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Objective: To perform a systematic review and meta-analysis to determine if day case cleft lip surgery has an impact on complications and 30-day readmission rate. Design: A systematic review was conducted using PRISMA guidelines. Databases included; PubMed, Science Direct, Ovid and Cochrane. Search terms; "Day Case", "Day Care", "outpatient", "Ambulatory" AND "Cleft", "Cleft Lip". Meta-analysis was performed using RevMan 5. Setting: Eligible study types included; randomised controlled trials, observational studies (prospective and retrospective) and case series. Patients/Participants: Paediatric patients undergoing primary cleft lip repair. Interventions: Day case surgery versus inpatient admission post-operative. Main Outcome Measure(s): Primary outcome measure: Primary cleft lip repair performed as a day case in paediatric patients. Secondary outcome measures: 1. Complication rates and 30-day re-admission to hospital rate. 2. Patient suitability for day case surgery. Results: Ten papers with 13 804 patients undergoing primary cleft lip repair were included, 28% were discharged on the day of surgery (Range 17%-81%). There was no significant difference in complication rate between the inpatient and day case cohorts. There was a significant reduction in 30-day readmission rates in the day case cohort. Conclusions: This meta-analysis indicates there is no difference in complication rates for patients discharged on the day of surgery compared to those admitted overnight. Complications encountered were infrequent, non-life threatening and often occurred more than 24 h following discharge. There was an observed reduction in 30-day readmission rates for day-case patients. This is likely to represent a variation in baseline characteristics which deemed them suitable for day case surgery pre-operatively. [ABSTRACT FROM AUTHOR]

Musculoskeletal (MSK) injuries are the most common and debilitating work-related injuries among healthcare providers. These injuries often occur due to a lack of awareness and insufficient guidance during the early years of medical training. Recognizing the need to address this issue, the Comprehensive Cleft Care Workshop (CCCW) has taken steps to integrate an ergonomics session into its curriculum. The goal of this initiative is to enhance awareness on ergonomics, improve the integration of ergonomics into daily routine, and ultimately reduce the occurrence of MSK injuries among healthcare professionals. [ABSTRACT FROM AUTHOR]

Background: Breastfeeding infants with a cleft is difficult due to underlying anatomical deficits. The success of breastmilk feeding in this population is highly dependent on the mother. Nevertheless, the rate and duration of breastmilk feeding are often poor in this population due to early cessation of breastmilk production. These infants are therefore at high risk for “failure to thrive”. Aim: The study aimed to identify the challenges encountered by mothers having infants with cleft in establishing and maintaining breastmilk production. Objective: To explore the factors that impact establishing and maintaining breastmilk production viz., a) Mother-infant separation b) Access to Lactation and Feeding consultation c) Breastmilk expression strategies d) Formula supplementation rate e) Motivating or demotivating factors to breastmilk feeding. Method: This study was a phone survey conducted on 28 mothers who had availed lactation and feeding consultations between 2019 and 2020. Results: Various factors impacting the onset and establishment of breastmilk feeding noted were, separation of mother and infant at birth and the duration of separation, lack of access to professional help in lactation and feeding during stay in hospital, irregular and inappropriate breast milk expression, early formula supplementation demotivation due to various lactation and feeding challenges. Conclusion: Support from healthcare professionals specialized in lactation and feeding consultation for mothers having infants with cleft particularly, Speech Pathologists, Nursing staff and Lactation Consultants is critical to increase the rate and duration of breastmilk feeding. Breastmilk feeding should be thus prioritized and supported to enable infants with cleft to thrive.

Background: Breastfeeding infants with a cleft is difficult due to underlying anatomical deficits. The success of breastmilk feeding in this population is highly dependent on the mother. Nevertheless, the rate and duration of breastmilk feeding are often poor in this population due to early cessation of breastmilk production. These infants are therefore at high risk for "failure to thrive". Aim: The study aimed to identify the challenges encountered by mothers having infants with cleft in establishing and maintaining breastmilk production. Objective: To explore the factors that impact establishing and maintaining breastmilk production viz., a) Mother-infant separation b) Access to Lactation and Feeding consultation c) Breastmilk expression strategies d) Formula supplementation rate e) Motivating or demotivating factors to breastmilk feeding. Method: This study was a phone survey conducted on 28 mothers who had availed lactation and feeding consultations between 2019 and 2020. Results: Various factors impacting the onset and establishment of breastmilk feeding noted were, separation of mother and infant at birth and the duration of separation, lack of access to professional help in lactation and feeding during stay in hospital, irregular and inappropriate breast milk expression, early formula supplementation demotivation due to various lactation and feeding challenges. Conclusion: Support from healthcare professionals specialized in lactation and feeding consultation for mothers having infants with cleft particularly, Speech Pathologists, Nursing staff and Lactation Consultants is critical to increase the rate and duration of breastmilk feeding. Breastmilk feeding should be thus prioritized and supported to enable infants with cleft to thrive. [ABSTRACT FROM AUTHOR]

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]

