ robotic assisted surgery system is a relatively new robotic platform developed by Medtronic. The study objective was to describe the experience of using Hugo™ robotic assisted surgery in gynecological surgeries and compare robotic assisted surgery-related outcomes between complex and non-complex gynecological patients at the Pacifica Salud Hospital. We performed secondary data retrospective analysis of 144 consecutive patients who underwent gynecological surgery with Hugo™ robotic assisted surgery system (Medtronic) at the Pacifica Salud hospital in Panama City from July 19, 2021, to August 3, 2023. Complex patients were defined as those with one or more risk factors for surgery complications. Descriptive analysis of participants' sociodemographic and robotic assisted surgery-related characteristics. Due to the non-normal distribution of the RAS-related numeric variables, we compared these variables between complex and non-complex cases of gynecological patients using Kruskal–Wallis's test. The study found that Hugo™ robotic assisted surgery system was safe for gynecological surgery in patients with and without risk factors for developing major surgery complications. None of the patients experienced any complications, and they had short hospital stays with low blood loss without requiring a blood transfusion. The Hugo™ robotic assisted surgery system was technically sound and did not present technical failures. The results could be a reference for adopting this technology and developing best practices in the Latin American region. [ABSTRACT FROM AUTHOR]

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.

To verify the effectiveness of experimental occupational therapy plus intensive standard rehabilitation compared to intensive standard rehabilitation alone on the reintegration to social activities of complex patients three months after hospital discharge. Patients with a score ≥ 9 on the Rehabilitation Complexity Scale at admission to an intensive rehabilitation ward were randomized to the control or experimental group. Both groups received intensive multidisciplinary rehabilitation aimed at recovering independence in the basic activities of daily life (ADL). The experimental group also received experimental occupational therapy services to address goals identified through the administration of the Canadian Occupational Performance Measure (COPM). Experimental occupational therapy began during the in-hospital phase and continued in the home-based setting. It consisted of teaching strategies, recommending aids, and providing personalized information regarding available community support. Ninety-two individuals with a mean age of 65 years (female 44.6%) were enrolled. The experimental group significantly improved participation measured by the Reintegration to Normal Living Index (mean changes 8.61, 95% CI: 1–16.23, p = 0.027). The performance and satisfaction scores of the COPM, both during hospitalization and after discharge, and independence in ADL also improved. No differences in mood disturbances were found. Early post-discharge occupational therapy integrated with multidisciplinary rehabilitation improves the social participation of complex patients. Future research should investigate the concrete feasibility of implementing this complex intervention cost-effectively and in different contexts. ClinicalTrials.gov Identifier NCT03668938 (first posted date 13/09/2018) Early post-discharge rehabilitation assists patients' transition from hospital to home by improving the management of problems they encounter. In complex patients, occupational therapy initiated during hospitalization and extended to the early post-discharge phase improves social participation, independence in basic and instrumental daily activities, and performance and satisfaction when carrying out relevant occupational activities. The strong partnership between the Occupational Therapist and the patient improves compliance to treatment, enhancing the chances of success of rehabilitation interventions. [ABSTRACT FROM AUTHOR]

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]

Introduction Emergent clinical care and patient movements through the military evacuation system improves survival. Patient management differs when transporting from the point-of-injury (POI) to the first medical treatment facility (MTF) versus transporting from the Role 2 to the Role 3 MTF secondary to care rendered within the MTF, including surgery and advanced resuscitation. The objective of this study was to describe care provided to patients during theater inter-facility transports and compare with pre-hospital transports (POI to first MTF). Materials and Methods We performed a retrospective chart review of patients with the Role 2 to the Role 3 transports in Afghanistan and Iraq from 2007 to 2016. Data collected included procedures and events at the MTF and during transport. We compared the intra-theater transport data (Role 2 to Role 3) to data from a previous study evaluating pre-hospiital transports (POI to first MTF). Results We reviewed the records of 869 Role 2 to Role 3 transport patients. Role 2 to Role 3 transports were longer in duration compared to POI transports (39 minutes vs. 23 minutes) and were more likely to be staffed by advanced personnel (nurses, physician assistants, and physicians) (57% vs. 3%). The sample primarily consisted of military-aged males (mean age 27 years) who suffered from explosive or blunt force injuries. Procedures performed during each phase of care reflected the capabilities of the teams and locations. Pain and cardiac events were more common in POI evacuations compared to the Role 2 to Role 3 transports, but documentation of respiratory events, hemodynamic events, neurologic events, and equipment failure was more common during the Role 2 to Role 3 transports. Survival rates were slightly higher among the Role 2 to Role 3 cohort (98% vs. 95%, difference 3% [95% confidence interval of the difference 1-5%]). Conclusions Inter-facility transports (Role 2 to Role 3) are longer in duration, transport more complex patients, and are staffed by more advanced level provider types compared to transports from POI. [ABSTRACT FROM AUTHOR]

