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Technology plays a role in nearly every aspect of healthcare delivery. Health systems must continually invest in new and existing technology and analytics platforms to scale initiatives, enable innovation, and achieve interoperability to meet the needs and expectations of patients and clinicians while remaining focused on the organization's mission and strategic priorities. In this process, decision-makers must determine how to allocate technological resources to platforms that meet clinical and administrative needs while reducing the need for frequent replacement or reconfiguration. Advances in artificial intelligence and its capabilities add urgency and complexity to technology investment decisions. An important consideration during this process is when to build new technology infrastructure and when to partner with existing companies and buy technology solutions. This case study explores a major academic medical center's approach to that decision, including the factors that influenced it and the outcomes of two solutions that were developed in-house., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Foundation of the American College of Healthcare Executives.)

Objectives: Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders., Methods: A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care., Results: We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers., Conclusions: A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care., Competing Interests: Declaration of conflict of interest None., (Published by Elsevier Inc.)

Background: Academic libraries play a significant role in the student learning process. However, student needs and preferences as well as new paradigms of learning are driving libraries to transition from quiet book repositories to places of collaboration and open information. This descriptive, mixed methods case presentation explores the transition of one library, the United States Air Force School of Aerospace Medicine Franzello Aeromedical Library, in three key areas: collection, capability, and facility. Due to the niche subject matter and audience the library serves, this case also describes how the Franzello Aeromedical Library's distinct collection and capability remained intact throughout modernization., Case Presentation: The Franzello Aeromedical Library's modernization project aimed to augment the library as a cutting-edge resource supporting USAFSAM's education, consultation, and research mission to equip Aerospace Medicine Airmen with the skills and knowledge for healthcare delivery in austere environments. This project was approached using five phases: 1) best practices baseline, 2) baseline evaluation of library visitor needs, 3) collection weeding, 4) capability, and 5) space design and construction., Conclusion: As a result of this complex two-year project, several recommendations were gleaned. Use the effort as an opportunity to market library services to new audiences. Ensure all stakeholders are at the table from day one and in perpetuity to save time, and consider using purposeful decision-making models, such as Courses of Action, to make tough calls. Be prepared for delays by padding your timeline and compromise where necessary to keep the project alive. Finally, the authors recommend using in-project discovery and findings to plan for future need justification., (Copyright © 2024 Melanie Lazarus, Theresa Bedford, Sara Craycraft, Elizabeth Irvine, Cathy Stahl, Kristen Young.)

North Carolina Integrated Care for Kids (NC InCK) is a pilot health care delivery and payment model for Medicaid-enrolled children in five North Carolina counties. We describe early learnings from the NC InCK approach to promote the vision of whole-child health for children in North Carolina., Competing Interests: Disclosure of interests: S.A. led the design and launch of the NC InCK model at Duke Health in the role of Managing Director. R. Cholera serves as the Executive Director for NC InCK. R. Chung serves as Population Health Director for NC InCK. K.F. serves as Early Childhood Director for NC InCK. M.S. serves as Health Director for NC InCK., (Copyright ©2023 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Purpose/objectives: The purpose of this case study is to describe the movement of spiritual care into outpatient, managed care and population health settings, as it has evolved in a major not-for-profit health care system in the United States. The objective is to begin to establish the effectiveness of integrating spiritual care as a part of the interdisciplinary team (IDT) in these contexts., Primary Practice Settings: The case study presents two practice settings: a remote patient monitoring program for patients with complex medical conditions, and integration into population health as a part of a Medicare Advantage Insurance program that is a cooperative venture between the health care system (Ascension) and an established insurance program (Centene)., Findings/conclusions: The cases presented suggest that the integration of spiritual care into the outpatient, managed care and population health contexts has a threefold benefit: enhancing patient care, increasing the effectiveness of the IDT, and providing for the care and support of the members of the IDTs themselves., Implications for Case Management Practice: The cases presented suggest inclusion of spiritual care in the care management/population health approach to patient care is viable and valuable both for the benefit of the patient and the functioning of the care team., Competing Interests: The author reports no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The article presents a case study involving the medical group's motivation for seeking recognition from the U.S. National Committee for Quality Assurance (NCQA) as a patient-centered medical home (PCMH). It indicates that PCMH principles were consistent with the culture and mission of the organization. It reveals that some PCMH components were viewed as part of the patient-centered culture of the organization, whereas others helped the practice compete in its local market.

Abstract: Reducing racial and ethnic disparities in health care has become an important policy goal in the United States and other countries, but evidence to inform interventions to address disparities is limited. The objective of this study was to identify important dimensions of interventions to reduce health care disparities. We used qualitative research methods to examine interventions aimed at improving diabetes and/or cardiovascular care for patients from racial and ethnic minority groups within five health care organizations. We interviewed 36 key informants and conducted a thematic analysis to identify important features of these interventions. Key elements of interventions included two contextual factors (external accountability and alignment of incentives to reduce disparities) and four factors related to the organization or intervention itself (organizational commitment, population health focus, use of data to inform solutions, and a comprehensive approach to quality). Consideration of these elements could improve the design, implementation, and evaluation of future interventions to address racial and ethnic disparities in health care. [Copyright &y& Elsevier]