Abstract Background Parents’ Evaluation of Developmental Status, (PEDS), is a validated screening tool designed for primary health care clinicians to assess child development. Despite widespread use by local government child-nurse services, PEDS has not been tested in Australian general practice. We examined the effect of an intervention that aimed to use PEDS to improve documented assessment of child developmental status during routine general practice consultations. Methods The study took place in a single general practice in Melbourne, Australia. The intervention included training of all general practice staff regarding PEDS processes and provision of PEDS questionnaires, scoring and interpretation forms. Mixed methods incorporated audits of clinical records of young children (1 to ≤ 5 years) before and after the intervention, and written questionnaires and a focus group (informed by the Theoretical Domains Framework and COM-B model) with receptionists, practice nurses and general practitioners. Results Documented developmental status more than doubled after the intervention with almost one in three (30.4%) records documenting the PEDS tool. Overall, staff responses to questionnaires indicated that PEDS processes had been successfully implemented, half of the staff felt PEDS had developed their professional skills and clinicians expressed confidence using the tool (71%). Thematic analysis of the focus group transcript revealed divided reactions to PEDS screening with most barriers arising from general practitioners’ motivation to use PEDS tools and perceptions of environmental constraints. Conclusions A team-practice intervention that applied PEDS training and implementation, more than doubled documented rates of child developmental status during routine visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance and long-term sustainability of PEDS use in practices.

Background: Parents' Evaluation of Developmental Status, (PEDS), is a validated screening tool designed for primary health care clinicians to assess child development. Despite widespread use by local government child-nurse services, PEDS has not been tested in Australian general practice. We examined the effect of an intervention that aimed to use PEDS to improve documented assessment of child developmental status during routine general practice consultations. Methods: The study took place in a single general practice in Melbourne, Australia. The intervention included training of all general practice staff regarding PEDS processes and provision of PEDS questionnaires, scoring and interpretation forms. Mixed methods incorporated audits of clinical records of young children (1 to ≤ 5 years) before and after the intervention, and written questionnaires and a focus group (informed by the Theoretical Domains Framework and COM-B model) with receptionists, practice nurses and general practitioners. Results: Documented developmental status more than doubled after the intervention with almost one in three (30.4%) records documenting the PEDS tool. Overall, staff responses to questionnaires indicated that PEDS processes had been successfully implemented, half of the staff felt PEDS had developed their professional skills and clinicians expressed confidence using the tool (71%). Thematic analysis of the focus group transcript revealed divided reactions to PEDS screening with most barriers arising from general practitioners' motivation to use PEDS tools and perceptions of environmental constraints. Conclusions: A team-practice intervention that applied PEDS training and implementation, more than doubled documented rates of child developmental status during routine visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance and long-term sustainability of PEDS use in practices. [ABSTRACT FROM AUTHOR]

Purpose: Practice nurse (PN)-led patient consultations and PN-led dosage adjustments of permanent medication are uncommon and not well studied in general practice (GP) in Germany. We investigated the perspectives of patients with common chronic diseases in Germany, diabetes mellitus (DM) type 2 and/or arterial hypertension (AT), on PN-led patient consultations and dosage adjustments of permanent medications in GP. Patients and Methods: In this exploratory qualitative study, online focus groups were conducted using a semi-structured interview guide. Patients were recruited from collaborating GPs according to a predefined sampling plan. Patients were eligible for this study if they had DM or AT treated by their GP, were on at least one permanent medication and were aged 18 years or older. Focus group transcripts were analyzed using thematic analyses. Results: Analyses of two focus groups, involving a total of 17 patients, revealed four main themes: (1) openness to the PN-led care and perceived benefits, eg because of patients' confidence in PNs' skills, or patients' impression that PN-led care would better meet their needs and increase their compliance. Some patients had (2) reservations and perceived risks, especially for PN-led medication changes eg feeling that medication adjustments were a GP's issue. Patients identified (3) reasons for encounters where they were likely to accept PN-led consultation and medication advice, eg management of DM, AT and thyroid disease. Patients also saw several important general requirements for the implementation of PN-led care in German general practice (4). Conclusion: There is a potential for openness towards PN-led consultation and PN-led medication adjustment for permanent medication in patients with DM or AT. This study is the first qualitative study to investigate PN-led consultations and medication advice in German general practice. If the implementation of PN-led care is planned, our findings add the patients' perspectives of acceptable reasons for encounter for PN-led care and their general requirements. [ABSTRACT FROM AUTHOR]

This article explores the theoretical terrain surrounding compassion in organizational settings to clarify how conceptually (dis)similar concepts like social support, team care, and organizational compassion manifest different agentic perspectives on compassion. Toward this end, we articulate a working definition of compassion and suggest that a communicative frame focused on intersubjective sense-making and interpretation can deepen our understanding of who is responsible for care and compassion within organizations. Existing research on this subject considers who or what provides compassion—individuals, teams, policies—and how compassion can assuage suffering and promote individual and organizational flourishing. Extending this work, we document core dimensions of each form of compassion for greater conceptual clarity and precision, proposing a metaphor for each. Finally, we reflect on the implications of each type of compassion for resilience and the ways current notions of compassion typify the rationality/emotionality duality and gendered nature of emotion work in organizations.