Background: Individuals with multimorbidity and complexity have multifaceted care needs requiring integrated and collaborative care from nurses, families, and health care teams. Nurses, as the frontline care professionals, should develop therapeutic relationships with patients and their families and professional relationships with health care team members to ensure the delivery of effective integrated care. Failure to develop effective interpersonal and professional relationships can negatively affect patient care. Objective: The purpose of this study was to explore nurses' challenges with developing interpersonal and professional relationships during integrated care for individuals with multimorbidity and complexity. Methods: A descriptive qualitative design was used. We interviewed a purposive sample of 19 nurses with experience of caring for individuals with multimorbidity and complexity across two hospitals in Pakistan. Semi-structured interviews were used for data collection, and data were analyzed using reflexive thematic analysis. Results: Two challenges were identified affecting the relationships between patients' families and nurses, and two challenges influencing the professional relationships within the team. Families withheld information, controlled care access of their relatives, posed unrealistic demands, and abused nurses, affecting nurse-family relationships. Power struggles to demonstrate authority in decision-making were common within health care teams, affecting nurses' professional capacity to provide effective care. Conclusions: Health care team, patient, and family collaboration is instrumental in improved care for individuals with multimorbidity and complexity. Nurse leaders and health care organizations should take initiatives to address nurses' interpersonal confrontations to support them in the provision of quality care. [ABSTRACT FROM AUTHOR]

Aims and objectives: To explore behavioural indicators of compassionate nursing care from the perspectives of individuals with multimorbidities and complex needs. Background: Complex patients are individuals with multimorbidity and/or mental health concerns, andoften with medication and drug‐related problems requiring ongoing person‐centered care, mental health interventions, and family and community resources. They are frequent consumers of health‐care services and it is documented that these patients experience discrimination and substandard care. Compassionate care can improve patient care experiences and health outcomes. However, missing is the guidance on how to provide compassionate care for this population from the perspectives of complex patients. Design: A qualitative descriptive approach was conducted in eastern Canada from December 2020–April 2021. The COREQ guidelines were followed for reporting. Methods: Data from in‐person and virtual semi‐structured interviews with 23 individuals having experiences as complex patients were analysed using reflexive thematic analysis. Among them 19 were homeless and lived in a shelter. Findings Six indicators of compassionate nursing care were generated: sensitivity, awareness, a non‐judgmental approach, a positive demeanour, empathic understanding, and altruism. Conclusions: Individuals perceived that nurses who acknowledge personal biases are better at providing compassionate care by manifesting compassion through their genuine and selfless interest in the complicated health problems and underlying socio‐cultural determinants of each patient. Kindness, positivity, and a respectful nursing approach elicit openness and the sharing of heartfelt concerns. Relevance to clinical practice: Comprehensive health assessment, dedicated efforts to know the patient as a human being, and listening to the patient's preferences can improve health outcomes among individuals with complex needs. Healthcare administrators can effect the change by supporting nurses to address complex health and social care needs with compassion. Patient or public contribution: Patients and healthcare professionals helped in data collection at the community care centre. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with multiple physical and, or, mental health issues and, or, drug‐related problems are known as complex patients. These patients are often recipients of poor‐quality care. Compassionate nursing care is valuable to promote better care experiences among this patient population. Implementation strategies should be designed to enhance compassionate nursing care delivery. The study aimed to gain understanding of barriers to compassionate care delivery to propose implementation to promote compassionate nursing care of complex patients. Design: An exploratory sequential mixed methods study was conducted. Methods: Phase 1 was the qualitative component during which 23 individuals with multimorbidities were interviewed for exploring their perceptions of barriers to compassionate nursing care. The barriers were integrated with implementation science frameworks using the building technique during phase 2 to develop a Q‐sort survey of implementation strategies for phase 3. Nurses, nurse managers, health care administrators, policymakers, and compassionate care experts responded to the survey by ranking the 21 implementation strategies, out of which five met the Q‐factor analysis criteria. Results: Participant‐perceived barriers to nurse compassion could be categorized under knowledge, intentions, skills, social influences, behavioral regulation, reinforcement, emotion, and environmental context and resources. The five highest‐ranked strategies included facilitation, consultation with stress experts, involvement of patients and families, modeling compassion through shadowing, and utilizing implementation teams. Conclusions: Enablement and modeling were the integration functions represented by the highest‐ranked implementation strategies. Enabling nurses to provide compassionate care through emotional support and mental health counseling, and, modeling compassion and compassionate care through shadowing were recommended and rated as highly relevant by the majority of stakeholders. Clinical Relevance: Enhancing nurses compassionate behaviors toward complex patients requires facilitating them in enacting compassion in practice through modeling and support from organizations and nurse managers. [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.