For more than 30 years, the network of Centers for Disease Control and Prevention (CDC)-funded Prevention Research Centers (PRCs) has worked with local communities and partners to implement and evaluate public health interventions and policies for the prevention of disease and promotion of health. The COVID-19 pandemic tested the PRC network's ability to rapidly respond to multiple, simultaneous public health crises. On April 28, 2020, to assess the network's engagement with activities undertaken in response to the early phase of the pandemic, PRC network leadership distributed an online survey to the directors of 34 currently or formerly funded PRCs, asking them to report their PRCs' engagement with predetermined activities across 9 topical areas and provide case studies exemplifying that engagement. We received responses from 24 PRCs, all of which reported engagement with at least 1 of the 9 topical areas (mean, 5). The topical areas with which the greatest number of PRCs reported engagement were support of frontline agencies (21 of 24, 88%) and support of activities related to health care (21 of 24, 88%). The mean number of activities with which PRCs reported engagement was 11. The PRCs provided more than 90 case studies exemplifying their work. The results of the survey indicated that the PRCs mobilized their personnel and resources to support the COVID-19 response in less than 6 weeks. We posit that the speed of this response was due, in part, to the broad and diverse expertise of PRC personnel and long-standing partnerships between PRCs and the communities in which they work.

Objective: The study sought to develop an in-depth understanding of how hospitals with a long history of health information technology (HIT) use have responded to the COVID-19 (coronavirus disease 2019) pandemic from an HIT perspective., Materials and Methods: We undertook interviews with 44 healthcare professionals with a background in informatics from 6 hospitals internationally. Interviews were informed by a topic guide and were conducted via videoconferencing software. Thematic analysis was employed to develop a coding framework and identify emerging themes., Results: Three themes and 6 subthemes were identified. HITs were employed to manage time and resources during a surge in patient numbers through fast-tracked governance procedures, and the creation of real-time bed capacity tracking within electronic health records. Improving the integration of different hospital systems was identified as important across sites. The use of hard-stop alerts and order sets were perceived as being effective at helping to respond to potential medication shortages and selecting available drug treatments. Utilizing information from multiple data sources to develop alerts facilitated treatment. Finally, the upscaling/optimization of telehealth and remote working capabilities was used to reduce the risk of nosocomial infection within hospitals., Discussion: A number of the HIT-related changes implemented at these sites were perceived to have facilitated more effective patient treatment and management of resources. Informaticians generally felt more valued by hospital management as a result., Conclusions: Improving integration between data systems, utilizing specialized alerts, and expanding telehealth represent strategies that hospitals should consider when using HIT for delivering hospital care in the context of the COVID-19 pandemic., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Outbreaks of COVID-19 among nursing homes, assisted living facilities, and other long-term care facilities in the United States have had devastating effects on residents. Restrictions such as banning visitors, sequestering residents, and testing health care staff have been implemented to mitigate the spread of the virus. However, consequences include a decline in mental and physical health, decompensation, and a sense of hopelessness among residents. We present and explore a case study at an assisted living facility addressing the ethical issues in balancing the management of the community versus the resident's right to autonomy and self-determination. A team of palliative care experts was brought into assisted living facilities to manage patients, care for well residents, and provide input in advance care planning and symptom management. The principles of self-determination and autonomy, stewardship, and distributive justice were explored. The use of nursing skills in triage and assessment, principles in public health, and the 8 domains of palliative care provided a comprehensive framework for structuring emergency operations. Palliative interventions and the role of palliative care nurses played an integral part in addressing ethical challenges in the containment of the virus and the deleterious effects of social isolation among the elderly., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 by The Hospice and Palliative Nurses Association. All rights reserved.)

Introduction: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic., Initial Work: Implementation of telehealth began in 2017. Health system barriers, provider and patient reluctance, and inadequate reimbursement prevented widespread adoption at the time. COVID-19 served as the catalyst to accelerate telehealth efforts., Implementation: COVID-19 resulted in the need for patient care with "social distancing." In addition, due to the pandemic, the Centers for Medicare and Medicaid Services and other insurers began expanded reimbursement for telehealth. More than 2000 providers received virtual health training in less than 2 weeks. In March 2020, we provided 2376 virtual visits, and in April 5293, which was more than 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual., Lessons Learned: Several key lessons are important for future efforts regarding clinical implementation: (1) prepare for innovation, (2) cultivate an innovation mindset, (3) standardize (but not too much), (4) technological innovation is necessary but not sufficient, and (5) communicate widely and often., Competing Interests: Conflict of interest: None., (© Copyright 2021 by the American Board of Family Medicine.)

None: Telehealth has been a well-established system of care delivery at Kaiser Permanente Northwest Pediatric Gastroenterology since before the COVID-19 era, where 54% of our completed pediatric gastroenterology encounters in the past year were virtual visits. Although it was previously limited in its use across the majority of health care in the US, telehealth is now a widely accepted system in the face of the COVID-19 pandemic. However, this unprecedented rapid expansion of telehealth within both new and established telehealth systems is not without challenges or quality concerns. In this report, we present our single-center experience from the past year where virtual care was already an integral part of our clinical practice in pediatric gastroenterology and review satisfaction data and quality measures from the COVID-19 era where our existing telehealth system expanded to nearly exclusive virtual care., (Copyright © 2021 The Permanente Press. All rights reserved.)

