Ensuring continuity of patient care across the healthcare interface: Telephone follow‐up post‐hospitalization

Abstract Backround Chronic diseases and multimorbidity are common in the ageing population and affect the health related quality of life. Health care resources are limited and the continuity of care has to be assured. Therefore it is essential to find demonstrable tools for best treatment practices for patients with chronic diseases. Our aim was to study the influence of a participatory patient care plan on the health-related quality of life and disease specific outcomes related to diabetes, ischemic heart disease and hypertension. Methods The data of the present study were based on the Participatory Patient Care Planning in Primary Care. A total of 605 patients were recruited in the Siilinjärvi Health Center in the years 2017–2018 from those patients who were followed up due to the treatment of hypertension, ischemic heart disease or diabetes. Patients were randomized into usual care and intervention groups. The intervention consisted of a participatory patient care plan, which was formulated in collaboration with the patient and the nurse and the physician during the first health care visit. Health-related quality of life with the 15D instrument and the disease-specific outcomes of body mass index (BMI), low density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1C) and blood pressure were assessed at the baseline and after a one-year follow-up. Results A total of 587 patients with a mean age of 69 years were followed for 12 months. In the intervention group there were 289 patients (54% women) and in the usual care group there were 298 patients (50% women). During the follow-up there were no significant changes between the groups in health-related quality and disease-specific outcomes. Conclusions During the 12-month follow-up, no significant differences between the intervention and the usual care groups were detected, as the intervention and the usual care groups were already in good therapeutic equilibrium at the baseline. Trial registration ClinicalTrials.gov Identifier: NCT02992431. Registered 14/12/2016

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Integrating Genomic Screening into Primary Care: Provider Experiences Caring for Latino Patients at a Community-Based Health Center

Journal of Primary Care & Community Health ◽

10.1177/21501327211000242 ◽

2021 ◽

Vol 12 ◽

pp. 215013272110002

Author(s):

Tarika Srinivasan ◽

Erica J. Sutton ◽

Annika T. Beck ◽

Idali Cuellar ◽

Valentina Hernandez ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Patient Care ◽

Health Center ◽

Care Provider ◽

Primary Care Provider ◽

Genomic Sequencing ◽

Community Based ◽

Genomic Screening

Introduction: Minority communities have had limited access to advances in genomic medicine. Mayo Clinic and Mountain Park Health Center, a Federally Qualified Health Center in Phoenix, Arizona, partnered to assess the feasibility of offering genomic screening to Latino patients receiving care at a community-based health center. We examined primary care provider (PCP) experiences reporting genomic screening results and integrating those results into patient care. Methods: We conducted open-ended, semi-structured interviews with PCPs and other members of the health care team charged with supporting patients who received positive genomic screening results. Interviews were recorded, transcribed, and analyzed thematically. Results: Of the 500 patients who pursued genomic screening, 10 received results indicating a genetic variant that warranted clinical management. PCPs felt genomic screening was valuable to patients and their families, and that genomic research should strive to include underrepresented minorities. Providers identified multiple challenges integrating genomic sequencing into patient care, including difficulties maintaining patient contact over time; arranging follow-up medical care; and managing results in an environment with limited genetics expertise. Providers also reflected on the ethics of offering genomic sequencing to patients who may not be able to pursue diagnostic testing or follow-up care due to financial constraints. Conclusions: Our results highlight the potential benefits and challenges of bringing advances in precision medicine to community-based health centers serving under-resourced populations. By proactively considering patient support needs, and identifying financial assistance programs and patient-referral mechanisms to support patients who may need specialized medical care, PCPs and other health care providers can help to ensure that precision medicine lives up to its full potential as a tool for improving patient care.

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Reframing resilience: Strengthening continuity of patient care to improve the mental health of immigrants and refugees

International Journal of Mental Health Nursing ◽

10.1111/inm.12650 ◽

2019 ◽

Vol 29 (1) ◽

pp. 69-79 ◽

Cited By ~ 3

Author(s):

Lloy Wylie ◽

Ann Marie Corrado ◽

Nandni Edwards ◽

Meriem Benlamri ◽

Daniel E. Murcia Monroy

Keyword(s):

Mental Health ◽

Patient Care ◽

Continuity Of Patient Care ◽

Immigrants And Refugees

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Author response for "Burnout, depersonalization, and anxiety contribute to post‐traumatic stress in frontline health workers at COVID‐19 patient care, a follow‐up study"

10.1002/brb3.2007/v2/response1 ◽

2020 ◽

Author(s):

José Adán Miguel‐Puga ◽

Davis Cooper‐Bribiesca ◽

Francisco José Avelar‐Garnica ◽

Luis Alejandro Sanchez‐Hurtado ◽

Tania Colin‐Martínez ◽

...

