Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a ...tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends.
Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data.
Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient—a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities.
The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.
Advances in technology such as telemedicine (TM) have made access to cost‐effective, quality health care feasible for remote patients. TM is especially well suited for patients with chronic disorders ...such as haemophilia and related haemostatic disorders that benefit not only from more frequent interaction with care providers at a specialized haemophilia treatment center but also from consultations with other specialists. Telehealth refers to a broader application of TM and includes non‐clinical services such as education, provider training, administrative meetings etc. Collaboration with the local primary care provider for management and implementation is key for successful and sustainable TM. This review article provides an overview of types of telemedicine, technical aspects, its benefits and challenges and focuses on the applicability of this technology to persons with bleeding and other blood disorders. Examples of TM strategies, process flow of TM clinic and experiences at the authors haemophilia treatment center (HTC) setting are shared. In addition, mobile health (mHealth) and electronic health (eHealth), both a part of telehealth, and their applications are briefly described. Clearly, widespread adoption of this technology will not only enhance care of patients but will enable more people, especially in underserved areas, to receive specialty care.
Abstract
Background
Currently, there is a lack of evidence to guide optimal care for acute kidney injury (AKI) survivors. Therefore, post-discharge care by a multidisciplinary care team (MDCT) may ...improve these outcomes. This study aimed to demonstrate the outcomes of implementing comprehensive care by a MDCT in severe AKI survivors.
Methods
This study was a randomized controlled trial conducted between August 2018 to January 2021. Patients who survived severe AKI stage 2–3 were enrolled and randomized to be followed up with either comprehensive or standard care for 12 months. The comprehensive post-AKI care involved an MDCT (nephrologists, nurses, nutritionists, and pharmacists). The primary outcome was the feasibility outcomes; comprising of the rates of loss to follow up, 3-d dietary record, drug reconciliation, and drug alert rates at 12 months. Secondary outcomes included major adverse kidney events, estimated glomerular filtration rate (eGFR), and the amount of albuminuria at 12 months.
Results
Ninety-eight AKI stage 3 survivors were enrolled and randomized into comprehensive care and standard care groups (49 patients in each group). Compared to the standard care group, the comprehensive care group had significantly better feasibility outcomes; 3-d dietary record, drug reconciliation, and drug alerts (
p
< 0.001). The mean eGFR at 12 months were comparable between the two groups (66.74 vs. 61.12 mL/min/1.73 m
2
,
p
= 0.54). The urine albumin: creatinine ratio (UACR) was significantly lower in the comprehensive care group (36.83 vs. 177.70 mg/g,
p
= 0.036), while the blood pressure control was also better in the comprehensive care group (87.9% vs. 57.5%,
p
= 0.006). There were no differences in the other renal outcomes between the two groups.
Conclusions
Comprehensive care by an MDCT is feasible and could be implemented for severe AKI survivors. MDCT involvement also yields better reduction of the UACR and better blood pressure control.
Trial registration
Clinicaltrial.gov: NCT04012008 (First registered July 9, 2019).
To understand the challenges in delivering comprehensive care for patients recovering from stroke in Guangdong Province, China.
A cross-sectional qualitative study was conducted in two tertiary ...hospitals with different socio-economic characteristics in Guangdong Province, Southern China. Interviews were conducted with 16 stroke care providers including doctors, nurses, rehabilitation therapists and care workers. The interviews were audiotaped, transcribed and translated from Mandarin to English. Thematic analysis was used to draw out descriptive and analytical themes relating to care providers' experiences of existing routine stroke care services and the perceptions of challenges in delivering comprehensive stroke care.
The interviews with stroke care providers highlighted three key factors that hinder the capacity of the two hospitals to deliver comprehensive stroke care. First, expertise and knowledge regarding stroke and stroke care are lacking among both providers and patients; second, stroke care systems are not fully integrated, with inadequate coordination of the stroke team and inconsistency in care following discharge of stroke patients; third, stroke patients have insufficient social support.
While comprehensive stroke care has become a priority in China, our study highlights some important gaps in the current provision of stroke care.
IMPLICATIONS FOR REHABILITATION
Comprehensive integrated stroke care is essential to maximize the effectiveness of stroke services and in China it needs to be further improved.
Multidisciplinary stroke care systems should strengthen collaborations across all relevant disciplines and should include a clear role for registered nurses.
Follow-up care after discharge needs more engagement with family caregivers.
Introduction
Bleeding from the reproductive tract in women is a natural event, generally occurring with menstruation and childbirth. Women with an underlying bleeding disorder may experience heavy ...menstrual bleeding (HMB) and thereby, unacceptable blood loss. Up to 20% of US women with abnormal uterine bleeding and a normal gynaecological exam may have an underlying bleeding disorder corresponding to almost 2–3 million American women. These females face many obstacles in achieving optimum medical care for their problems. A haematologist may not evaluate these women as they are treated symptomatically. Recognition of an underlying bleeding disorder is not straightforward and many come to attention after serious bleeding events. Although mortality from HMB is uncommon, the true burden of HMB is its impact on health‐related quality of life. To address these issues, women with HMB require a comprehensive approach to their care.
Methods
These reasons compelled us to institute a multidisciplinary Young Women's Blood Disorders (YWBD) Program at our institution.