Objective: This study aims to analyze health determinants affecting patients with cleft palate, specifically examining the relationships between the Social Vulnerability Index (SVI), failure to thrive (FTT), and healthcare utilization within the initial 30 days and first year of life., Methods: A retrospective analysis was conducted on patients with a cleft palate at a tertiary care center over an 11-year period. Data included demographics, weight percentile trends, pediatric emergency department (PED) visits, hospital admissions, SVI scores, cleft palate type, and FTT diagnoses. Statistical analyses were performed using SPSS., Results: Social Vulnerability Index was not significantly correlated with health outcomes in cleft palate. Patients with FTT exhibited lower gestational age ( P  = .002) and birth ( P  = .005), one-month ( P  = .001), and one-year ( P  = .001) weight percentiles. FTT diagnosis was associated with increased PED visits ( P  = .000) and hospital admission ( P  = .000) in the first year of life. Early presentation to the PED was associated with increased PED visits ( P  = .000) and hospital admissions ( P  = .004) within the first year of life., Conclusion: No direct link was found between SVI and FTT. Early hospital readmission emerged as a significant outcome, indicating increased healthcare utilization in patients that require early medical intervention. Failure to thrive significantly impacted healthcare utilization, emphasizing the importance of addressing feeding issues early in this patient population. This study contributes to understanding health disparities in cleft palate patients and highlights the need for nuanced exploration of regional factors influencing outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The objective was to describe the lives of adolescents, who were born with cleft lip and palate (CL/P), in comparison to the general population as recorded in Growing up in Ireland (GUI), the national longitudinal study of children and youth., Design: This was a cross-sectional study. Setting: The study was performed in a cleft center at a university teaching hospital. Participants: Adolescents born with CL/P in the years 2007 to 2009. Interventions: Growing up in Ireland questionnaires, which assessed demographics, health and experience of friendship, school, leisure, and social life, were adapted and administered to adolescents and their parents/guardians, who were identified from a prospectively maintained cleft database. Data were compared to that of GUI Cohort '08. Main Outcome Measures: Outcome measures comprised primary caregiver and young person self-report items. Mental health and psychological well-being were assessed using validated instruments including the Strengths and Difficulties Questionnaire., Results: Thirty adolescents (10 female, 20 male) participated in the LIA-Cleft group. LIA-Cleft respondents indicated poorer ratings of both medical and dental health than the GUI group. Responses to questions regarding friendship, bullying, physical activity, social media, and screen time were similar in the GUI and LIA-Cleft groups. The LIA-Cleft group were less satisfied with their lives and exhibited lower self-esteem than the GUI group, but did not differ in measures of mental health and well-being or socioemotional well-being., Conclusions: In spite of reporting poorer medical and dental health, young people who were born with CL/P in Ireland lead lives that are broadly similar to their peers in the general population., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To perform a systematic review and meta-analysis to determine if day case cleft lip surgery has an impact on complications and 30-day readmission rate., Design: A systematic review was conducted using PRISMA guidelines. Databases included; PubMed, Science Direct, Ovid and Cochrane. Search terms; "Day Case", "Day Care", "outpatient", "Ambulatory" AND "Cleft", "Cleft Lip". Meta-analysis was performed using RevMan 5., Setting: Eligible study types included; randomised controlled trials, observational studies (prospective and retrospective) and case series., Patients/participants: Paediatric patients undergoing primary cleft lip repair., Interventions: Day case surgery versus inpatient admission post-operative., Main Outcome Measure(s): Primary outcome measure: Primary cleft lip repair performed as a day case in paediatric patients. Secondary outcome measures: 1. Complication rates and 30-day re-admission to hospital rate. 2. Patient suitability for day case surgery., Results: Ten papers with 13 804 patients undergoing primary cleft lip repair were included, 28% were discharged on the day of surgery (Range 17%-81%). There was no significant difference in complication rate between the inpatient and day case cohorts. There was a significant reduction in 30-day readmission rates in the day case cohort., Conclusions: This meta-analysis indicates there is no difference in complication rates for patients discharged on the day of surgery compared to those admitted overnight. Complications encountered were infrequent, non-life threatening and often occurred more than 24 h following discharge. There was an observed reduction in 30-day readmission rates for day-case patients. This is likely to represent a variation in baseline characteristics which deemed them suitable for day case surgery pre-operatively., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Prior studies have linked the timing of craniosynostosis surgeries to several postoperative outcomes. However, less is known regarding the influence of sociodemographic factors on surgical timing for this population. This study investigates the influence of social vulnerability index (SVI), race, and urbanicity on the timing of craniosynostosis surgery., Retrospective data from 2013 to 2023 were queried from Cosmos, a national deidentified database from Epic electronic health record. Patients were stratified into sociodemographic cohorts, and chi-square tests were used to compare the proportion of each cohort undergoing craniosynostosis surgeries before and after 6 months of age., More than 3000 patients were identified for each predetermined metric for sociodemographic analysis (SVI n = 3369, race n = 3541, urbanicity n = 3375). The proportion of patients undergoing surgery at 5 months or less decreased and those undergoing any surgery at 6 months or more increased ( P  < .0001) with increasing SVI. There was also a significant association of surgical timing and patient race ( P  < .0001) but not urbanicity., SVI and patient race are associated with the timing of craniosynostosis surgery. Specifically, higher social vulnerability and certain racial groups are correlated with delayed surgical intervention. This delay in presentation may result in the inability to take advantage of more minimally invasive options, such as strip craniectomy with or without cranial spring placement. These findings highlight the need for targeted, patient-specific, interventions to address disparities in access to timely craniosynostosis surgery., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study sought to understand cleft team clinician experiences of transitioning patients from pediatric to adult cleft care services in New Zealand., Design: The qualitative study conducted 4 interviews and 4 focus groups with Cleft Team clinicians either in person or over Zoom. Data were analyzed using inductive thematic analysis to identify themes., Participants: Twelve Cleft Team clinicians from 4 Health New Zealand cleft services., Results: Patients are treated by the same clinicians both before and after transition, however, changes at age 16 include gaining treatment decision-making autonomy, inpatient stays within general plastic surgery wards, and evolving life experiences outside of the hospital. Clinicians reported unmet psychosocial needs of patients and their families, and difficulties experienced by patients returning to cleft services as adults. The development of peer support networks between adolescents and young adults who have experiences of cleft care is also recommended., Conclusions: Ongoing cleft care provision and expansion of services are recommended. Furthermore, future studies to understand patients' perspectives of transition are paramount, and incorporating patient voice into any proposed interventions is essential. Potential supports for families of patients with a cleft should also be further investigated, and the application of international standards would promote increased consistency and collaboration between the practice of Cleft Team clinicians around the world., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Musculoskeletal (MSK) injuries are the most common and debilitating work-related injuries among healthcare providers. These injuries often occur due to a lack of awareness and insufficient guidance during the early years of medical training. Recognizing the need to address this issue, the Comprehensive Cleft Care Workshop (CCCW) has taken steps to integrate an ergonomics session into its curriculum. The goal of this initiative is to enhance awareness on ergonomics, improve the integration of ergonomics into daily routine, and ultimately reduce the occurrence of MSK injuries among healthcare professionals., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The financial burden of cleft-craniofacial team care is substantial, and high costs can hinder successful completion of team care. Solution: Collaboration with multiple stakeholders including providers, insurers, and patient guardians, as well as hospital administrators, is critical to increase patient retention and improve final clinical outcomes. What We Do That is New: At our cleft and craniofacial center, charges for a team care visit fall into one of three categories—hospital fees, professional fees, or external fees. There are four types of hospital fees depending on (1) whether the patient is new or returning, and (2) whether the patient saw ≤4 or ≥5 providers. To further elucidate the financial burden (out-of-pocket costs) directly borne by families of children with cleft lip and/or palate, we conducted a retrospective review of billing records of team care visits made between September 2019 and March 2020. Out-of-pocket costs for a single team care visit (on a commercial insurance plan) ranged from $4 to approximately $1220 and had a median (IQR) of $445 ($118, $749). [ABSTRACT FROM AUTHOR]