Purpose: Collegial support meetings (CSM) have been set up in the Gustave Roussy Cancer Center for inpatients whose complex care requires a multi-professional approach involving many participants: oncologists but also health-caregivers, a member of the palliative care team, an intensivist, and a psychologist. This study is aimed at describing the role of this newly multidisciplinary meeting implemented in a French Comprehensive Cancer Center. Methods: Each week, the health-caregivers decide which situations should be examined, depending on the difficulty of a case. The discussion goes on to include the goal of treatment, the intensity of care, ethical and psychosocial issues, and the patient’s life plan. Finally, to obtain feedback from the teams, a survey has been distributed to assess the interest in the CSM. Results: In 2020, 114 inpatients were involved, and 91% were in an advanced palliative situation. During the CSMs, 55% of the discussions focused on whether to continue specific cancer treatment—29% about whether to continue invasive medical care—50% about optimizing supportive care. We estimate that between 65 and 75% of CSMs influenced further decisions. Death occurred during the hospitalization for 35% of the patients that were discussed. The lapse of time between last chemotherapy and death was 24 days (IQR, 28.5). CSMs were well received, since 80% of the teams find these meetings useful. Conclusions: CSMs reach conclusions for medical and nursing staff involved, in order to improve the management of inpatients with cancer in advanced palliative situation and to define the better goals of care. [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

Aims and Objectives: To determine nurses' perceived barriers to the delivery of person‐centred care to complex patients with multiple chronic conditions in acute care settings. Background: Complex patients have multiple physical and mental health problems, and their life is also greatly affected by sociocultural and economic determinants of health. These patients require person‐centred care, but nurses often find it challenging to provide effective care to these patients due to their complex health needs. Design: A descriptive qualitative design was used. The COREQ guidelines were followed for reporting. Methods: Semi‐structured interviews were conducted with a purposive sample of 19 nurses in two hospitals. Data were analysed using deductive thematic analysis guided by the Theoretical Domains Framework, which entails 14 domains about factors affecting behaviours. Results: The key barriers were identified under environmental context and resources, social influences, emotions, knowledge and skills domains. Deep‐rooted social issues delay patients' health‐seeking and nurses' abilities to understand patients' needs and discern appropriate care. Interpersonal hostility influenced nurse–patient–families interactions, and doctor–nurses conflicts affected collaborative efforts towards optimal care. Conclusions: Nurses' perceived barriers to care were intertwined with the deep‐rooted social and cultural beliefs about nurses' image, patients' expectations and families' preference for home remedies over specialised nursing care. These barriers to person‐centred care demonstrate an intricate interplay of personal, social and organisational issues and power struggles. Multifaceted implementation strategies targeting environmental context and resources, social influences, emotions, knowledge and skills domains may be beneficial to enable nurses to provide better person‐centred care to complex patients. Relevance to clinical practice: Designing implementation facilitation teams, organising person‐centred care grand rounds, and allocation of stress management resources to address hostility, social‐cultural influences, and organisational barriers is essential. Nurses could focus on their self‐awareness and collaborative skills to address emotional and interprofessional conflicts. [ABSTRACT FROM AUTHOR]

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]