Background: With the mandate to review all available literature in the study's inclusion parameters, systematic review projects are likely to require full-text access to a significant number of articles that are not available in a library's collection, thereby necessitating ordering content via interlibrary loan (ILL). The aim of this study is to understand what effect a systematic review service has on the copyright royalty fees accompanying ILL requests at an academic health sciences library., Case Presentation: The library created a custom report using ILLiad data to look specifically at 2018 ILL borrowing requests that were known to be part of systematic reviews. This subset of borrowing activity was then analyzed to determine its impact on the library's copyright royalty expenditures for the year. In 2018, copyright eligible borrowing requests that were known to be part of systematic reviews represented only approximately 5% of total filled requests that involved copyright eligible borrowing. However, these systematic review requests directly or indirectly caused approximately 10% of all the Spencer S. Eccles Library copyright royalty expenditures for 2018 requests., Conclusion: Based on the sample data set, the library's copyright royalty expenditures did increase, but the overall financial impact was modest., (Copyright © 2021 Christy Jarvis, Joan Marcotte Gregory, Alison Mortensen-Hayes, Mary McFarland.)

The COVID-19 pandemic has created a situation unparalleled in our lifetime. As the medical community has attempted to navigate a sea of ever-changing information and policies, this uncertainty has instead bred creativity, community, and evolution. Necessity is the mother of invention, and one of the by-products of our rapidly changing environment is the increased reliance on telemedicine. Here, we discuss our experience with incorporating telemedicine into an urban academic pediatric otolaryngology practice, the challenges that we have encountered, and the principles unique to this population.

Policy Points Strategically purchasing health care has been and continues to be a popular policy idea around the world. Key asymmetries in information, market power, political power, and financial power hinder the effective implementation of strategic purchasing. Strategic purchasing has consistently failed to live up to its promises for these reasons. Future strategies based on strategic purchasing should tailor their expectations to its real effectiveness., Context: Strategic purchasing of health care has been a popular policy idea around the world for decades, with advocates claiming that it can lead to improved quality, patient satisfaction, efficiency, accountability, and even population health. In this article, we report the results of an inquiry into the implementation and effects of strategic purchasing., Methods: We conducted three in-depth case studies of England, the Netherlands, and the United States. We reviewed definitions of purchasing, including its slow acquisition of adjectives such as strategic, and settled on a definition of purchasing that distinguishes it from the mere use of contracts to regulate stable interorganizational relationships. The case studies review the career of strategic purchasing in three different systems where its installation and use have been a policy priority for years., Findings: No existing health care system has effective strategic purchasing because of four key asymmetries: market power asymmetry, information asymmetry, financial asymmetry, and political power asymmetry., Conclusions: Further investment in policies that are premised on the effectiveness of strategic purchasing, or efforts to promote it, may not be worthwhile. Instead, policymakers may need to focus on the real sources of power in a health care system. Policy for systems with existing purchasing relationships should take into account the asymmetries, ways to work with them, and the constraints that they create., (© 2020 Milbank Memorial Fund.)

Nurse-led models of care are an important strategy in the management of patients with chronic disease because of the person-centered approach that allows the needs of the individual to be prioritized and addressed in accessible settings. Hepatitis C is caused by a blood-borne virus that can cause liver disease and liver cancer; it predominantly affects marginalized populations, including people who inject drugs. Since 2013, all oral, direct-acting antiviral regimens have been available to cure hepatitis C. Nurses are well placed to be involved in the delivery of hepatitis C testing and treatment because of their extensive reach within marginalized communities and holistic approach to patient care. Four case studies of nurse-led models of care operating in Australia, Canada, the United Kingdom, and the United States are presented to illustrate the important role nurses have in delivering accessible, person-centered hepatitis C testing and treatment. Each case study demonstrates the success of overcoming barriers to hepatitis C testing and treatment such as geographic isolation, incarceration, social marginalization, and inflexible healthcare systems. Achieving the global target to eliminate hepatitis C by 2030 will require the nursing profession to embrace its role as the first point of contact to the healthcare system for many members of marginalized communities potentially at risk of hepatitis C. Nurses are well placed to reduce barriers and facilitate access to healthcare by scaling up activities focused on hepatitis C testing and treatment.

Gender disparities in medical publication have been demonstrated in several specialties. This descriptive bibliometric analysis aims to determine the gender ratio of scholarly authorship at the Robert Graham Center (RGC) over an 11-year period. We examined publications by RGC researchers and assessed first, second, and last author gender. Of 229 publications, 65.5% had a male first author and 34.5% had a female first author. Of the 217 publications with a last author, 13.4% had a female last author. This study aims to inform the broader discussion about authorship gender parity in academic medicine using a one-site case-study approach., (© 2020 Annals of Family Medicine, Inc.)

Purpose: Internationally, health professions education scholarship units (HPESUs) are often developed to promote engagement in educational scholarship, yet little is known about how HPESUs change over time or what factors support their longevity. In hopes of helping HPESUs thrive, this study explored factors that shaped the evolution of 8 HPESUs over the past 14 years., Method: This study involved retrospective case-study analysis of the 8 American, Canadian, and Dutch HPESUs profiled in a 2004 publication. First, the research team summarized key elements of HPESUs from the 2004 articles, then conducted semistructured interviews with the current unit directors. In the first set of questions, directors were asked to reflect on how the unit had changed over time, what successes the unit enjoyed, what enabled these successes, what challenges the unit encountered, and how these challenges were managed. In the second set of questions, questions were tailored to each unit, following up on unique elements from the original article. The team used Braun and Clarke's 6-phase approach to thematic analysis to identify, analyze, and report themes., Results: The histories of the units varied widely-some had grown by following their original mandates, some had significant mission shifts, and others had nearly disappeared. Current HPESU directors identified 3 key factors that shaped their HPESU's longitudinal development: the people working within and overseeing the HPESU (the need for a critical mass of scholars, a pipeline for developing scholars, and effective leadership), institutional structures (issues of centralization, unit priorities, and clear messaging), and funding (the need for multiple funding sources)., Conclusions: Study findings offer insights that may help current HPESU directors to strategically plan for their unit's continued development. Tactically harnessing the factors identified could help directors ensure their HPESU's growth and contend with the challenges that threaten the unit's success.