As part of federal and local efforts to increase access to high quality, clinical preventive services (CPS) in underserved populations, the Los Angeles County Department of Public Health (DPH) partnered with six local health system and community organization partners to promote the use of team care for CPS delivery. Although these partners were at different stages of organizational capacity, post-program review suggests that each organization advanced team care in their clinical or community environments, potentially affecting >250,000 client visits per year. Despite existing infrastructure and DPH's funding support of CPS integration, partner efforts faced several challenges. They included lack of sustainable funding for prevention services; limited access to community resources that support disease prevention; and difficulties in changing health-care provider behavior. Although team care can serve as a catalyst or vehicle for delivering CPS, downstream sustainability of this model of practice requires further state and national policy changes that prioritize prevention. Public health is well positioned to facilitate these policy discussions and to assist health system and community organizations in strengthening CPS integration.

Abstract Background The high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC). Methods We analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs. Results Our results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care. Conclusions Institutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect.

According to the WHO guideline, palliative care is an integral component of COVID-19 management. The relief of physical symptoms and the provision of psychosocial support should be practiced by all healthcare workers caring for COVID-19 patients. In this review, we aim to provide a simple outline on COVID-19, suffering in COVID-19, and the role of palliative care in COVID-19. We also introduce 3 principles of palliative care that can serve as a guide for all healthcare workers caring for COVID-19 patients, which are (1) good symptom control, (2) open and sensitive communication, and (3) caring for the whole team. The pandemic has brought immense suffering, fear and death to people everywhere. The knowledge, skills and experiences from palliative care could be used to relieve the suffering of COVID-19 patients. [ABSTRACT FROM AUTHOR]

The article elucidates the management of a case of severe form of grade III hypertelorism with an intercanthal distance of 61 mm in a 4-year-old child. The management was especially challenging because of the patient's young age, degree of hypertelorism, wide cleft and simultaneous presence of 2 big (sincipital & basal) encephaloceles and a lipoma in the midline. This paper attempts to describe the attempted surgery, postoperative course and the learnings derived from its management to probably create a road-map for surgeons faced with such a challenge in future., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

To describe and compare the healthcare trajectories of patients with CL/P under two different income-based programs for health coverage in Colombia, known in Colombia as a health insurance regime (contributory and subsidized), in Medellín, 2021., Non-experimental, cross-sectional questionnaire-based study., Primary level of clinical care in Medellín, Colombia., Twenty-eight 15- to 21-year-olds with CL/P and primary caregivers., Individuals with CL/P answered the survey. Patients with syndromic CL/P and patients with cognitive disabilities were excluded. The calculation of the probabilistic sample was performed based on the formula for finite populations using databases from 2 health insurance companies. The analysis was descriptive and bivariate. Chi-square and Fisher tests were used to analyze the variables of interest., Continuity of the care pathway was measured with proxy indicators: (1) access to comprehensive CL/P treatment; (2) timeliness of access to comprehensive CL/P treatment; (3) differences in access to and timeliness of comprehensive CL/P treatment between patients under both health insurance coverage., No differences were found when comparing the healthcare trajectories of young patients with CL/P who were in both health coverage. Differences were observed in the timeliness of care for patients with CL/P under the subsidized coverage who were more economically vulnerable. Delays in care were mainly linked to administrative procedures required for orthodontic procedures, bone grafts, and maxillofacial surgeries., Despite the health system's guarantee of equal care across income levels, differences in the timeliness of care persist for patients from lower-income families., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: We sought to calculate the waste generated by cleft lip and palate (CL/P) procedures and to increase awareness of the environmental impact of our speciality., Design: Waste from 5 CL/P procedures was categorised into 5 streams and weighed. A carbon calculator tool was used to convert weight of waste in to estimated carbon emission over a 12-month period., Setting: The study was carried out in a university teaching hospital., Patients and Participants: This was an assessment of the waste produced from 5 paediatric CL/P procedures., Main Outcome Measures: Weight of waste produced as result of CL/P procedures, measured in kilograms (kg); weight of CO 2 , measured in kg., Results: We found that 768.5 kg of surgical waste was generated