Development and pilot evaluation of a complex intervention to improve experienced continuity of care in patients with cancer.
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ABSTRACT:
SUBMITTER: King M
PROVIDER: S-EPMC2634705 | biostudies-other | 2009 Jan
REPOSITORIES: biostudies-other
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Project description:BackgroundOver the past decades, health care services for pancreatic surgery were reorganized. Volume norms were applied with the result that only a limited number of expert centers perform pancreatic surgery. As a result of this centralization of pancreatic surgery, the patient journey of patients with pancreatic tumors has become multi-institutional. To illustrate, patients are referred to a center of expertise for pancreatic surgery whereas other parts of pancreatic care, such as chemotherapy, take place in local hospitals. This fragmentation of health care services could affect continuity of care (COC). The aim of this study was to assess COC perceived by patients in a pancreatic care network and investigate correlations with patient-and care-related characteristics.MethodsThis is a pilot study in which patients with (pre) malignant pancreatic tumors discussed in a multidisciplinary tumor board in a Dutch tertiary hospital were asked to participate. Patients were asked to fill out the Nijmegen Continuity of Care-questionnaire (NCQ) (5-point Likert scale). Additionally, their patient-and care-related data were retrieved from medical records. Correlations of NCQ score and patient-and care-related characteristics were calculated with Spearman's correlation coefficient.ResultsIn total, 44 patients were included (92% response rate). Pancreatic cancer was the predominant diagnosis (32%). Forty percent received a repetition of diagnostic investigations in the tertiary hospital. Mean scores for personal continuity were 3.55 ± 0.74 for GP, 3.29 ± 0.91 for the specialist and 3.43 ± 0.65 for collaboration between GPs and specialists. Overall COC was scored with a mean 3.38 ± 0.72. No significant correlations were observed between NCQ score and certain patient-or care-related characteristics.ConclusionContinuity of care perceived by patients with pancreatic tumors was scored as moderate. This outcome supports the need to improve continuity of care within multi-institutional pancreatic care networks.
| S-EPMC8094517 | biostudies-literature
Project description:BACKGROUND:Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS:RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS:We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS:RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.
| S-EPMC6792180 | biostudies-literature
Project description:Objectives(A) To measure the extent to which different candidate outcome measures identified high-risk prescribing that is potentially changeable by the data-driven quality improvement in primary care (DQIP) intervention.(B) To explore the value of reviewing identified high-risk prescribing to clinicians.(C) To optimise the components of the DQIP intervention.DesignMixed method study.SettingGeneral practices in two Scottish Health boards.Participants4 purposively sampled general practices of varying size and socioeconomic deprivation.Outcome measuresPrescribing measures targeting (1) high-risk use of the non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelets; (2) 'Asthma control' and (3) 'Antithrombotics in atrial fibrillation (AF)'.InterventionThe prescribing measures were used to identify patients for review by general practices. The ability of the measures to identify potentially changeable high-risk prescribing was measured as the proportion of patients reviewed where practices identified a need for action. Field notes were recorded from meetings between researchers and staff and key staff participated in semistructured interviews exploring their experience of the piloted intervention processes.ResultsPractices identified a need for action in 68%, 25% and 18% of patients reviewed for prescribing measures (1), (2) and (3), respectively. General practitioners valued being prompted to review patients, and perceived that (1) 'NSAID and antiplatelet' and (2) 'antithrombotics in AF' were the most important to act on. Barriers to initial and ongoing engagement and to sustaining improvements in prescribing were identified.Conclusions'NSAIDs and antiplatelets' measures were selected as the most suitable outcome measures for the DQIP trial, based on evidence of this prescribing being more easily changeable. In response to the barriers identified, the intervention was designed to include a financial incentive, additional ongoing feedback on progress and reprompting review of patients, whose high-risk prescribing was restarted after a decision to stop.Trial registration numberClinicaltrials.gov NCT01425502.
| S-EPMC3902335 | biostudies-literature
Project description:BackgroundThe Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA).ObjectiveWe evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019).DesignA stepped-wedge implementation trial with six geographically diverse sites.ParticipantsThe six facility QI teams were multi-disciplinary, clinical staff.InterventionsPREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback.Main measuresUsing a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year.Key resultsFacility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation.ConclusionsThe CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.Trial registrationclinicaltrials.gov: NCT02769338.