Background: Care coordination occurs largely through care coordinators' interactions with patients and community partners to identify and address patients' individual needs. More frequent and higher-quality communication with each may enhance care coordination effectiveness., Purpose: The purpose of this study was to understand (a) how care coordinator perceptions of interactions with patients and community partners, respectively, compared to each other group's perceptions of their interactions with care coordinators and (2) whether these dynamics between care coordinators and community partners changed over time., Methodology: The research context was a comparative case study of provider-based care coordination projects funded through the Texas 1115(a) Medicaid waiver. The Relational Coordination instrument was administered through (a) two waves of in-person interviews with care coordinators (2014-2015 and 2015-2016) at a total of 10 sites across the state, (b) a single 2016 phone survey with 159 patients at nine of those sites, and (c) phone surveys with representatives of the community resources that care coordinators had identified as key partners in 2014-2015 and again in 2015-2016., Results: Care coordinators reported more frequently needing both patients and community partners than either other group reported relative to care coordinators. Frequency of need and mutual influence with community partners increased in the first 2 years of the care coordination programs' implementation. The perceived quality of interactions between care coordinators and both patients and community partners was positive, but with room for improvement., Conclusion: Care coordination may entail limited interactions with patients and community partners, especially at program inception. As care coordination programs mature, interactions may become more frequent and influence with partners may expand., Practice Implications: Decision makers should support care coordinators in improving the quality of their communication with both patients and community partners, as well as allow time for these relationships to develop.

The evolving healthcare environment has put a new emphasis on population health. Healthcare organizations, and the nurses who work in them, are in a unique position to reach beyond hospital walls to address unmet needs and improve the health and lives of the community they serve. This month's Magnet Perspectives column examines nurses' growing impact on population health through the lens of the 2019 Magnet Prize winner, OSF HealthCare Saint Francis Medical Center. Learn how OSF Saint Francis nurses developed an innovative program to address food insecurity among their community's most vulnerable residents and improve health outcomes. The column also explores how American Nurses Credentialing Center Magnet-recognized organizations promote strong external partnerships that extend nurses' influence from the traditional one-patient-at-a-time approach to broader, population-based outreach.

Quantitative metrics are used to develop profiles of health care institutions, including hospitals, nursing homes, and dialysis clinics. These profiles serve as measures of quality of care, which are used to compare institutions and determine reimbursement, as a part of a national effort led by the Center for Medicare and Medicaid Services in the United States. However, there is some concern about how misclassification in case-mix factors, which are typically accounted for in profiling, impacts results. We evaluated the potential effect of misclassification on profiling results, using 20 744 patients from 2740 dialysis facilities in the US Renal Data System. In this case study, we compared 30-day readmission as the profiling outcome measure, using comorbidity data from either the Center for Medicare and Medicaid Services Medical Evidence Report (error-prone) or Medicare claims (more accurate). Although the regression coefficient of the error-prone covariate demonstrated notable bias in simulation, the outcome measure-standardized readmission ratio-and profiling results were quite robust; for example, correlation coefficient of 0.99 in standardized readmission ratio estimates. Thus, we conclude that misclassification on case-mix did not meaningfully impact overall profiling results. We also identified both extreme degree of case-mix factor misclassification and magnitude of between-provider variability as 2 factors that can potentially exert enough influence on profile status to move a clinic from one performance category to another (eg, normal to worse performer).

Telehealth is an acknowledged strategy to meet patient healthcare needs. In critical care settings, Tele-ICU's are expanding to deliver clinical services across a diverse spectrum of critically ill patients. The expansion of telehealth provides increased opportunities for advanced practice providers including advanced practice nurses and physician assistants; however, limited information on roles and models of care for advanced practice providers in telehealth exist. This article reviews current and evolving roles for advanced practice providers in telehealth in acute and critical care settings across 7 healthcare systems in the United States. The health system exemplars described in this article identify the important role of advanced practice providers in providing patient care oversight and in improving outcomes for acute and critically ill patients. As telehealth continues to expand, additional opportunities will lead to novel roles for advanced practice providers in the field of telehealth to assist with patient care management for subacute, acute, and critically ill patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Indigenous communities often face disproportionate challenges across a variety of health domains, and effective prevention strategies are sorely needed. Unfortunately, evidence is scant regarding what approaches are effective for these communities. A common approach is to take an evidence-based practice or program with documented effectiveness in other populations and implement it with Indigenous populations. While a science of intervention adaptation is emerging, there remains little guidance on processes for adaptation that strategically leverage both existing scientific evidence and Indigenous prevention strategies. In this paper, two case studies illustrate promising practices for adaptation, documenting the approaches of two research teams funded under the National Institutes of Health's initiative to support Intervention Research to Improve Native American Health (IRINAH). These teams worked with distinct Indigenous populations in the USA and Canada to culturally adapt the same prevention program, the Iowa Strengthening Families Program for Parents and Youth 10-14. The approaches of these two teams and the programs that resulted are compared and contrasted, and critical elements of adaptation in partnership with Indigenous communities are discussed.

