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This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation. [ABSTRACT FROM AUTHOR]

Background Advance care planning (ACP) is an ongoing conversation where healthcare professionals explore patients' and families' wishes in order to act within their best interests. The COVID19 pandemic continues to highlight the importance of timely ACP, namely while our patients have capacity. We noted that despite advancing age, accumulating co-morbidities and high clinical frailty scores (CFS); ACP discussions were not taking place within our elderly department. We aimed to increase ACP conversations and ensure documentation on ReSPECT forms to allow continuity within primary care. Methods 10 patients per ward were randomly selected. 69 patients met inclusion criteria (over 65 with CFS ≥5 or any patient with dementia). We reviewed electronic and paper records and defined evidence of ACP as ReSPECT form including preferred place of death (PPoD), or discussion with patient or relative in medical notes. We randomly selected a pilot ward and applied interventions over 4 weeks: • Small group teaching to junior doctors • Visiting ward MDTs to identify appropriate patients for ACP • Presenting baseline data to geriatricians • Visual aids from the palliative care team and prompt sheets for doctors. Results Prior to our interventions, 22% of our sample had evidence of advance care planning, 33% of discussions documented on ReSPECT form. Following our intervention period we reviewed medical notes on our pilot ward. 58% patients now had evidence of ACP, with 66% documented on a ReSPECT form. Conclusion We achieved a significant increase in advance care planning within our elderly medicine department, and are therefore better equipped to provide personalised care alongside our patients' wishes and values. Next steps: • Expanding teaching across the multi-disciplinary team • ACP 'champions' to highlight appropriate patients • Expansion of initial interventions across the department We hope to embed and maintain this change through education, training and inspiring others. [ABSTRACT FROM AUTHOR]

The Covid-19 pandemic presented a wide range of challenges to cancer control. People with possible symptoms of cancer were considered less likely to present for investigation. Patients with cancer were concerned about increased risk of illness or death from this novel virus. Cancer services had to ensure continued delivery of time-sensitive care. Public health skills and leadership have been key to Ireland’s National Cancer Control Programme’s COVID response. The multi-disciplinary skill set within the Programme includes an understanding of health protection principles, experience in rapid service redesign, monitoring of service delivery, patient and public communication, advocacy and guidance development, all of which have been integral to the pandemic response. Specific areas addressed include: rapid turnaround of guidance documents for cancer services, to minimise Covid-19 risk; patient information materials for those on treatment or with a history of cancer; development of novel service delivery mechanisms, such as a virtual national psychooncology service; a media campaign to combat decreased presentations with possible cancer and to reassure those currently on treatment; development of pre-surgical cocooning guidance and testing pathway; advocating for prioritisation of timesensitive cancer diagnosis and treatment, and the wider health & wellbeing needs of those cocooning; advocating for and supporting the implementation of priority vaccination for those undergoing cancer treatment. Cross-sectoral collaboration has been facilitated by existing networks and relationships, allowing rapid responses to be deployed and actioned. The leaner guidance development process employed during the pandemic enabled timely response. A two-way communication system with cancer services allowed swift cascade of information and gathering of intelligence which empowered action. Learning from the cancer setting was transferable to other high-risk groups. Key messages: • The potential impact of the pandemic on non-COVID care was far reaching, including at all stages of the cancer patient journey, from pre-diagnosis to living with or beyond cancer. • The programmatic approach to cancer control in Ireland facilitated concerted efforts to respond to the challenges posed by the pandemic. [ABSTRACT FROM AUTHOR]

Background: Family Medicine is a novel discipline in many countries, where the motivation for training and value added to communities is not well-described. Our purpose was to understand the reason behind the choice of Family Medicine as a profession, the impact of Family Medicine on communities, and Family Medicine's characterizing qualities, as perceived by family doctors around the world. Methods: One-question video interviews were conducted using an appreciative inquiry approach, with volunteer participants at the 2016 World Organization of Family Doctors conference in Rio de Janeiro. Qualitative data analysis applied the thematic, framework method. Results: 135 family doctors from 55 countries participated in this study. Three overarching themes emerged: 1) key attributes of Family Medicine, 2) core Family Medicine values and 3) shared traits of family doctors. Family Medicine attributes and values were the key expressed motivators to join Family Medicine as a profession and were also among expressed factors that contributed to the impact of Family Medicine globally. Major sub-themes included the principles of comprehensive care, holistic care, continuity of care, patient centeredness, and the patient-provider relationship. Participants emphasized the importance of universal care, human rights, social justice and health equity. Conclusion: Family doctors around the world shared stories about their profession, presenting a heterogeneous picture of global Family Medicine unified by its attributes and values. These stories may inspire and serve as positive examples for Family Medicine programs, prospective students, advocates and other stakeholders. [ABSTRACT FROM AUTHOR]