Keyword(s):

Patient Care ◽

Traumatic Stress ◽

Health Workers ◽

Author Response ◽

Post Traumatic Stress ◽

Follow Up Study ◽

Frontline Health Workers ◽

Post Traumatic

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Review for "Burnout, depersonalization, and anxiety contribute to post‐traumatic stress in frontline health workers at COVID‐19 patient care, a follow‐up study"

10.1002/brb3.2007/v1/review2 ◽

2020 ◽

Keyword(s):

Patient Care ◽

Traumatic Stress ◽

Health Workers ◽

Post Traumatic Stress ◽

Follow Up Study ◽

Frontline Health Workers ◽

Post Traumatic

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PEDIATRIC SCREENING EXAMINATIONS IN PRIVATE PRACTICE

PEDIATRICS ◽

10.1542/peds.41.1.115 ◽

1968 ◽

Vol 41 (1) ◽

pp. 115-119

Author(s):

Glenn Austin ◽

William Foster ◽

John C. Richards

Keyword(s):

Medical Care ◽

Patient Care ◽

Private Practice ◽

Pediatric Practice ◽

Paramedical Personnel ◽

Assistant Physician ◽

Special Value ◽

System Review ◽

Pediatric Screening

A pediatric assistant performs health screening examinations in a private pediatric practice without the presence of the doctor. Only patients between the ages of 6 to 12 years who have no apparent significant problems and who have had a complete physical and history by a pediatrician the year previously are accepted for the screening, which includes a system review, height, weight, visual and hearing testing, hemoglobin, urinalysis, and immunizations. The pediatric assistant, chosen for her ability to communicate with mothers, is of special value in listening to minor complaints. The chart is reviewed by the child's pediatrician and problems are discussed with the assistant. Physician follow-up is accomplished if deemed helpful. This is accepted by patients, allows continuity of personal comprehensive medical care in the pediatric office at a reduced cost, and allows the physician more time for patient care while increasing efficient use of paramedical personnel. Possible misuse of screening examinations, with resulting impersonal and fragmented medical care, is discussed.

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Implementing a tracking system for confirmatory diagnostic results after positive newborn screening for cystic fibrosis—implications for process quality and patient care

European Journal of Pediatrics ◽

10.1007/s00431-020-03849-4 ◽

2020 ◽

Author(s):

Gwendolyn Gramer ◽

Inken Brockow ◽

Christiane Labitzke ◽

Junmin Fang-Hoffmann ◽

Andreas Beivers ◽

...

Keyword(s):

Cystic Fibrosis ◽

Newborn Screening ◽

Patient Care ◽

Tracking System ◽

Process Quality ◽

Federal State ◽

Cost Calculation ◽

Confirmatory Testing ◽

Before And After

Abstract Newborn screening for cystic fibrosis (CF-NBS) was introduced in Germany in 2016. Currently, systematic follow-up of positive CF-NBS results is not implemented or reimbursed in the NBS program. We investigated results of confirmatory testing over 24 months after implementation of CF-NBS for a large German NBS center before and after introduction of an active tracking system and performed a cost calculation for tracking. Results are compared with the federal state of Bavaria, where a centralized tracking system has been in place for many years. At the NBS center, 244 of 281,907 children had a positive CF-NBS result requiring diagnostic confirmation. Before implementation of a telephone tracking system, only 43% of confirmatory results were returned despite repeated written requests. The consecutive strategy including telephone tracking led to an increase of resolved cases to 84%. However, the centralized tracking system in Bavaria, assigning children with positive CF-NBS directly to a responsible CF-center, resolved 99% of cases. The calculated additional cost for a tracking system in Germany including telephone tracking is 1.20€ per newborn screened. Conclusion: The implementation of a tracking system achieves a distinct improvement in CF-NBS with justifiable costs. The effect can be limited by absence of centralized organization of confirmatory testing. What is Known:• Newborn screening for cystic fibrosis (CF-NBS) has been performed for many years in several countries worldwide• While many studies have focused on different CF-NBS strategies, the organization of confirmatory testing and process quality concerning returned information to the NBS center has so far received less attention. What is New:• The implementation of an active tracking system achieves a distinct improvement of clarified cases after positive CF-NBS with justifiable costs.• The effect of a tracking system can be limited by the absence of a centralized organization of confirmatory testing.

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