Opioid misuse is a national health crisis that requires sustained treatment, prevention, and recovery efforts. This study evaluates the innovative treatment approaches that two states - Kentucky and Missouri - implemented in their states using State Targeted Response to the Opioid Crisis Grant (Opioid STR) program funds from the Substance Abuse Mental Health and Services Administration (SAMHSA), as well as preliminary findings from the Opioid STR national, cross-site evaluation that is funded and managed by SAMHSA. The Kentucky approach discusses the Emergency Department (ED) bridge model, which links patients discharged from EDs to appropriate professional treatment and recovery services. Missouri implemented the Medication First (MedFirst) model, an evidence-based treatment for individuals with opioid use disorder (OUD). These states highlight novel approaches likely being implemented throughout the country to combat the opioid epidemic. Findings from the case studies and supported by the national evaluation indicate that key factors to successful program implementation - supportive state policies, partnerships and collaborations, and sustainability - facilitated the implementation of planned interventions. The novel approaches discussed combined with care across the continuum (prevention, treatment and recovery) and continued federal support is likely to have an impact on reducing opioid misuse across the U.S., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

The rapid growth and diffusion of digital media technologies has changed the landscape of market segmentation in the last two decades, including its use in promoting prosocial and behavior change. New, population-specific and culturally appropriate prevention strategies can leverage the potential of digital media to influence health outcomes, especially for the greatest users of digital technology, including youth and young adults. Health behavior change campaigns are increasingly shifting resources to social media, creating opportunities for innovative interventions and new research methods. This article examines three case studies of digital segmentation: (1) tobacco control from the Truth Initiative, (2) community-based public health programs from the Centers for Disease Control and Prevention, and (3) substance use (including opioids) and other risk behavior prevention from Public Good Projects. These case studies of recent digital segmentation efforts in the not-for-profit, government, and academic sectors show that it increases reach and frequency of messages delivered to priority populations. The practice of digital segmentation is rapidly growing, shows early signs of effectiveness, and may enhance future public health campaigns. Additional research could optimize its use and effectiveness in promoting prosocial and behavior change campaign outcomes.

Background: Emergency foods distributed during a federal disaster relief response must follow the federal Dietary Guidelines for Americans according to the 1990 National Nutrition Monitoring Related Research Act. Nutrition information about emergency foods for household distribution is scarce., Methods: According to structured observation protocols, foods received daily at a federal distribution center in Puerto Rico after Hurricane María (November 10-25, 2017) were grouped into Dietary Guidelines for Americans ChooseMyPlate food groups. Data about their sodium, saturated fat, added sugar, and fiber content per serving were captured. Registered dietitians designed meal plans with the foods distributed., Results: Of 107 unique food items, 41% were snacks and sweets; and 13%, 4%, 13%, and 7% were fruits, vegetables, proteins, and grains, respectively. Fifty-eight percent of all foods were low in fiber (≤1 g); 46% included high amounts of sodium, saturated fats, or added sugars (≥20% daily value). The registered dietitians were able to design meal plans that complied with the Dietary Guidelines for Americans food group recommendations, but they exceeded upper daily limits for sodium, saturated fat, or added sugars., Conclusions: In view of projected increases in natural disasters and diet-related chronic diseases, DGA compliance must be improved so that federal emergency foods can support the health of survivors., (Copyright © 2019 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

While community health workers (CHWs) are employed in various arrangements, little is known about the association between organizational structure and CHW experiences. Seventeen in-depth interviews were conducted with CHWs, supervisors, and leadership employed in one centrally organized setting to investigate organizational structure and perceptions of CHW effectiveness. A model that hired employees but assigned them to various settings offered support and unique career advancement opportunities. Coordinated education, ongoing trainings, and persistent supervision were perceived to improve the accuracy of resource information and facilitated collaboration across the health care system with increased health care team communication, offering insights into other organizational structures.

Background: Maximizing vaccination uptake is crucial in generating herd immunity and preventing infection incidence (Quach et al., Am J Infect Control 11:1017-23, 2013). Vaccination of healthcare personnel (HCP) against influenza is vital to influenza infection control in healthcare settings, given the consistent exposure of HCP to high-risk patients like: those with compromised immune systems, children, and the elderly (Johnson & Talbot, Curr Opin Infect Dis 24: 363-369, 2011). Influenza vaccination uptake among HCP remains suboptimal: in 2017-18, 47.6% of HCP who worked in settings where influenza vaccination was not mandatory were vaccinated against influenza in United States (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). Mandatory vaccination policies result in HCP influenza vaccination uptake rates substantially higher than opt-in influenza vaccination campaigns (94.8% vs. 47.6%) (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018)., Goals: The Israel Journal of Health Policy Research has published articles focused on the issues of influenza vaccination (Yamin et al., Isr J Health Policy Res 3: 13, 2014), improving influenza vaccination coverage of HCP (Weber et al., Isr J Health Policy Res 5: 1-5, 2016), influenza vaccination motivators among HCP (Nutman and Yoeli, Isr J Health Policy Res 5: 52, 2016), legal imposition of vaccination (Kamin-Friedman, Isr J Health Policy Res 6:58, 2017), and mandatory vaccination (Gostin, Cell Biosci 8: 1-4, 2018). Each article explores factors influencing disease prevention from different angles within an Israeli context. This article attempts to fuse these topics by investigating how to apply aspects of American mandatory influenza vaccination policy targeted at HCP in an Israeli context., Methods: Critical document analysis was conducted on relevant literature and policy discussing influenza prevention interventions among HCP within the United States. Mandatory vaccination policies were highlighted. A discussion of the professional responsibility of HCP to vaccinate against influenza serves as background. Case studies of hospitals in the United States that implemented mandatory vaccination policies for their employees are analyzed. The article concludes with analysis exploring how qualities of mandatory influenza vaccination policy of HCP could take shape in Israel, giving contextual limitations, urging Israeli health policy makers to reflect on lessons learned from the American case study., Main Findings and Conclusion: Mandatory HCP influenza vaccination policies in comparison to non-mandatory interventions are most effective in obtaining maximum influenza vaccination uptake among HCP (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). Many HCP cite individual objections to influenza vaccination rooted in personal doubts and ethical concerns. The ethical responsibility of HCP to their patients and work environments to prevent and lower influenza infection incidence arguably overrules such individual objections. Mandatory HCP influenza vaccination policies are an effective method of maximizing HCP influenza vaccine uptake and minimizing the spread of the influenza virus within healthcare settings. Still, cultural, social and political sensitivity must be taken into consideration when implementing both full-on mandatory HCP influenza vaccination policies and/or aspects of mandatory policies, especially within an Israeli context.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems., (© 2019 Annals of Family Medicine, Inc.)

