scholarly journals The Behavioral Recovery Outreach (BRO) Team: A Transitional Care Model for Veterans With Complex Care Needs

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 46-46
Author(s):  
Kathleen Matthews ◽  
Grant Bauste ◽  
Emily Luitjens
Keyword(s):  
Transitional Care ◽  
Policy Implications ◽  
Behavioral Recovery ◽  
Care Needs ◽  
Post Discharge ◽  
Community Based ◽  
Delivery Of Care ◽  
Program Fidelity ◽  
Complex Care Needs

Abstract In 2012, VA Central Iowa developed a novel program known as the Behavioral Recovery Outreach (BRO) Team to address unmet needs of our aging Veteran population with complex medical, psychological, neurocognitive and behavioral concerns. BRO Teams provide evidence-informed treatments in inpatient VA settings, and transitional care/support post-discharge to ensure successful placement and stability in the community. We will discuss how implementation science informed the expansion of this model from a local pilot to a nationally disseminated program. We will explore the challenges of ensuring program fidelity while fostering innovation and adaptation. Given the challenges of national dissemination, we will highlight the predicted and unforeseen aspects of program evaluation and policy implications. Finally, we will discuss the impacts of the COVID-19 pandemic on delivery of care methods and community-based interactions, as well as how this program has improved the lives and quality of care for this high-risk Veteran population.

scholarly journals A Transitional Care Model for Veterans With Complex Needs During COVID: The Behavioral Recovery Outreach (BRO) Team

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 46-46
Author(s):  
Kathleen Matthews ◽  
Latrice Vinson
Keyword(s):  
Transitional Care ◽  
Lessons Learned ◽  
Future Research ◽  
Complex Care ◽  
Veterans Health ◽  
Behavioral Recovery ◽  
Care Needs ◽  
Program Outcomes ◽  
Complex Care Needs ◽  
Team Model

Abstract The Veterans Health Administration’s Care for Patients with Complex Problems (CP)2 Program developed a national infrastructure to disseminate promising practice models to improve care for Veterans with complex medical, mental health, and/or neurocognitive conditions, who may also have behaviors disruptive to care. A strategic priority is improving safe and effective transitions to community care for Veterans with complex care needs, many of whom have historically been limited to VA settings as a result of behavioral concerns. The Behavioral Recovery Outreach (BRO) Team was the first model identified for national dissemination and evaluation at partner sites. Developed at VA Central Iowa, BRO is an interdisciplinary team model that identifies Veterans in long-term VA care settings with complex care needs to engage in individualized behavioral programing to manage/stabilize behaviors and safely transition them to more appropriate and less costly community settings. This symposium will describe the BRO team model, highlight the facilitators and barriers to nationally disseminating the BRO model with VA partner facilities, discuss adaptations in continuing community transitions following the COVID-19 pandemic, and describe program outcomes. The first speaker will discuss development of the BRO model and outcomes of a regional dissemination. The second speaker will present results from the program evaluation of the national dissemination. The final speaker will describe BRO Team expansion and lessons learned from the perspective of a VA partner facility. The (CP)2 Program Director will integrate findings and highlight implications for scaling and evaluating promising models for national dissemination for policy, practice, and future research.

Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Janet Prvu Bettger ◽  
Sara Jones ◽  
Anna Kucharska-Newton ◽  
Janet Freburger ◽  
Walter Ambrosius ◽  
...  
Keyword(s):  
Transitional Care ◽  
Discharge Planning ◽  
Care Transitions ◽  
Cluster Randomized Trial ◽  
Stroke Patients ◽  
Care Needs ◽  
Post Discharge ◽  
Exact Test ◽  
Chi Squared

Background: Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals. Methods: Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test. Results: As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals. Conclusion: Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.

