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Objective: Characterize the interventions and assistance employed by a cleft nurse navigator (CNN) which have mediated improvement in care equity at our institution. Design: Retrospective study. Setting: Academic tertiary care center. Patients, Participants: Patients presenting with cleft lip and/or cleft palate presenting between August 2020 and August 2021 with exclusions for syndromic diagnosis, Pierre-Robin sequence, late (> 6 months) presentation, and prior cleft surgery at outside institutions. Interventions: Multidisciplinary cleft nurse navigator program Main Outcome Measure(s): Family interactions with the CNN by phone, text, and email across the first year of life including feeding support, nasoalveolar molding (NAM) assistance, appointment scheduling, financial assistance, addressing perioperative concerns, and facilitating physician consults. Patient weight and surgical timing were also recorded. Results: Sixty-nine patients were included with a total of 639 interactions between the CNN and families. Scheduling support (30%), addressing perioperative concerns (22%), and feeding support (20%) were the most common interactions. Feeding support and NAM assistance were heavily distributed in the first 3 months of life compared to after 3 months (P <.001). Median age at first contact was 1 week (range: 22 weeks gestation-14 weeks). There was no difference in the proportion of families receiving feeding support, NAM assistance, or scheduling assistance based on insurance status or race (P >.05 for all). Conclusions: Scheduling assistance, addressing perioperative concerns, and feeding support are the predominant methods by which the CNN interacts with and assists families of patients with cleft conditions. CNN service distribution is largely equitable between demographic groups. [ABSTRACT FROM AUTHOR]

Background: Malignant fungating wounds occur in advanced cancer patients, often in the last 6 to 12 months of life, when malignant cells breach the skin, causing a non-healing wound. Little is known about the perspectives of clinicians who treat these patients or how collaboration is facilitated among different specialties. Objective: To understand the experiences and perceived roles of clinicians who treat patients with malignant fungating wounds from a multidisciplinary perspective. Design: A qualitative study using narrative interviews was conducted and data was analyzed to identify themes that encompass the experiences of clinicians who treat patients malignant fungating wounds and put these experiences in a temporal context. Setting/subjects: Ten clinicians who treat patients with malignant fungating wounds (n = 10) from various metropolitan research hospitals were interviewed. The clinicians were of different disciplines, including physicians and nurses, and different specialties, including palliative care, oncology, and wound care. Results: Three themes emerged that described how clinicians of varying disciplines and specialties understood their roles and navigated the transition from curative to palliative care for patients with malignant fungating wounds: (1) making the best of fragmented care (2) collaboration between oncology and wound care (3) transitioning from curative to palliative care. Conclusion: Findings of the study present a timeline of clinical care for patients, with different specialties taking the lead at different points in clinical time. Recognizing when collaboration between specialties is essential, as well as when communication fails, or clinicians have differing perspectives is important to facilitate the best care possible for patients. [ABSTRACT FROM AUTHOR]

Introduction: For many patients, primary care is an appropriate setting for advance care planning (ACP). ACP focuses on what matters most to patients and ensuring health care supports patient-defined goals. ACP may involve interactions between a clinician and a patient, but for seriously ill patients ACP could be managed by a team. Methods: We are conducting a cluster randomized trial comparing team-based to clinician-focused ACP using the Serious Illness Care Program (SICP) in 42 practices recruited from 7 practice-based research networks (PBRNs). Practices were randomized to one of the two models. Patients are referred to the study after engaging in ACP in primary care. Our target enrollment is 1260 subjects. Patient data are collected at enrollment, six months and one year. Primary outcomes are patient-reported goal-concordant care and days at home. Secondary outcomes include additional patient measures, clinician/team experience, and practice-level measures of SICP implementation. Study Implementation: This trial was designed and is conducted by the Meta-network Learning and Research Center (Meta-LARC), a consortium of PBRNs focused on integrating engagement with patients, families, and other stakeholders into primary care research and practice. The trial pairs a comparative effectiveness study with implementation of a new program and is designed to balance fidelity to the assigned model with flexibility to allow each practice to adapt implementation to their environment and priorities. Our dissemination will report the results of comparing the two models and the implementation experience of the practices to create guidance for the spread of ACP in primary care. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate three approaches adopting collaborative depression care model in Los Angeles County safety net clinics with predominantly Latino type 2 diabetes patients. Methods: Pre–post differences in treatment rates and symptom reductions were compared between baseline, 6-month, and 12-month follow-ups for each approach: (a) Multifaceted Depression and Diabetes Program (MDDP) grant–hired social workers dedicated for depression care, (b) Diabetes–Depression Care-Management Adoption Trial (DCAT) supported care (SC) by clinic social workers in diabetes disease management teams, and (c) DCAT-automated care-management technology-facilitated care (TC) model. All social workers were guided by a depression care protocol. Results: All approaches significantly increased treatment rate, the largest improvement being MDDP (40%), followed by TC (30%) and then SC (20%). Similar patterns were found in symptom improvement (≥50% depression score reductions) and self-rated health. TC was the only approach to significantly improve patient diabetes self-care. Discussion: Activated social workers and technology facilitation provide promising effective adoption of collaborative depression team care in safety net. [ABSTRACT FROM AUTHOR]