Background: Multimorbidity and patient complexity are increasing, yet undergraduate medical education curricula remain dominated by single disease frameworks, where students are often shielded from exposure to this complexity. Why this shielding continues to occur is understandable; however, this may leave graduates feeling underprepared for real-world practice. This study aimed to explore medical students' experiences of encountering, managing and dealing with complexity and to provide informed recommendations for integrating complexity into clinical teaching., Methodology: Situated within a constructivist paradigm, this qualitative study involved focus groups (n = 4) with fourth- and fifth-year medical students (n = 17) from two Scottish Universities. Data were analysed using reflexive thematic analysis., Findings: Learners in this study recognised multimorbidity, complex communication and emotionally charged interactions in their definitions of complexity. They described varying levels of exposure to complexity and opportunities to engage meaningfully with complex patients. Students felt that supervisors who shield students from learning opportunities with complex patients, together with a failing healthcare system, were critical limiting factors in their development. Learners emphasised the powerful role of supervisors in their learning experiences, which limited their ability to experiment and learn from productive failure but felt that with guided scaffolding and supervision, teaching and learning in this space could be meaningfully enhanced., Conclusion: Exposure to and engagement with complex patients offer critical learning opportunities that may allow students to explore and better develop skills in managing complexity. With appropriate scaffolding, students can be empowered to embrace complexity in the clinical learning environment, potentially equipping them to care for complex patients., (© 2025 The Author(s). The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

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]

Community case managers (CCMs) play a crucial role in the continuity of care for complex patients in the community. However, they are often considered as non‐members of the healthcare team and not actively engaged by the primary care team because of the unique landscape of social services in Singapore. Given that these two distinct professional groups had minimal collaboration previously, integrating CCMs as partners of patient care within the primary care team may pose many challenges. The objective of this qualitative study was to understand the challenges encountered by CCMs when collaborating with primary care services. This exploratory qualitative descriptive study used individual in‐depth interviews. CCMs were selected using convenience and snowball sampling. The interviews were semi‐structured, guided by a topic guide. Fourteen CCMs were interviewed within a period of 12 weeks (October–December 2018). Thematic analysis was used to analyse the transcripts. Two researchers coded each transcript independently, and a coding framework was agreed upon. Potential themes were then independently developed based on the coding framework. Fourteen individual in‐depth interviews were conducted. Six themes emerged from the data, i.e., self‐identity, patient factor, inter‐professional factor, collaborative culture, confidentiality and organisational structure. Challenges that resonated with previous studies were self‐identity, inter‐professional factors and confidentiality, whereas other challenges such as patient factors, collaborative culture and organisational structure were unique to Singapore's healthcare landscape. Significant challenges were encountered by CCMs when collaborating with primary care services. Understanding these challenges is key to refining intervention in current models of comprehensive community care between medical and non‐medical professionals. [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]

Interprofessional student hotspotting involves experiential and longitudinal learning about team-based care for patients with complex medical and social needs. As an emerging strategy for interprofessional education, there have been few research studies to examine student perspectives. This study used a descriptive qualitative approach to examine the experiences and perspectives of health professions students who participated in a six-month interprofessional student hotspotting program. At the end of the program, focus group interviews were conducted with 24 health professions students from medicine, social work, pharmacy, nursing, and health psychology. Thematic analysis revealed four themes: Observed benefits of interprofessional collaboration ; Gained skills for collaborative care ; Experienced difficulty managing group dynamics ; and Learned approaches to caring for complex patients. The hotspotting program helped deepen students' appreciation for interprofessional team-based care. Repeated practice of teamwork skills during the six-month clinical learning experience resulted in students feeling more prepared to provide collaborative care for complex patients. • Student hotspotting is a strategy for providing longitudinal and experiential IPE. • Students observed the benefits of interprofessional collaborative care. • Collaboration skills were practiced while providing team-based care to patients. • Faculty guidance can assist students to grow their ability to manage team conflict. • Hotspotting promotes learning the care of medically and socially complex patients. [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.

Frequent presenters to the Emergency Department (ED) are known to have complex physical, behavioural and social needs. The study aimed to analyse the system's behaviour to generate new insights into ED high utilisers with complex mental health issues. A retrospective cohort study of the ED presentations of 200 high utilisers during a 12-month period was conducted. Analyses included psychiatric diagnoses, re-presentation rates, cost-benefit analysis of services and patient journey maps to illustrate the patient experience. The profiled high utilisers represented nearly a quarter of total ED mental health presentations and were more likely to be single and unemployed. Diagnostically, Borderline Personality Disorder and Schizophrenia predominated. The re-presentation rate was high (70% within 28 days) and mental health attributable costs represented nearly three quarters of total health costs. The study revealed a disintegrated service system for ED high utilisers with mental health issues, resulting in suboptimal clinical outcomes and substantial costs. To deliver value-based mental healthcare our lessons were; (1) stabilise the system's interaction with the patient by ensuring service responses are consistent with their enhanced management plan (2) all the system's parts channel the patient into various support services including psychological treatment with one therapist. The top 200 high utilisers presented to emergency 1928 times within 12 months The re-presentation rate amongst the study's cohort was high (70% within 28 days) A high prevalence of BPD and schizophrenia was noted for this cohort The study reveals a disintegrated service system for ED high utilisers, resulting in suboptimal clinical outcomes and substantial costs for the service A need for early identification, consistency in service responses and various support services to be provided by the hospital including psychological treatment [ABSTRACT FROM AUTHOR]