by CL/P procedures at our centre annually. This equates to 2653 kg of CO 2 ., Conclusions: This study serves as a reminder of surgeons' responsibility to oversee how the waste we produce is disposed of., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objective: To examine ear and hearing clinical practices across American Cleft Palate-Craniofacial Association (ACPA) approved teams in the United States., Design: Multi-site prospective, observational, longitudinal study., Setting: Seventeen Cleft Palate Teams in the United States., Patients, Participants: Children with cleft palate, with or without cleft lip (CP ± L), born between 2015 and 2022, evaluated by 18 months (n = 1246)., Interventions: None., Main Outcome Measure(s): Standard of care otolaryngology and audiology appointments evaluated in the context of whether otolaryngology and audiology services were provided as embedded care within the team visit or as ancillary services., Results: Over 71% of infants passed newborn hearing screening (NBHS). By age 18 months, only 40% of infants received audiologic follow-up while 93.6% of children received otolaryngology care. Follow-up was significantly better for infants served by teams with embedded providers versus those who refer families for ancillary services; the odds of seeing an audiologist by 18 months were three times as high among participants seen by teams with embedded audiology (OR = 3.25; CI = 2.0, 5.2) while those seen by teams with embedded otolaryngologists had more than double the odds of seeing an otolaryngologist by 18 months (OR = 2.2; CI = 1.5, 3.2)., Conclusions: There is considerable variability across ACPA-approved centers in the US regarding the timing and completion of otolaryngology and audiologic follow-up for children with CP ± L. This study highlights the importance of following established standards of care and the impact that team composition and access to clinical services can have on equity of care., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To assess the barriers to obtaining care for patients with orofacial clefts through a survey of Florida-based orthodontists and families and an analysis of the Pediatric Health Information System (PHIS) database., Design: A cross-sectional study utilizing multiple-choice questionnaires completed by Florida orthodontists and caregivers of patients who attended a Florida-based cleft and craniofacial clinic. Additionally, data from the PHIS database were analyzed to investigate national factors affecting the age of alveolar bone grafting (ABG)., Setting: Craniofacial team in Florida., Patients/participants: The survey included 39 orthodontists (7.1% response rate) and 48 caregivers (41% response rate) The PHIS study included 1182 patients., Main Outcome Measures: Barrier to orthodontic care and age of ABG., Results: Orthodontic Survey : Among the surveyed orthodontists, 71% treated cleft/craniofacial patients, 37% accepted Medicaid, and 55% provided pro-bono care. Poor reimbursement was identified as the most common barrier (58%). Caregiver Survey : Most patients were insured by Medicaid (67%), with 55% incurring out-of-pocket expenses. PHIS Database : The average age of ABG was 10.3 years (SD = 3.2). Government funding was associated with a 6.0-month delay in ABG (p = 0.047) and residing in non-Medicaid expanded states was linked to a 6.0-month delay (p = 0.023). Post-Medicaid expansion status was also associated with a delay (p = 0.004)., Conclusions: Access to oral care is difficult for patients with OFC. Despite both federal and state mandates, many financial and non-financial barriers still exist in accessing orthodontic care and a majority of patients experience significant out-of-pocket expenses despite statutorily mandated insurance coverage., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The high costs of chronic conditions call for new treatment approaches that reduce costs while ensuring desirable health outcomes. There has been a growing transformation of care delivery models from conventional referral systems to integrated care models. This study seeks to evaluate the cost-saving impact of integrated care delivery model under pay-for-performance (P4P) scheme with continuity of care at institution level (ICOC).Methods: We analyzed the Taiwan National Health Insurance claim data of 21,725 diabetic patients who visited clinics and/or hospitals at least four times a year for 8 years. Using average local provider P4P participation rate (for each accreditation level) as an instrumental variable in two-stage least squares (2SLS) regressions, we have estimated consistent estimates of the ICOC elasticities for all-cause inpatient and outpatient costs.Results: Our results show that ICOC significantly reduced inpatient costs but increased outpatient costs with the elasticity for treatment costs of -11.6 and 1.03, respectively. The decrease in inpatient costs offset the increase in outpatient costs and the resulting total cost saving showed significant association with ICOC. The saving effect of ICOC is especially robust among patients who used clinics as their principal source of care.Conclusions: Institutional continuity of care has a substantial impact on the treatment costs of diabetes patients. In the context where inpatient care costs are significantly higher than that of the outpatient care, ICOC would lead to a meaningful cost-saving effect. For new diabetes patients, care by clinics demonstrated the strongest saving effect. [ABSTRACT FROM AUTHOR]