Background. Knowledge gaps remain about how the Ryan White human immunodeficiency virus (HIV)/AIDS Program (RW) contributes to health outcomes. We examined the association between different RW service classes and retention in care (RiC) or viral suppression (VS). Methods. We identified Virginians engaged in any HIV care between 1 January and 31 December 2014. RW beneficiaries were classified by receipt of ≥1 service from 3 classes: Core medical, Support, and insurance and/or direct medication assistance through the AIDS Drug Assistance Program (ADAP). Receipt of all RW classes was defined as comprehensive assistance. We used multivariable logistic regression to compare the odds of RiC and of VS by comprehensive assistance and by RW classes alone and in combination. Results. Among 13 104 individuals, 58% received any RW service and 17% comprehensive assistance. Comprehensive assistance is significantly associated with RiC (adjusted odds ratio [aOR], 8.8 [95% confidence interval {CI}, 7.2-10.8]) and viral suppression (aOR, 3.3 [95% CI, 2.9-3.8]). Receiving any 2 RW classes or Core alone is significantly associated with RiC and VS, with the strength of association decreasing as the number of classes decreases. Recipients of Support alone are significantly less likely to have VS (aOR, 0.75 [95% CI, .59-.96]). For ADAP recipients also receiving Core and/or Support, insurance assistance is significantly associated with VS compared to receiving direct medication only (aOR, 1.6 [95% CI, 1.3-1.9]); this relationship is not significant for those who receive ADAP alone. Conclusions. Receiving more classes of RW-funded services is associated with improved HIV outcomes. For some populations with insurance, RW-funded services may still be required for optimal health outcomes. [ABSTRACT FROM AUTHOR]

The article presents a study which investigated the views of primary care patients of Medicare-funded team care in chronic disease management (CDM) in Australia. The researchers detail the study design, participants and setting, data collection procedure and outcomes. It implies that patients are likely to engage with a structured team care approach to CDM driven by personal obligation and sufficient financial incentive.

Introduction: Primary care is changing to a team-based model. A number of high-performing primary-care practices in the United States have succeeded in making the transition to team-based care. Method: Site visits were conducted to 29 high-performing primary-care practices. Observations made in these practices were summarized for common elements exhibited by care teams. A limited literature search was done to review corroborating evidence. Results: Teams observed in the 29 practices were found to exhibit 9 elements: a stable team structure, colocation, a culture shift in progress from physician-driven to team-based care, defined roles with training and skill checks to reinforce those roles, standing orders and protocols, defined workflows and workflow mapping, staffing ratios adequate to facilitate new roles, ground rules, and modes of communication, including team meetings, huddles, and minute-to-minute interaction. Discussion: These 9 elements may be helpful to practices making the transition to team-based care. [ABSTRACT FROM AUTHOR]

The ageing population and increasing prevalence of chronic illness have contributed to the need for significant primary care reform, including increased use of multidisciplinary care and task substitution. This cross-sectional study explores conditions under which older patients would accept having health professionals other than their general practitioner (GP) involved in their care for chronic disease management (CDM). Ten practices were randomly sampled from a contiguous major city and inner regional area. Questionnaires were distributed to consecutive patients aged 60 years and over in each practice. Agency theory was used to inform analyses. Statistical analysis was undertaken using Wald's test, growth modelling and linear regression, controlling for the clustered design. The response rate was 53% (n = 272). Most respondents (79%) had at least one chronic health condition. Respondents were more comfortable with GP than with practice nurse management in the CDM scenario (Wald's test = 105.49, P < 0.001). Comfort with practice nurse CDM was positively associated with increased contact with their GP at the time of the visit (β = 0.41, P < 0.001), negatively associated with the number of the respondent's chronic conditions (β = -0.13, P = 0.030) and not associated with the frequency of other health professional visits. Agency theory suggests that patients employ continuity of care to optimise factors important in CDM: information symmetry and goal alignment. Our findings are consistent with the theory and lend support to ensuring that interpersonal continuity of care is not lost in health care reform. Further research exploring patients' acceptance of differing systems of care is required. [ABSTRACT FROM AUTHOR]