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]

The aim of this study is to examine the impact of opening a medical psychiatric unit (MPU) on a variety of outcomes. In this non-equivalent groups design, there were two groups: 'pre-MPU' and 'actual MPU'. Staff assessed whether patients in the pre-MPU group were eligible for admission to a planned MPU, resulting in virtual admissions and discharges. The actual MPU group consisted of patients admitted after opening of the MPU. The length of stay (LOS) in the hospital was one day longer for patients in the MPU group (8.68 vs. 9.89, p =.004), but the LOS on the MPU was comparable in both groups (5.63 vs. 6.06, p =.231). The LOS on the intensive care unit (ICU) was longer in the MPU group (0.10 vs. 0.40, p <.001), even as the time patients were physically restraint (0.28 vs. 0.83, p <.001). In the pre-MPU group, the odds were not significantly different for involuntary commitment (OR = 0.92; p =.866) and death within six months after discharge (OR = 1.84; p =.196). Both physical restraint and ICU admission have a link with patient complexity, it therefore seemed that opening of the MPU resulted in the treatment of more complex patients with a comparable LOS on the MPU. The LOS on the MPU was not significantly different between the groups before and after opening of the MPU. Opening of the MPU resulted in the admission of patients that were admitted more days to the ICU and to more days of physically restraint. It can be considered that opening of the MPU resulted in an increased ability to treat complex patients. [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]

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]

Understanding how unmet basic needs impact health care in patients with complex conditions is vital to improve health outcomes and reduce health care costs. The purpose of this observational study was to explore the association between health care and socioeconomic needs and health care utilization and disease management among patients with chronic conditions at an intensive, patient-centered, office-based program. The study used a cross-sectional design and a convenience sampling approach. Data were collected through a patient questionnaire and medical records. Analysis included descriptive and inferential statistics. Data from 48 established patients were analyzed. Financial and lack of transportation were the 2 most frequently reported unmet needs. More than 65% of participants had their chronic condition(s) under control. Sex and ethnicity were the only 2 demographic variables that yielded significant differences (P ≤ 0.01) on visits to the emergency room and having chronic condition(s) under control. Those who reported having unmet transportation needs were more likely to have a condition uncontrolled and to have lost medical appointments compared to those who had this social need met (P ≤ 0.05). Statistically significant differences in terms of missing medical appointments also were found between those whose overall financial and housing needs were unmet and those who had those needs met (P ≤ 0.05). Results indicate that participating patients generally had good control of their conditions. The study adds evidence in support of the call for health care to address patients' socioeconomic needs, and the health care benefits of intensive case management programs. The model may be considered for adoption throughout New Mexico, and nationally. [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]

Objectives: Voriconazole, a triazole antifungal, is frequently prescribed in a complex patient population with comorbidities that require concomitant administration of QT interval-prolonging medications. We sought to evaluate QT interval prolongation in patients receiving concomitant therapy with voriconazole and amiodarone and to assess the development of any potentially fatal cardiac arrhythmias as a result.Methods: We conducted a retrospective observational study of patients who had received amiodarone and voriconazole concomitantly between 2005 and 2015, with a prior period of monotherapy, who had ECG data during monotherapy (baseline) and concomitant therapy (follow-up).Results: We included 46 patients in our final analysis. Overall, the mean change in QT corrected (QTc) from baseline to follow-up was 49.0 ms (P < 0.001). Eighteen (39.1%) patients had a follow-up QTc interval ≥500 ms, with 17 (37.0%) having a change in QTc interval ≥60 ms from baseline to follow-up. Men were more likely to have a follow-up QTc interval of ≥500 ms. In multivariate analysis, only low serum potassium concentration and concomitant 'possible' QT-prolonging drugs were associated with a follow-up QTc interval ≥500 ms and a lower baseline QTc interval was associated with a change in QTc interval of ≥60 ms. Discharge diagnoses of cardiac arrhythmias and events were assessed and none was found to be related to concomitant therapy.Conclusions: Concomitant therapy with amiodarone and voriconazole significantly prolonged the QTc interval to a degree greater than that on monotherapy. However, no clinically significant cardiac events were observed. [ABSTRACT FROM AUTHOR]

