Primary care is the foundation of effective and high-quality health care. The role of primary care clinicians has expanded to encompass coordination of care across multiple providers and management ...of more patients with complex conditions. Enabling technology has the potential to expand the capacity for primary care clinicians to provide integrated, accessible care that channels expertise to the patient and brings specialty consultations into the primary care clinic. Furthermore, technology offers opportunities to engage patients in advancing their health through improved communication and enhanced self-management of chronic conditions. This paper describes enabling technologies in four domains (the body, the home, the community, and the primary care clinic) that can support the critical role primary care clinicians play in the health care system. It also identifies challenges to incorporating these technologies into primary care clinics, care processes, and workflow.
Despite the evidence showing that young people aged 12-25 years have the highest incidence and prevalence of mental illness across the lifespan, and bear a disproportionate share of the burden of ...disease associated with mental disorder, their access to mental health services is the poorest of all age groups. A major factor contributing to this poor access is the current design of our mental healthcare system, which is manifestly inadequate for the unique developmental and cultural needs of our young people, if we are to reduce the impact of mental disorder on this most vulnerable population group, transformational change and service redesign is necessary. Here, we present three recent and rapidly evolving service structures from Australia, Ireland and the UK that have each worked within their respective healthcare contexts to reorient existing services to provide youth-specific, evidence-based mental healthcare that is both accessible and acceptable to young people.
Are public and private organizations fundamentally different? This question has been among the most enduring inquiries in public administration. Our study explores the impact of organizational ...ownership on two complementary aspects of performance: service quality and access to services for impoverished clients. Derived from public management research on performance determinants and nursing home care literature, our hypotheses stipulate that public, nonprofit, and for-profit nursing homes use different approaches to balance the strategic tradeoff between two aspects of performance. Panel data on 14,423 facilities were analyzed to compare measures of quality and access across three sectors using different estimation methods. Findings indicate that ownership status is associated with critical differences in both quality and access. Public and nonprofit organizations are similar in terms of quality, and both perform significantly better than their for-profit counterparts. When compared to nonprofit and, in some cases, for-profit facilities, public nursing homes have a significantly higher share of Medicaid recipients. The paper proposes strategies to address the identified long-term care divide.
Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to ...expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.
Approximately 25% of school-aged children in the United States have vision abnormalities, most commonly refractive error that can be corrected with spectacles. Limited follow-up adherence after ...failed school-based vision screening led to an increase in school-based eye care programs that provide screening, eye examinations, and spectacle prescription at the school. These programs address the access barrier and often provide the first point of contact between children and eye care. Nevertheless, several lower prevalence conditions, such as amblyopia, strabismus, and glaucoma, cannot be adequately treated in the school setting, and some require frequent and long-term follow-up, necessitating referral to eye care providers in the community. We conducted a literature review and identified 10 programs that provided school-based screening, examinations, and spectacle prescription and reviewed their referral rates, criteria, mechanisms, adherence, ocular findings at referral, and long-term care plans. Most programs referred 1% to 5% of screened children. Most communicated with parents or guardians through referral letters and used various strategies to incentivize adherence. Referral adherence was 20-50% in the four programs that reported these data. School-based eye care programs rarely referred children for long-term follow-up care needs, such as updating spectacle prescriptions annually.
➤ Bone health evaluations should be incorporated into care pathways for fragility fractures in all patients who are fifty years of age or older.➤ A fracture liaison service (FLS) is an established ...and proven method to achieve recommended standards of care for fragility fractures, including intervention for osteoporosis, secondary fracture prevention, and bone health evaluation.➤ The FLS facilitates patient care by automatically including all patients with a fragility fracture within a health-care system to provide them with the intervention that they need and to prevent avoidable fracture-related complications or readmissions.➤ An FLS functions with three key personnelthe FLS coordinator (usually an advanced practice provider), a physician champion (usually an orthopaedic surgeon), and a nurse navigator.
Implementation of bedside rounds enhances communication and collaboration between physicians and nurses, resulting in improved clinical outcomes. Yet, the literature demonstrates that it remains ...difficult for nurses to attend rounds if they don't know when they are happening.
This project aimed to increase nurses' presence and participation at bedside rounds in a pediatric acute care unit, enhance teamwork and collaboration, and improve quality outcomes.
Nurses carried a pager so that physicians could alert them of rounds. Perception of teamwork and collaboration was assessed via surveys pre- and post-intervention as well as the annual survey evaluating RN and MD interactions from the National Database of Nursing Quality Indicators™ (NDNQI®). Other quality outcome measures included length of stay and patient satisfaction through Press Ganey™ surveys.
Findings demonstrated that when nurses were notified in advance, their participation in rounds increased from 44.4 to 73%. Length of stay decreased from 2.5 days prior to the project to an average of 2.10 days during the project. Scores on inpatient satisfaction surveys increased from 82.4 to 92.2%, and nursing communication improved from 83.3 to 95.65%.
Interprofessional collaboration as reflected by the inclusion of nurses at bedside rounds led to positive outcomes in patient care.
Increasing nurses' presence and providing them with a role at rounds is an important step towards fostering teamwork and collaboration with physicians and enhancing team-based care in a pediatric inpatient setting. Further research measuring the impact of interprofessional collaboration in healthcare is needed.
Jean Adams and colleagues argue that population interventions that require individuals to use a low level of agency to benefit are likely to be most effective and most equitable.
During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often ...mark an inflection point in these patients’ illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique “teachable moment” to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.
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