Study Objective. To determine the relationship between poor adherence and self-efficacy or social support after a pharmacist intervention. Design. Post-hoc analysis of data from two randomized controlled trials of physician-pharmacist collaborative interventions (6 and 9 too, respectively) to improve blood pressure control. Setting. Eleven university-affiliated primary care clinics. Patients. Five hundred eighty-four patients (aged 21-85 yrs) with uncontrolled primary hypertension; 296 were in the intervention group and 288 were in the control group. Intervention. Pharmacists provided intensified hypertension management and drug adherence counseling to patients in the intervention group. Measurements and Main Results. Social support and self-efficacy questionnaires were administered at baseline and end-of-study visits. Patient adherence was monitored by using the Morisky self-reported adherence questionnaire. Self-reported adherence scores improved significantly in the control group (p=0.0053) but not in the intervention group; however, adherence at baseline in both groups was high. There were small, but significant, improvements in self-efficacy (p<0.04) and social support (p<0.05) scores in the intervention group but not the control group at the end of the study. Social support and, to a lesser extent, self-efficacy improved as a function of duration of study participation (9-mo vs 6-mo intervention), regardless of whether the patient received the intervention. Blood pressure control in both groups improved significantly at the end of the study; however, mean blood pressure was significantly lower in the intervention group (129.7/76.6 mm Hg) compared with the control group (140.8/78.9 mm Hg; p<0.0001 for systolic, p=0.032 for diastolic). Conclusion. Social support and self-efficacy improved significantly in the intervention group at the end of the pharmacist intervention. Drug adherence was correlated with self-efficacy even though drug adherence did not improve significantly in the intervention group. The fact that social support and self efficacy improved as a function of duration of study participation suggests that participation in a research study may have had a positive influence on these measures. Even though the changes in social support, self-efficacy, and drug adherence were modest, there was significantly better blood pressure control in the intervention group compared with the control group. These findings indicate that changes in drug adherence, self-efficacy, or social support probably played a minor role in the blood pressure outcomes in these studies. [ABSTRACT FROM AUTHOR]

Background: Older people are frequent emergency department (ED) users who present with complex issues that are linked to poorer health outcomes following the index visit, often have increased ED length of stay, and tend to have raised healthcare costs. Encouraging evidence suggests that ED teams involving health and social care professionals (HSCPs) can contribute to enhanced patient flow and an improved patient experience by improving care decision-making and thus promoting timely and effective care. However, the evidence supporting the impact of HSCP teams assessing and intervening with older adults in the ED is limited and identifies important methodological limitations, highlighting the need for more robust and comprehensive investigations of this model of care. This study aims to evaluate the impact of a dedicated ED-based HSCP team on the quality, safety, and clinical- and cost-effectiveness of care of older adults when compared with usual care.Methods: The study is a single-site randomised controlled trial whereby patients aged ≥65 years who present to the ED of a large Irish hospital will be randomised to the experimental group (ED-based HSCP assessment and intervention) or the control group (usual ED care). The recruitment target is 320 participants. The HSCP team will provide a comprehensive functional assessment as well as interventions to promote a safe discharge for the patient. The primary outcome is ED length of stay (from arrival to discharge). Secondary outcomes include: rates of hospital admissions from the ED, ED re-visits, unplanned hospital admissions and healthcare utilisation at 30 days, and 4 and 6 months of follow-up; patient functional status and quality of life (at baseline and follow-up); patient satisfaction; cost-effectiveness in terms of costs associated with ED-based HSCP compared with usual care; and perceptions on implementation by ED staff members.Discussion: This is the first randomised controlled trial testing the impact of HSCPs working in teams in the ED on the quality, safety, and clinical- and cost-effectiveness of care for older patients. The findings of this study will provide important information on the effectiveness of this model of care for future implementation.Trial Registration: ClinicalTrials.gov, NCT03739515 . Registered on 12 November 2018. [ABSTRACT FROM AUTHOR]