Résumé Introduction La médecine interne est une spécialité hospitalière. À côté de son expertise dans les maladies rares, cette spécialité partage avec la médecine générale la prise en charge globale des patients. Son positionnement dans le virage ambulatoire reste à préciser. L'objectif de notre travail était d'évaluer l'intérêt d'un hôpital de jour de médecine interne ouvert sur la médecine de ville. Méthodes Nommé Centre Vi'TAL (ville–hôpital), cet hôpital de jour s'adresse aux médecins traitants qui font face à des difficultés diagnostiques, thérapeutiques, ou de synthèse chez un patient complexe. La demande du médecin, adressée par courriel entraîne une concertation avec un interniste le jour même. Si la demande relève bien d'un hôpital de jour, le patient est accueilli dans les 7 jours. Dans les autres situations, les patients sont dirigés vers la consultation, l'hospitalisation complète voire les urgences. Résultats En 14 mois, le centre Vi'TAL a accueilli 213 (144 femmes, 69 hommes) patients, d'âge moyen 53,6 ans, adressés par 88 médecins de ville pour un nombre total de 282 séances d'hôpital de jour. Les motifs de demande étaient un problème diagnostique (n = 105), thérapeutique (n = 43) ou de synthèse (n = 65). Conclusion Dans le virage ambulatoire prôné par les tutelles, la médecine interne a toute sa place dans la valorisation de l'hôpital de jour comme lieu de diagnostic et de synthèse en lien avec la ville, tout en laissant le médecin traitant coordonnateur des soins de leur patient. Ce temps de synthèse est utile pour les patients et efficient pour le système de santé. Abstract Introduction Internal medicine is an in-hospital speciality. Along with its expertise in rare diseases, it shares with general medicine the global care of patients but its place in the ambulatory shift has yet to be defined. The objective of our work was to evaluate the benefits of an internal medicine day-hospital devoted to general medicine. Methods Named "Centre Vi'TAL" to underline the link between the city and the hospital, this novel activity was implemented in order to respond quickly to general practitioners having difficulties to synthesize their complex patients or facing diagnostic or therapeutic problems. Using preferentially email for communication, the general practitioners can contact an internist who is committed to respond on the same day and take over the patient within 7 days if day-hospital is appropriate for his condition. The other patients are directed either to the emergency department, consultation or full hospitalization. Results In 14 months, the center has received 213 (144 women, 69 men) patients, mean age 53.6, addressed by 88 general practitioners for 282 day-hospital sessions. Requests included problem diagnoses (n = 105), synthesis reviews for complex patients (n = 65), and treatment (n = 43). Conclusion In the ambulatory shift advocated by the authorities, this experience shows that internal medicine should engage in the recognition of day-hospital as a place for diagnosis and synthesis reviews connected with the city while leaving the general practitioners coordinator of their patient care. This activity of synthesis in day-hospital is useful for the patients and efficient for our healthcare system. [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]

Purpose: Inpatients admitted to rehabilitation express needs not linked to disease causing hospitalization. This observational cross-sectional study identifies features and occupational needs of complex inpatients during rehabilitation, focusing on function and ability, regardless of diagnosis. Method: This study included sixteen adult inpatients with stroke, deemed complex according to Rehabilitation Complexity Scale-Extended, at admission to Rehabilitation ward (from July 2014 to February 2015). Patients with primary psychiatric disorders, language barriers, cognitive or severe communication deficits were excluded. Upon admission, a multidisciplinary team collected data on general health, independence in daily activities (Modified Barthel Index), fatigue (Fatigue Severity Scale), resistance to sitting and ability to perform instrumental activities (Instrumental Activities of Daily Living). The occupational therapist identified occupational needs according to Canadian Occupational Performance Measure. Results: Inpatients enrolled in this study were dependent in basic ADL, limited in instrumental ADL and easily fatigable. Their occupational needs related to self-care (75%) and, to a lesser extent, productivity (15%) and leisure (10%). According to inpatients, rehabilitation process should firstly address self-care needs, followed by productivity and leisure problems. Conclusions: Despite small sample size, this study described patterns of occupational needs in complex inpatients with stroke. These results will be implemented in client-centered rehabilitation programs to be tested in a phase-two trial. [ABSTRACT FROM AUTHOR]