Results
Herein, we describe the process of developing this program involving paediatric haematology, adolescent medicine and paediatric/adolescent gynaecology, and the expertise of a laboratory coagulationist, a nutritionist and nursing professionals. We also describe our experience with patient selection, the role of each specialty in the program, our approach to testing, the coordination of care and overall management of this patient population. Lastly, we propose metrics that could be followed in justifying the support of such a program.
Conclusions
There is a growing need to offer comprehensive care to women with HMB and blood disorders. The YWBD program at our institution appears to be successful in delivering optimal care to young women affected with HMB.
Introduction: Chagas disease, caused by infection with the parasite Trypanosoma cruzi, represents a huge public health problem in the Americas, where millions of people are affected. Despite the ...availability of two drugs against the infection (benznidazole and nifurtimox), multiple factors impede their effective usage: (1) gaps in patient and healthcare provider awareness; (2) lack of access to diagnosis; (3) drug toxicity and absence of treatment algorithms to address adverse effects; (4) failures in drug supply and distribution; and (5) inconsistent drug efficacy against the symptomatic chronic stage.
Areas covered: We review new approaches and technologies to enhance access to diagnosis and treatment to reduce the disease burden. We also provide an updated picture of recently published and ongoing anti-T. cruzi drug clinical trials. Although there has been progress improving the research and development (R&D) landscape, it is unclear whether any new treatments will emerge soon. Literature search methodologies included multiple queries to public databases and the use of own-built libraries.
Expert opinion: Besides R&D, there is a major need to continue awareness and advocacy efforts by patient associations, local and national governments, and international agencies. Overall, health systems strengthening is essential to ensure vector control commitments, as well as patient access to diagnosis and treatment.
Abstract The role of the nurse continues to develop, probably at greater speed than ever before. Would Florence Nightingale ever have dreamt of nurses who could manage whole episodes of patient care ...from diagnosis, through admission, requesting investigations, prescribing treatments and evaluating outcomes? She probably did - when she instigated the first nursing outcome measures looking at infection control. Nurses can and do, do most things. What is important is that they are appropriately trained and continue to develop skills, that are relevant both to them and the patients for whom they care. Assessing this ability, or competence, requires knowledge and skills in itself. In this paper we describe the process of defining competence in haemophilia nursing. Some of these competencies are transferable from other areas of nursing, others are haemophilia-specific. Together they provide a personal development framework for nurses who work within haemophilia as part or all of their role.
Coordinating physiotherapy care for persons with haemophilia Timmer, Merel A.; Blokzijl, Johan; Schutgens, Roger E. G. ...
Haemophilia : the official journal of the World Federation of Hemophilia,
November 2021, Letnik:
27, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Introduction
Physiotherapy is highly recommended for persons with haemophilia (PWH), to regain functioning after bleeding and to maintain functioning when dealing with haemophilic arthropathy. ...However, many PWH live too far from their Haemophilia Comprehensive Care Centre (HCCC) to receive regular treatment at their HCCC. Physiotherapists in primary care may have limited experience with a rare disease like haemophilia.
Aim
To explore experiences of stakeholders with primary care physiotherapy for PWH and develop recommendations to optimize physiotherapy care coordination.
Methods
A RAND approach was used, consisting of a Delphi procedure with e‐mailed questionnaires and a consensus meeting. Included stakeholders were PWH, physiotherapists from HCCC's and primary care physiotherapists. HCCC physiotherapists approached patients from their centre and primary care physiotherapists from their network to fill in the questionnaires. Purposive sampling was used to select participants from the survey sample for the consensus meeting.
Results
Ninety‐six primary care physiotherapists, 54 PWH and eight HCCC physiotherapists completed the questionnaire. Subsequently, four PWH, three primary care physiotherapists and four HCCC physiotherapists participated in the consensus meeting. The questionnaires yielded 33 recommendations, merged into a final list of 20 recommendations based on the consensus meeting. The final rank‐order consists of 13 recommendations prioritized by at least one stakeholder.
Conclusion
Commitment to a formal network is considered not feasible for a rare disease like haemophilia. Development of a practice guideline, easy‐accessible information and contact details, two‐way and open communication between HCCC and primary care and criteria to refer back to the HCCC are recommended.
Background: Palliative Care (PC) was a core component of Primary Health Care services during the World Health Assembly Resolution, 2014. The study aims to develop a Comprehensive Palliative Care ...Model (CPCM) for patients with life-threatening conditions compliant with the local context and unmet needs. Materials and Methods: A mixed-methods approach will be adopted for the three-phased study in two districts of Telangana. Phase I, a literature review, will be performed to explore globally available PC models, followed by an on-ground observational study. Phase II will address the gaps in existing models while identifying the unmet needs of the patients and caregivers. The outcome of the above phases will help develop a CPCM in Phase III. The developed model will be validated using the Delphi technique. Results: The expected outcomes of the study are a) Phase-I: Details of the PC models available globally and locally, b) Phase-II: Availability of essential resources in the Health and Wellness Centers (HWCs), Knowledge and Attitude of the PC team, Barriers to provide PC, Unmet needs, and c) Phase-III: CPCM model Conclusion: The study attempts to provide a holistic PC model, considering the health system, patients, and caregivers and offering policy suggestions to the state.
PDF