One goal of the Affordable Care Act is to increase insurance coverage by improving competition and lowering premiums. To facilitate this goal, the federal government enacted online marketplaces in the 395 rating areas spanning 34 states that chose not to establish their own state-run marketplaces. Few multivariate regression studies analyzing the effects of competition on premiums suffer from endogeneity, due to simultaneity and omitted variable biases. However, United Healthcare's decision to enter these marketplaces in 2015 provides the researcher with an opportunity to address this endogeneity problem. Exploiting the variation caused by United Healthcare's entry decision as an instrument for competition, we study the impact of competition on premiums during the first 2 years of these marketplaces. Combining panel data from five different sources and controlling for 12 variables, we find that one more insurer in a rating area leads to a 6.97% reduction in the second-lowest-priced silver plan premium, which is larger than the estimated effects in existing literature. Furthermore, we run a threshold analysis and find that competition's effects on premiums become statistically insignificant if there are four or more insurers in a rating area. These findings are robust to alternative measures of premiums, inclusion of a non-linear term in the regression models and a county-level analysis.

Purpose: Healthcare service quality in the USA has gained importance under value-based payment models. Providing feedback to front-line staff is a vital component of managing service performance, but complex organizational dynamics can prevent effective communication. This work explored the performance management of appointment desk staff at Mayo Clinic Arizona, identified barriers to effective management and sought to standardize the process for monitoring service performance., Design/methodology/approach: Multiple data sources, including qualitative inquiry with 31 employees from the primary care and surgery departments, were used. The research was conducted in two phases - facilitated roundtable discussions with supervisors and semi-structured interviews with supervisors and staff six months after implementation of service standards. Participants were probed for attitudes about the service standards and supervisor feedback after implementation., Findings: While all staff indicated a positive work environment, there was an unexpected and pervasive negative stigma surrounding individual feedback from one's supervisor. Half the participants indicated there had been no individual feedback regarding the service standards from the supervisor. Presenting service standards in a simple, one-page format, signed by both supervisor and the patient service representative (PSR), was well received., Originality/value: Combining rapid-cycle quality improvement methodology with qualitative inquiry allowed efficient development of role-specific service standards and quick evaluation of their implementation. This unique approach for improving healthcare service quality and identifying barriers to providing individual feedback may be useful to organizations navigating a more value- and consumer-driven healthcare market.

Development and implementation of policy, systems, and environmental (PSE) change is a commonly used public health approach to reduce disease burden. The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program conducted a demonstration with 13 programs to determine whether and to what extent dedicated resources would enhance the adoption of PSE strategies. This paper describes results of the qualitative portion of a longitudinal, mixed-methods evaluation of this demonstration. Case studies were conducted with a diverse subset of the 13 programs, and 106 in-depth interviews were completed with state/tribal program staff, community partners, and decision makers. Interviews addressed PSE change planning and capacity building, partnerships, local context, and how programs achieved PSE change. Dedicated PSE resources, including a policy analyst, helped increase PSE change capacity, intensify focus on PSE change overall, and accomplish specific PSE changes within individual jurisdictions. Stakeholders described PSE change as a gradual process requiring preparation and prioritization, strategic collaboration, and navigation of local context. Findings suggest that the demonstration program, including PSE-dedicated funds and a policy analyst, was successful in both increasing PSE change capacity and achieving PSE change itself. These results may be useful to other state, tribal, territorial, and public health organizations planning or implementing PSE change strategies.

Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services (such as care coordination and social supports) in fee-for-service reimbursement. Accountable care organizations (ACOs) have potential to improve serious illness care because of their widespread dissemination, strong financial incentives for care coordination in downside-risk models, and flexibility in shared savings spending. Through a national survey we found that 94 percent of ACOs at least partially identify their seriously ill beneficiaries, yet only 8-21 percent have widely implemented serious illness initiatives such as advance care planning or home-based palliative care. We selected six diverse ACOs with successful programs for case studies and interviewed fifty-three leaders and front-line personnel. Cross-cutting themes include the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations. We discuss the implications of the recent Medicare ACO regulatory overhaul and other policies related to serious illness quality measures, risk adjustment, attribution methods, supporting rural ACOs, and enhancing timely data access.