Supporting Goal-Oriented Primary Health Care for Seniors’ with Multimorbidity and Complex Care Needs using Mobile Technology: Mixed-Methods, Stepped-Wedge Cluster Randomized Trial of the ePRO Tool. (Preprint)

2021 ◽  
Author(s):  
Carolyn Steele Gray ◽  
Phat (Eduard) Chau ◽  
Farah Tahsin ◽  
Sarah Harvey ◽  
Mayura Loganathan ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Primary Care ◽  
Control Period ◽  
Self Management ◽  
Care Needs ◽  
Ethnographic Data ◽  
Care Practices ◽  
Primary Care Practices ◽  
Complex Care Needs

BACKGROUND Goal-oriented care is being adopted to deliver person-centred primary care to older adults with multimorbidity and complex care needs. While this model holds promise, implementation remains a challenge. Digital health solutions may enable processes to improve adoption, however, they require evaluation to determine feasibility and impact. OBJECTIVE This study evaluates the implementation and effectiveness of the electronic Patient Reported Outcome (ePRO) mobile application and portal system, designed to enable goal-oriented care delivery in inter-professional primary care practices. The research questions driving this study are: 1) Does ePRO improve quality of life and self-management in older adults with complex needs, and 2) what mechanisms are likely driving observed outcomes? METHODS A multi-method pragmatic randomized control trial using a stepped-wedge design and ethnographic case studies was conducted over a 15-month period in 6 comprehensive primary care practices across Ontario with a target enrolment of 176 patients. The 6 practices were randomized into either early (3-month control period; 12-month intervention) or late (6-month control period; 9-month intervention) groups. The primary outcome measure of interest was the Assessment of Quality of Life-4D (AQoL-4D). Data were collected at baseline and at 3 monthly intervals for the duration of the trial. Ethnographic data included observations and interviews with patients and providers at the mid-point and end of the intervention. Outcome data were analyzed using linear models conducted at the individual level, accounting for cluster effects at the practice level, and ethnographic data was analyzed using qualitative description and framework analysis methods. RESULTS Recruitment challenges resulted in fewer sites and participants than expected; only 142 of the 176 eligible patients were identified due to lower than expected provider participation and fewer than expected patients willing to participate or perceived as ready to engage in goal setting. Of 142 patients approached, 45 patients participated (32%). Patients set a variety of goals related to self-management, mental health, social health and overall well-being. Due to underpowering, the impact of ePRO on quality of life could not be definitively assessed; however the intervention group, ePRO plus usual care (M = 15.28, SD = 18.60), demonstrated non-significant slight decrease in quality of life, t(24)= -1.20, P = 0.24, when compared to usual care only (M = 21.76, SD = 2.17). The ethnographic data reveals a complex implementation process, in which the meaningfulness (or coherence) of the technology to individuals lives and work acted as a key driver to adoption and tool appraisal. CONCLUSIONS This trial experienced many unexpected and significant implementation challenges related to recruitment and engagement. Future studies could be improved through better alignment of the research methods and intervention to the complex and diverse clinic settings, dynamic goal-oriented care process, and readiness of provider and patient participants. CLINICALTRIAL ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954?intr=epro&cntry=CA&rank=1

scholarly journals Towards Better Health, Social, and Community-Based Services Integration for Patients with Chronic Conditions and Complex Care Needs: Stakeholders’ Recommendations

2020 ◽  
Vol 17 (22) ◽  
pp. 8437
Author(s):  
Catherine Hudon ◽  
Maud-Christine Chouinard ◽  
Marie-Dominique Beaulieu ◽  
Mathieu Bisson ◽  
Danielle Bouliane ◽  
...  
Keyword(s):  
Health Care Services ◽  
Interprofessional Collaboration ◽  
Inductive Method ◽  
Quebec City ◽  
Complex Care ◽  
Care Needs ◽  
Community Based ◽  
Services Integration ◽  
Complex Care Needs ◽  
Community Based Services

The objective was to report on issues related to patients with complex care needs and recommendations identified by 160 key participants at a summit in Quebec City about better integration of primary health care services for patients with chronic diseases and complex care needs. A descriptive qualitative approach was used. While focus groups were led by a facilitator, a rapporteur noted highlights and a research team member took independent notes. All notes were analyzed by using a thematic analysis according to an inductive method. Seven issues were identified, leading to the formulation of recommendations: (1) valuing the experience of the patient; (2) early detecting of a non-homogeneous patient population; (3) defining interprofessional collaboration based on patient needs; (4) conciliating services provided by clinical settings according to a registered clientele-based logic with the population-based logic; (5) working with the community sector; (6) aligning patient-oriented research values with existing challenges to primary care integration; and (7) promoting resource allocation consistent with targeted recommendations. The summit highlighted the importance of engaging all stakeholders in improvement of integrated care for patients with complex care needs. The resulting recommendations target shared priorities towards better health, social, and community-based services integration for these patients.

scholarly journals Programmes to support transitions in care for children and youth with complex care needs and their families: a scoping review protocol