| S-EPMC7878645 | biostudies-literature
Project description:People who struggle with mental health problems can provide valuable insight into understanding and improving the coordination of mental health and welfare services. The aims of the study were to explore service users' experiences and perceptions of continuity of care within and across services relevant to personal recovery, to elicit which dimensions of continuity of care are most essential to service users, and to generate ideas for improving service users' experiences of continuity of care.In the context of a hermeneutic-phenomenological approach, ten service users at a community mental health centre were interviewed about their experiences of continuity of care in and across services. Eight of these were re-interviewed two years later. A collaborative research approach was adopted. Data were analysed by means of a data-driven stepwise approach in line with thematic analysis.Following the analysis five themes representing experiences of continuity of care were developed. Each theme ranged from poor to good experiences of continuity of care: Relationship - from experiencing frequent setbacks and anxiety due to breaks in relationships, to feeling safe in an ongoing personal relationship; Timeliness - from experiencing frustrating waiting times with worsening of problems, to getting help when needed; Mutuality - from having a one-sided struggle, to a situation in which both professionals and service users take initiatives; Choice - from not having the opportunity to make practical arrangements within the context of one's everyday life, to having an array of support options to choose from; Knowledge - from feeling confused and insecure because one does not know what is happening, to feeling safe because one is informed about what is going to happen. Participants provided a range of suggestions for improving experiences of continuity of care.A discrepancy between aspects of continuity that are essential for service users and their experiences of actual practice was revealed. The valid evidence generated in the present collaborative study therefore offers knowledge to policy makers, professionals and service users that may be of help in their future efforts in orienting primary care, mental health, addiction and welfare services towards recovery.
| S-EPMC5698968 | biostudies-literature
Project description:At hospital discharge, many older patients are at health and nutritional risk, indicating a requirement for ongoing care. We aim to evaluate the effects of comprehensive individualized care by geriatric-experienced care professionals, the so-called "pathfinders", on nutritional status (NS) of older patients after discharge. A total of 244 patients (median age 81.0 years) without major cognitive impairment were randomized to Intervention Group (IG: 123) or Control Group (CG: 121) for a 12-month intervention, with up to 7 home visits and 11 phone calls. The comprehensive individualized care contained nutritional advice, when required. The intervention effect after three (T3m) and 12 (T12m) months on change in MNA-SF (Mini Nutritional Assessment-Short Form) and BMI was evaluated by Univariate General Linear Model (ANOVA), adjusted for age, sex, living situation, and activities of daily living. At baseline, mean MNA-SF did not differ between IG and CG (10.7 ± 2.6 vs. 11.2 ± 2.5, p = 0.148); however, mean BMI was significantly lower in IG compared to CG (27.2 ± 4.7 vs. 28.8 ± 4.8 kg/m2, p = 0.012). At T3m, mean change did not differ significantly between the groups, neither in MNA-SF (0.6; 95%CI: -0.1-1.3 vs. 0.4; -0.3-1.1, p = 0.708) nor in BMI (-0.2; -0.6-0.1 vs. 0.0; -0.4-0.4 kg/m2, p = 0.290). At T12m, mean change of MNA-SF was significantly higher in IG than in CG (1.4; 0.5-2.3 vs. 0.0; -0.9-0.8; p = 0.012). BMI remained unchanged in IG, whereas it slightly declined in CG (0.0; -0.7-0.6 vs. -0.9; -1.6--0.2 kg/m2, p = 0.034). We observed rather small effects of comprehensive individualized care by pathfinders on NS in older patients 12 months after discharge. For more pronounced effects nutrition expertise might be needed.
| S-EPMC8466902 | biostudies-literature
Project description:To evaluate the effect of an activation intervention delivered in community senior centers to improve health outcomes for chronic diseases that disproportionately affect older adults.Two-group quasi-experimental study.Two Los Angeles community senior centers.One hundred sixteen senior participants.Participants were invited to attend group screenings of video programs intended to inform about and motivate self-management of chronic conditions common in seniors. Moderated discussions reinforcing active patient participation in chronic disease management followed screenings. Screenings were scheduled over the course of 12 weeks.One center was assigned by coin toss to an encouragement condition in which participants received a $50 gift card if they attended at least three group screenings. Participants in the nonencouraged center received no incentive for attendance. Validated study measures for patient activation, physical activity, and health-related quality of life were completed at baseline and 12 weeks and 6 months after enrollment.Participants attending the encouraged senior center were more likely to attend three or more group screenings (77.8% vs 47.2%, P=.001). At 6-month follow-up, participants from either center who attended three or more group screenings (n=74, 64%) reported significantly greater activation (P<.001), more minutes walking (P<.001) and engaging in vigorous physical activity (P=.006), and better health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) mental component summary, P<.001; SF-12 physical component summary, P=.002).Delivering this pilot intervention in community senior centers is a potentially promising approach to activating seniors that warrants further investigation for improving chronic disease outcomes.