Background: Multiple studies have questioned the validity of clinical codes in hospital administrative data. We examined variability in reporting a postoperative ileus (POI)., Objective: We aimed to analyse sources of coding variations to understand how clinical coding professionals arrive at POI coding decisions and to verify existing knowledge that current clinical coding practices lack standardised applications of regulatory guidelines., Method: Two medical records (cases 1 and 2) were provided to 15 clinical coders employed by a midsize nonprofit hospital in the northwest region of the United States. After coding these cases, the study participants completed a survey, reported on the application of guidelines, and participated in a focus group led by a health information management regulatory compliance expert., Results: Only 5 of the 15 clinical coders correctly indicated no POI complication in case 1 where the physician documentation did not establish a link between the POI as a complication of care and the surgery. In contrast, 13 of the 15 study participants correctly coded case 2, which included clear physician documentation and contained the clinical parameters for the coding of the POI as a complication of care. Clinical coder education, credentials, certifications, and experience did not relate to the coding performance. The clinical coders inconsistently prioritised coding rules and valued experience more than education., Conclusion and Implications: The application of International Classification of Diseases, Ninth Revision, Clinical Modification; coding conventions; Centers for Medicare and Medicaid Services coding guidelines; and American Hospital Association coding clinic advice was subject to the clinical coders' interpretation; they perceived them as conflicting guidance. Their reliance on subjective experience in dealing with this conflicting guidance may limit the accuracy of reporting outcomes of clinical performance.

This article is a case study that discusses the development and implementation of an internal learning object repository (LOR) for a large national organization with a distributed working environment. It describes the organizational environment and why an internal LOR was needed. It describes technical considerations, including the various document management systems (DMS) available, and why an open source DMS was selected to use as an internal LOR. Lastly, this article weighs the benefits and challenges of implementing a LOR across a distributed working environment and reflects on challenges associated with implementation.

Objective: We explored post-Affordable Care Act hospital and skilled nursing facility (SNF) perspectives in discharge and admission practices., Method: Interviews were conducted with 138 administrative personnel in 16 hospitals and 25 SNFs in eight U.S. markets and qualitatively analyzed., Results: Hospitals may use prior referral rates and patients' geographic proximity to SNFs to guide discharges. SNFs with higher hospital referral rates often use licensed nurses to screen patients to admit more preferred patients. While SNFs with lower hospital referral rates use marketing strategies to increase admissions, these patients are often less preferred due to lower reimbursement or complex care needs., Conclusion: An unintended consequence of increased hospital-SNF integration may be greater disparity. SNFs with high hospital referral rates may admit well-reimbursed or less medically complex patients than SNFs with lower referral rates. Without policy remediation, SNFs with lower referral rates may thus care for more medically complex long-term care patients.

Background: Different countries have different preferences regarding health, and there are different value sets for popular preference-based measures across different countries. However, the cost of collecting data to generate country-specific value sets can be prohibitive for countries with smaller population size or low- and middle-income countries (LMIC). This paper explores whether existing preference weights could be modelled alongside a small own country valuation study to generate representative estimates. This is explored using a case study modelling UK data alongside smaller US samples to generate US estimates., Methods: We analyse EQ-5D valuation data derived from representative samples of the US and UK populations using time trade-off to value 42 health states. A nonparametric Bayesian model was applied to estimate a US value set using the full UK dataset and subsets of the US dataset for 10, 15, 20 and 25 health states. Estimates are compared to a US value set estimated using US values alone using mean predictions and root mean square error., Results: The results suggest that using US data elicited for 20 health states alongside the existing UK data produces similar predicted mean valuations and RMSE as the US value set, while 25 health states produce the exact features., Conclusions: The promising results suggest that existing preference data could be combined with a small valuation study in a new country to generate preference weights, making own country value sets more achievable for LMIC. Further research is encouraged.

Objectives: Describe an interdisciplinary spinal cord injury home care program (SCIHCP), sample demographics for the veteran participants, and initial impact of SCIHCP on health care utilization and mortality., Design: Retrospective review., Setting: SCIHCP of the Spinal Cord Injury Center, VA North Texas Health Care System (VANTHCS)., Participants: Patients with SCI/D enrolled in the SCIHCP during January 6, 2006 through January 9, 2012, whose injury occurred at least one year prior to enrollment(n = 125)., Main Outcome Measures: VANTHCS hospital admissions, length of stay (LOS), and emergency department (ED) visits evaluated one year before and one year after SCIHCP enrollment; mortality evaluated one-year post-enrollment., Results: There were no significant changes in number of ED visits, number of hospital admissions, or LOS over time. More home care visits and more mental health comorbidities predicted more hospital admissions. Older patients and those with more mental health comorbidities were more likely to experience increases in LOS. These prediction models were significant after adjusting for injury level, age, race, time since SCI, and number of medical comorbidities. More home care visits were associated with lower likelihood of mortality post-enrollment., Conclusions: Inpatient and ED utilization did not change one year after enrollment, but more SCIHCP visits predicted more hospital admissions and lower likelihood of mortality in the post-evaluation year. The support, education, and care continuity SCIHCP generates might be related to increased inpatient access and lower mortality rate. Veterans with increased mental health comorbidities used inpatient services more, and might need additional support.