BMJ Open ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. e033978
Author(s):  
Shelley Doucet ◽  
Janet A Curran ◽  
Sydney Breneol ◽  
Alison Luke ◽  
Emilie Dionne ◽  
...  
Keyword(s):  
Scoping Review ◽  
Transitional Care ◽  
Research Policy ◽  
Children And Youth ◽  
Advisory Council ◽  
Complex Care ◽  
Care Needs ◽  
Transitions In Care ◽  
Scoping Reviews ◽  
Complex Care Needs

IntroductionChildren and youth with complex care needs (CCNs) and their families experience many care transitions over their lifespan and are consequently vulnerable to the discontinuity or gaps in care that can occur during these transitions. Transitional care programmes, broadly defined as one or more intervention(s) or service(s) that aim to improve continuity of care, are increasingly being developed to address transitions in care for children and youth with CCNs. However, this literature has not yet been systematically examined at a comprehensive level. The purpose of this scoping review is to map the range of programmes that support transitions in care for children and youth with CCNs and their families during two phases of their lifespan: (1) up to the age of 19 years (not including their transition to adult healthcare) and (2) when transitioning from paediatric to adult healthcare.Methods and analysisThe Joanna Briggs Institute methodology for scoping reviews (ScR) will be used for the proposed scoping review. ScR are a type of knowledge synthesis that are useful for addressing exploratory research questions that aim to map key concepts and types of evidence on a topic and can be used to organise what is known about the phenomena. A preliminary search of PubMed was conducted in December 2018.Ethics and disseminationEthical approval is not required where this study is a review of the published and publicly reported literature. The research team’s advisory council will develop a research dissemination strategy with goals, target audiences, expertise/leadership, resources and deadlines to maximise project outputs. The end-of-grant activities will be used to raise awareness, promote action and inform future research, policy and practice on this topic.

Community-Based Crime Prevention: An Assessment of the Eisenhower Foundation's Neighborhood Program

1989 ◽  
Vol 35 (3) ◽  
pp. 345-364 ◽  
Author(s):  
Susan F. Bennett ◽  
Paul J. Lavrakas
Keyword(s):  
Fear Of Crime ◽  
Technical Assistance ◽  
Planning Process ◽  
Policy Implications ◽  
Successful Implementation ◽  
Community Based ◽  
Program Success ◽  
Perceived Quality Of Life ◽  
Local Problems

The article assesses the implementation and impact of the Eisenhower Foundation's Neighborhood Program in ten communities. Most organizations successfully implemented the program and generated a level of participation that compares favorably to other programs. Despite successful implementation, the programs had only modest community impact. Fear of crime and concern about local problems declined slightly in some communities, but there was no documentable evidence of change in communities' crime or perceived quality of life. Of the Eisenhower Foundation guidelines, technical assistance was most clearly linked to program success, although the community planning process and advisory councils may have increased participation. Possible reasons for the small program impact and policy implications of the demonstration project are discussed.

scholarly journals Spreading Telehealth for Older Adults in Rural Areas Through Network of Geriatric Interprofessional Teams

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 796-796
Author(s):  
Steven Barczi ◽  
Megan Gately ◽  
Lauren Welch ◽  
Kathryn Nearing ◽  
Stephen Thielke ◽  
...  
Keyword(s):  
Older Adults ◽  
Rural Areas ◽  
Urban Areas ◽  
Care Needs ◽  
Community Based ◽  
Team Care ◽  
Geriatric Consultation ◽  
Complex Care Needs ◽  
Nursing Professionals ◽  
Community Based Services

Abstract Older adults living in rural areas have limited access to geriatrics interprofessional team care. In the Veteran healthcare system, geriatric teams such as geriatricians, nursing professionals, social workers, pharmacists and psychologists, located in urban areas link up with rural clinics to provide geriatric consultation remotely through clinical video telehealth and other means in the project GRECC Connect. Since its inception in 2014, the service has now grown to 16 geriatric teams offering consultation to over 100 clinic sites serving older rural Veterans. GRECC Connect delivered over 2,000 consultations in 2019, meeting complex care needs by identifying and linking geriatric services and management to patients with geriatric syndromes. The network of established geriatric teams, local champions and a shared Electronic Health Record facilitated the spread, while ongoing effort to build and maintain relationships between consultants and local rural provider teams and other community based services are important for ongoing success.

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