Abstract 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.

Introduction: Multiple neurodevelopmental problems affect 7–8% of children and require evaluation by more than one profession, posing a challenge to care systems. Description: The local problem comprised distressed parents, diagnostic processes averaging 36 months and 28 visits with 42% of children >4 years at referral to adequate services, and no routines for patient involvement. The co-design project was developed through a series of workshops using standard quality improvement methodology, where representatives of all services, as well as parents participated. The resulting integrated care model comprises a team of professionals who evaluate the child during an average of 5.4 appointments (N = 95), taking 4.8 weeks. Parents were satisfied with the holistic service model and 70% of children were under 4 at referral (p < 0.05). While 75% of children were referred, 25% required further follow-up by the team. Discussion: The Optimus model has elements of vertical, clinical and service integration. Reasons for success included leadership support, buy-in from the different organisations, careful process management, a team co-ordinator, and insistent user involvement. Conclusion: Evaluating multiple neurodevelopmental problems in children requires an integrated care approach. The Optimus care model is a relevant showcase for how people-initiated integrated care reforms can make it into usual care.

• There is no scale dedicated to dementia team care in geriatric care facilities. • We developed a team-care scale for behavioral and psychological symptoms of dementia. • This scale had sufficient evidence of model suitability, reliability, and validity. Understanding the behavioral and psychological symptoms of dementia (BPSD) is important for caregivers in long-term geriatric care facilities. In this study performed in 43 long-term care facilities, we evaluated the ability of caregivers to recognize BPSD through the development and validation of self-assessment scales. Reliability and validity of the scales were determined using Cronbach's alpha coefficient, the test/retest method, exploratory factor analysis, confirmatory factor analysis, criteria-related validity, and construct validity. We analyzed cross-sectional data from 310 participants. Factor analysis showed a positive correlation for all scale items (r s =.43–.73). Significant correlations arose from the test/retest method (r s =.48–.76). The α coefficient of all items except one was.70 or more, indicating sufficient reliability. Criteria-related validity (r s =.43–.73) and construct validity (r s =.13–.52) revealed a positive correlation. The BPSD Team Care Self-Assessment Scale is reliable and could ensure BPSD competency in caregivers. [ABSTRACT FROM AUTHOR]

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up. [ABSTRACT FROM AUTHOR]

Introduction: Multiple neurodevelopmental problems affect 7-8% of children and require evaluation by more than one profession, posing a challenge to care systems. Description: The local problem comprised distressed parents, diagnostic processes averaging 36 months and 28 visits with 42% of children >4 years at referral to adequate services, and no routines for patient involvement. The co-design project was developed through a series of workshops using standard quality improvement methodology, where representatives of all services, as well as parents participated. The resulting integrated care model comprises a team of professionals who evaluate the child during an average of 5.4 appointments (N = 95), taking 4.8 weeks. Parents were satisfied with the holistic service model and 70% of children were under 4 at referral (p < 0.05). While 75% of children were referred, 25% required further follow-up by the team. Discussion: The Optimus model has elements of vertical, clinical and service integration. Reasons for success included leadership support, buy-in from the different organisations, careful process management, a team co-ordinator, and insistent user involvement. Conclusion: Evaluating multiple neurodevelopmental problems in children requires an integrated care approach. The Optimus care model is a relevant showcase for how people-initiated integrated care reforms can make it into usual care. [ABSTRACT FROM AUTHOR]