Background: This case study describes the implementation and evaluation of a multisite teen health information outreach program. The objectives of the program were to increase health knowledge, health information literacy, interest in health careers, community engagement, and leadership skills of teens in disadvantaged communities., Case Presentation: Teens at six sites across the country participated in a multi-week curriculum that focused on various aspects of health literacy, information literacy, and leadership. Lesson topics addressed personal health, social determinants of health, information quality, and communication and advocacy skills. Program evaluation included both quantitative and qualitative components and focused on multiple knowledge and skills outcome variables. Results suggested that while teens at all sites showed improvement, particularly with respect to engagement and interest in the topics, the degree of gains in knowledge and information literacy measures varied significantly from site to site., Conclusion: On-site implementation planning, cohesive integration of added activities, and emphasis on retention can contribute to implementation and evaluation effectiveness. This work also underscores the limitation of a purely quantitative approach to capturing the impact of health information and stresses the importance of supplementing numerical scores and statistics with qualitative data.

Executive Summary: This article reports on a data-driven methodology for decision-making at a Veterans Affairs medical center (VAMC) to improve patient outcomes, specifically the 30-day standardized mortality ratio (SMR30). The quarterly strategic analytics for improvement and learning (SAIL) reports are used to visualize the data, study trends, provide actionable recommendations, and identify potential consequences.A case study using more than 4 years of data demonstrates the power of the methodology. After reviewing data and studying trends at other VAMCs, a decision is made to reduce the SMR30 value by 1%. In running correlation algorithms, in-hospital complications (IHC) are shown to be most closely correlated with SMR30. Modeling the results from 17 quarters' worth of data shows that a desired 1% change in SMR30 would require a targeted 18.6% decrease in IHC. This change, if accomplished, would yield good consequences on methicillin-resistant Staphylococcus aureus mitigation but potentially unintended consequences with catheter-associated urinary tract infections and patient safety indicators that would need to be monitored. This knowledge could enable healthcare leaders to make informed decisions of both potentially positive and unintended consequences that can be monitored and minimized. This study lays the groundwork for a healthy discussion among leaders, staff, and clinicians on the path forward, resources required, and-most importantly-a dashboard that reflects the progress each week rather than a quarterly SAIL report.

Objective: To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes., Data Sources/study Setting: Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015., Study Design/data Collection: Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared., Principal Findings: Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals., Conclusions: Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes., (© Health Research and Educational Trust.)

"Legal recursivity" is a concept introduced by socio-legal scholars to capture the progressive elaboration of transnational rules through policy linkages at the international and domestic levels, and the associated jurisdictional expansion of international institutions to new policy areas. Recursivity can take many forms, and this article introduces the concept of "antagonistic recursivity" to capture a dual process of recursive legal innovation and antagonistic obstruction by the same policy actors. The article shows how such antagonistic recursivity worked in the case of the global fight against private nuclear proliferators after the 2003 revelations about the reach of the A. Q. Khan network. In the case under study, antagonistic recursivities took the form of executive-driven innovation in rule-making and simultaneous subversion of the same rules by the executive most implicated in the new cycle of policy innovation: the United States government. This paradox can be explained in the following manner. Antagonistic recursivity, the article demonstrates, is likely to emerge when legal rules of global governance have already been previously defined in an opaque manner, so as to help hegemons follow multiple foreign policy goals: the subversion of the most recent policy innovations is then the unfortunate result of attempts to hide prior cover-ups rather than a purposeful violation of new rules., (© London School of Economics and Political Science 2018.)

For the past three decades, we have written on the history of occupational and environmental health, authoring books and articles on lead poisoning, silicosis, asbestosis, and angiosarcoma of the liver, among other diseases. One book, Deceit and Denial, focused specifically on the chemical and lead industries. Because of the rarity of historians who study this history, we have been asked to testify on behalf of workers who allege harm from these industrial materials and by state, county, and local governments who seek redress for environmental damages and funds to prevent future harm to children. In about 2010, we began testifying in law suits brought by individuals who claimed that they had suffered from cancers, specifically non-Hodgkin's lymphoma, because of polychlorinated biphenyls (PCBs) in their bodies. At that time, we wrote a Report to the Court about industry knowledge of the dangers of PCBs to workers and the environment. More recently, we have been approached by attorneys representing government agencies on the West Coast of the United States which are seeking funds to abate PCB pollution in their ports, bays, and waterways. The focus of these lawsuits is the Monsanto Corporation, the sole producer of PCBs in the United States from the 1930s through 1977. Through these law suits, an enormous trove of previously private Monsanto reports, papers, memos, letters, and studies have been made available to us and this paper is the result of our examination of these hundreds of thousands of pages. The documents from this collection (with the exception of privileged materials that Monsanto has not made public, and upon which we have not relied) are available on www.ToxicDocs.org , the website we have developed with Professor Merlin Chowkwanyun of Columbia's Mailman School of Public Health. (Almost all of the references that are from this collection can be accessed by readers by clicking on the reference hyperlink.) This monograph is adapted from a report to the court that was originally produced for litigation on behalf of plaintiffs in PCB lawsuits. We are grateful to the Journal of Public Health Policy for publishing this detailed examination of these documents and we hope it will stimulate further research into this important, and now public, archive of industry records.

The Mercy case study documents evidence of a clinically integrated supply chain strategy implemented in the peri-operative programs in three of the 46 hospitals in the Mercy system. Mercy became the first US health system to achieve "the perfect order," a supply chain industry standard with end-to-end integration of supply chain best practice in the Mercy system. To date, the Mercy strategy has demonstrated revenue growth of $8 billion, a 70% reduction in Never Events, a 33.3% reduction in supplies cost/case and a 29.5% reduction in labour costs/case in the perioperative programs in three hospitals., (Copyright © 2018 Longwoods Publishing.)