| S-EPMC2955177 | biostudies-literature
Project description:BACKGROUND:Children need access to high quality mental health care. Effective treatments now exist for a wide range of mental health conditions. However, these interventions are delivered with variable effectiveness in traditional mental health service settings. Innovative solutions are needed to improve treatment delivery quality and effectiveness. OBJECTIVE:The aim of this study was to develop a scalable, sustainable technology-based approach to improve the quality of care in child mental health treatment. METHODS:A tablet-based resource was developed with input from mental health training experts, mental health providers, and patients. A series of qualitative data collection phases (ie, expert interviews, patient and provider focus groups, usability testing) guided the initial concept and design of the resource, and then its refinement. The result was an iPad-based "e-workbook" designed to improve child engagement and provider fidelity in implementation of a best-practice treatment. We are currently conducting a small scale randomized controlled trial to evaluate the feasibility of e-workbook facilitated child mental health treatment with 10 providers and 20 families recruited from 4 local community-based mental health clinics. RESULTS:Usability and focus group testing yielded a number of strong, favorable reactions from providers and families. Recommendations for refining the e-workbook also were provided, and these guided several improvements to the resource prior to initiating the feasibility trial, which is currently underway. CONCLUSIONS:This study aimed to develop and preliminarily evaluate a tablet-based application to improve provider fidelity and child engagement in child mental health treatment. If successful, this approach may serve as a key step toward making best-practice treatment more accessible to children and families. As various technologies continue to increase in popularity worldwide and within the health care field more specifically, it is essential to rigorously test the usability, feasibility, acceptability, and effectiveness of novel health technology solutions. It is also essential to ensure that patients and providers drive decision making that supports the development of these resources to ensure that they can be seamlessly integrated into practice. TRIAL REGISTRATION:Clinicaltrials.gov NCT01915160; https://clinicaltrials.gov/ct2/show/NCT01915160 (Archived by WebCite at http://www.webcitation.org/6cPIiQDpu).
| S-EPMC4712346 | biostudies-literature
Project description:ObjectivesDevelopment and pilot evaluation of a personalized decision support intervention to help men with early-stage prostate cancer choose among active surveillance, surgery, and radiation.MethodsWe developed a decision aid featuring long-term survival and side effects data, based on focus group input and stakeholder endorsement. We trained premedical students to administer the intervention to newly diagnosed men with low-risk prostate cancer seen at the University of California, San Francisco. Before the intervention, and after the consultation with a urologist, we administered the Decision Quality Instrument for Prostate Cancer (DQI-PC). We hypothesized increases in two knowledge items from the DQI-PC: How many men diagnosed with early-stage prostate cancer will eventually die of prostate cancer? How much would waiting 3 months to make a treatment decision affect chances of survival? Correct answers were: "Most will die of something else" and "A little or not at all."ResultsThe development phase involved 6 patients, 1 family member, 2 physicians, and 5 other health care providers. In our pilot test, 57 men consented, and 44 received the decision support intervention and completed knowledge surveys at both timepoints. Regarding the two knowledge items of interest, before the intervention, 35/56 (63%) answered both correctly, compared to 36/44 (82%) after the medical consultation (P = .04 by chi-square test).ConclusionsThe intervention was associated with increased patient knowledge. Data from this pilot have guided the development of a larger scale randomized clinical trial to improve decision quality in men with prostate cancer being treated in community settings.
| S-EPMC6943165 | biostudies-literature
Project description:BackgroundA small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.MethodsCommunity and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.ResultsNineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.ConclusionsA pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated.Trial registrationClinicaltrials.gov Identifier: NCT01292096.
| S-EPMC3212942 | biostudies-literature