Objective: To assess the effectiveness of an interactive iPad-based educational module (cleft iBook) in enhancing parent/caregiver education related to cleft lip and/or cleft palate (CL/P) care., Design: A prospective study involving pre- and post-intervention surveys., Setting: The study was conducted at a craniofacial clinic in a dedicated children's hospital specifically during initial consultations for CL/P care., Participants: Thirty-two participants (parents/legal guardians/caregivers) ≥18 years of age, English and/or Spanish-speaking, and attending with a child with CL/P., Interventions: Participants were provided with iPads and engaged with the interactive iPad-based educational module. Pre- and post-intervention surveys were administered., Main Outcome Measure(s): The survey assessed the understanding of a CL/P diagnosis and management and usability of the iBook. Survey responses were graded on a 5-point Likert scale. Total scores for pre- and post-intervention surveys were compared., Results: Utilizing the cleft iBook module before consultation significantly enhanced comprehension in multiple domains: prenatal development of CL/P, dento-facial molding, surgical techniques, steps after the initial consultation, postoperative care, and the necessity of long-term care for affected children ( P  < .01). Cumulative survey scores increased by 10.2 points, reflecting significantly improved responses regarding overall comprehension ( P  < .001)., Conclusions: The interactive, iPad-based cleft educational module emerges as a viable, digital strategy for providing education and empowerment to parents and caregivers navigating the challenges of caring for a child with CL/P. The cleft iBook serves as a readily accessible resource, fostering connections among the child, caregivers, and care team., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To increase awareness and improve perioperative care of patients with cleft palate (CP) and coexisting cardiopulmonary anomalies., Design: Retrospective cohort., Setting: Multi-center., Patients/participants: Patients who underwent surgical repair of CP between 2012-2020 identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric Data File. Chi-squared analysis and Student's t-test were implemented to make associations between congenital heart disease (CHD) and congenital pulmonary disease (CPD) and postoperative complications. Multiple logistic regression was performed to identify associations between CP and CHD/CPD while controlling for age, gender, and ASA class. C2 values were used to assess the logistic regressions, with a significance level of 0.05 indicating statistical significance., Main Outcomes Measures: Length of stay (LOS), perioperative complications (readmission, reoperation, reintubation, wound dehiscence, cerebrovascular accidents, and mortality)., Results: 9 96 181 patients were identified in the database, 17 786 of whom were determined to have CP, of whom 16.0% had congenital heart defects (CHD) and 13.2% had congenital pulmonary defects (CPD). Patients with CHD and CPD were at a significantly greater risk of increased LOS and all but one operative complication rate (wound dehiscence) relative to patients with CP without a history of CHD and CPD., Conclusion: This study suggests that congenital cardiopulmonary disease is associated with increased adverse outcomes in the setting of CP repair. Thus, heightened clinical suspicion for coexisting congenital anomalies in the presence of CP should prompt referring providers to perform a comprehensive and multidisciplinary evaluation to ensure cardiopulmonary optimization prior to surgical intervention., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

I've Just Seen a Face is a new resource produced by author Amy Mendillo and is designed for parents of children with cleft lip and/or palate to help them to navigate the first year of life. In this invited article, Kenny Ardouin provides an overview of the book, and offers perspective on the content contained within, including potential issues for professionals working with cleft to consider. The review ends with recommendations for likely beneficiaries of the book, as well as considerations for additional future versions of the book., Competing Interests: Declaration of Conflicting InterestsThe author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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]

Objective: Children with craniofacial microsomia (CFM) have complex healthcare needs, resulting in evaluations and interventions from infancy onward. Yet, little is understood about families' treatment experiences or the impact of CFM on caregivers' well-being. To address this gap, the NIH-funded 'Craniofacial microsomia: Accelerating Research and Education (CARE)' program sought to develop a conceptual thematic framework of caregiver adjustment to CFM., Design: Caregivers reported on their child's medical and surgical history. Narrative interviews were conducted with US caregivers ( n  = 62) of children aged 3-17 years with CFM. Transcripts were inductively coded and final themes and subthemes were identified., Results: Components of the framework included: 1) Diagnostic Experiences, including pregnancy and birth, initial emotional responses, communication about the diagnosis by healthcare providers, and information-seeking behaviors; 2) Child Health and Healthcare Experiences, including feeding, the child's physical health, burden of care, medical decision-making, surgical experiences, and the perceived quality of care; 3) Child Development, including cognition and behavior, educational provision, social experiences, and emotional well-being; and 4) Family Functioning, including parental well-being, relationships, coping strategies, and personal growth. Participants also identified a series of "high" and "low" points throughout their journey and shared their priorities for future research., Conclusions: Narrative interviews provided rich insight into caregivers' experiences of having a child with CFM and enabled the development of a conceptual thematic framework to guide clinical care and future research. Information gathered from this study demonstrates the need to incorporate evidence-based psychological support for families into the CFM pathway from birth onward., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The purpose of this study was to determine if patients undergoing alveolar bone grafting (ABG) can be discharged home on the day of surgery safely and with high satisfaction., Design: This is a prospective cohort study of patients who underwent ABG over a 6-month period (August 2022 to February 2023). Medical records were reviewed, and postoperative surveys were provided to assess patient/family experience., Setting: Tertiary care free-standing pediatric hospital., Patients and Participants: Participants who had ABG using iliac marrow from the posterior iliac crest., Interventions: Subjects were assigned to overnight admission (ON) or day surgery (DS) based on hospital bed capacity., Main Outcome Measures: Main outcome measures were postoperative medical events and satisfaction with discharge timing., Results: 41 participants were included: ON, n = 20 (48.8%); DS, n = 21 (51.2%), and there were no differences between groups in any predictor variable. There were no postoperative medical events. Overall, families reported comfort managing pain, nausea, bleeding, hydration, and nutrition after discharge. Most (83.3% of the DS group and 69.2% of the ON group, P  = .644) reported satisfaction with the discharge timing they received, despite this being driven by hospital rather than patient factors. Reasons for some families preferring longer admission included fluid management (n = 2), anxiety about postoperative swelling (n = 2), and a long drive home (n = 1). For the ON group, 16.7% would have preferred same-day discharge., Conclusions: Same day discharge is safe and well-received in appropriately selected patients who undergo ABG using posterior iliac crest. Perioperative patient/family education is essential., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Cory M. Resnick: Consultant for AbbVie Pharmaceuticals without relevant relationship to the subject matter contained within this manuscript.

Background: The aim of the present study was to comprehensively investigate the meaning and practices of spiritual care for older people with dementia based on the perspective and experiences of nurses and care workers. Methods: The study was designed according to qualitative research strategies and used face‐to‐face interview data, with a focus on the experiences of nurses and care workers who care for elderly persons with dementia. Five nurses and 13 care workers from nine care facilities participated. We conducted 10 interviews, each with one to three participants, from April to August 2017. An open‐ended questionnaire concerning the meaning and practices of spiritual care for older people with severe dementia was used to comprehensively capture the participants' experiences of caring for older people with dementia. Qualitative content analysis was used to systematically identify ideas and patterns emerging from the qualitative data. Results: Three main themes emerged from the qualitative analysis of what constituted spiritual care for older people with dementia: (i) self‐esteem; (ii) communication; and (iii) individual difference. Conclusions: Nurses and care workers perceived self‐esteem as a core domain of spiritual care for older people with severe dementia. Reminiscing about important achievements and enjoying small pleasures in daily life enhance older people's self‐esteem. Communication strategies involving active listening and therapeutic lying can help maintain older people's self‐esteem and cognitive abilities. Older people with dementia respond in different ways to standardized care procedures, so care providers must employ of a variety of skilful approaches. [ABSTRACT FROM AUTHOR]

Background: Despite numerous interventions targeting medication adherence in patients with uncontrolled hypertension, practice-based trials in Latino patients are scant.Objective: To evaluate the effect of a systems-level adherence intervention, delivered by medical assistants (MAs), versus a comparison condition on medication adherence and blood pressure (BP) in 119 hypertensive Latino patients who were initially non-adherent to their antihypertensive medications.Study Design: Randomized control trial.Participants: Patients (50% women; mean age, 61 years) were recruited from April 2013 to August 2015 in a community-based practice in New York.Intervention: Systems-level approach that included an office system component built into the electronic health record and a provider support component consisting of nine MA-delivered health coaching sessions for improving medication adherence. The comparison group received the standard health coaching procedures followed at the clinic.Main Outcome Measures: The primary outcome was rate of medication adherence measured by an electronic monitoring device (EMD) across 6 months. The secondary outcomes were self-reported medication adherence measured by the eight-item Morisky Medication Adherence Scale (MMAS-8) and BP reduction from baseline to 6 months.Key Results: Adherence as measure by EMD worsened for both groups (p = 0.04) with no between-group difference (- 9.6% intervention and - 6.6% control, p = 0.66). While systolic BP improved in both groups, the difference between groups was not significant (- 6 mmHg in intervention vs. - 2.7 mmHg in control, p = 0.34). In contrast, the intervention group had a greater improvement in self-reported adherence (mean change 1.98 vs. 1.26, p = 0.03) when measured using the MMAS-8.Conclusions: Among Latinos with poorly controlled BP who were non-adherent to their antihypertensive medications, a systems-level intervention did not improve adherence as measured by EMD nor blood pressure. However, many patients reported challenges to using the EMD. Improvements in self-reported adherence suggest that this measure captures different aspects of adherence behavior than EMD.Clinical Trial Registration: NCT03560596. [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]