Social Workers in Primary Care Increase Access to Palliative Care

Clinical trials show that palliative care improves patient experiences and reduces costs, and use of palliative care and hospice care have been increasing over the past three decades. In the Veterans Administration health care system (VA), Veterans may receive palliative care concurrently with other treatments. However, many barriers exist to the use of palliative care, such as patients’ misperceptions. Social workers in primary care teams may increase use of this valuable service by establishing trust between patient and care team, educating patients and caregivers, and coordinating services. Leveraging a national social-work-staffing program as a natural experiment, we evaluated the effect of hiring one or more social workers to the primary-care team on use of palliative or hospice care among Veterans with a recent hospital stay. Our data included 91,675 episodes of care between 2016 and 2018. 1.45 percent of episodes were followed by use of palliative care or hospice within 30 days. The addition of one or more social workers through the staffing program was associated with an increase of 0.53 percentage points (p<0.001) in the probability of any palliative or hospice care, i.e., a more than 30% increase relative to the mean. Policy makers and health system leaders who seek to improve patient experience and reduce costs through increased access to palliative and hospice care could consider social work staffing as a policy tool to achieve those aims.

The 4Ms Provide A Structural Framework For Organizing Educational Materials

The John A Hartford Foundation and the Institute for Healthcare Improvement (IHI)’s 4Ms of mentation, mobility, medications and (what) matters most provide a much-needed framework for helping system leaders and frontline teams consistently deliver high-quality, age-friendly care. Geriatric Fast Facts (GFFs) is a virtual resource providing teachers/learners with peer-reviewed, evidence-based summaries on topics essential to older adult care via a searchable website [www.geriatricfastfacts.com]. To determine if GFFs can be classified by the 4Ms we initially did a free text search of all GFFs. That revealed GFFs whose foci were unrelated to the 4Ms (e.g., mobility emerged in a fluoroscopy GFF as a minor element related to patient positioning). Therefore, all GFFs were independently reviewed by a geriatrician and the website manager and classified according to the 4M rubric (a single GFF can be classified in multiple M’s such as #93 on Age Friendly Health Systems). Any differences were adjudicated by the GFF editor. 64% (60/ 93) of GFFs strongly linked to one of the 4Ms. The number of GFFs dedicated to the 4Ms are as follows: 20 what matters most, 18 medications, 13 mentation, and 9 mobility. Those that were not coded within 4Ms were often very disease/specialty oriented. A total of 36 were not classified. For example, GGF #39 focuses on the etiologies of anemia among older adults. The 4M framework can be easily applied to educational materials to support consistent and clear conceptual model across learning conditions and materials.

Challenges and Strategies to Maintain Fidelity to the MIRROR-TCM Intervention During the COVID-19 Pandemic

Randomized clinical trials (RCTs) have demonstrated that the multicomponent Transitional Care Model (TCM), an advanced practice registered nurse-led, team-based, care management strategy improves outcomes for older adults transitioning from hospital to home. However, healthcare systems’ adoption of the model has been limited. A multi-system, replication RCT (MIRROR-TCM) enrolling older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia began in February 2020 just as the outbreak of COVID-19 in the U.S. dramatically changed the healthcare and research landscape. The goal of this qualitative descriptive study is to explore the impact of COVID-19 on fidelity to the TCM intervention during this clinical trial. Using directed content analysis, recorded monthly meetings with health system leaders and staff were coded to identify challenges and strategies to maintaining fidelity to the intervention in the context of the pandemic. Analyses showed that COVID-19 impacted all 10 TCM components. The components with the most challenges were delivering services from hospital-to-home due to quarantining, restrictive facility policies, lack of personal protective equipment and limited telehealth availability; coordinating care due reduced availability of services, and screening at risk individuals because of fewer eligible patients. Strategies for addressing challenges included: exploring alternatives (e.g., increasing reliance on telehealth, expanding study eligibility), building and engaging networks (e.g., direct outreach to skilled nursing facility staff) and anticipating needs (e.g., preparing for shorter hospital stays). Findings highlight the importance of monitoring the contextual challenges to implementing an evidence-based intervention and actively engaging partners in identifying strategies to achieve fidelity.

Community-informed, integrated, and coordinated care through a community-level model: A narrative synthesis on community hubs

We identify the core services included in a community hub model of care to improve the understanding of this model for health system leaders, decision-makers in community-based organizations, and primary healthcare clinicians. We searched Medline, PubMed, CINAHL, Scopus, Web of Science, and Google from 2000 to 2020 to synthesize original research on community hubs. Eighteen sources were assessed for quality and narratively synthesized (n = 18). Our analysis found 4 streams related to the service delivery in a community hub model of care: (1) Chronic disease management; (2) mental health and addictions; (3) family and reproductive health; and (4) seniors. The specific services within these streams were dependent upon the needs of the community, as a community hub model of care responds and adapts to evolving needs. Our findings inform the work of health leaders tasked with implementing system-level transformations towards community-informed models of care.

Recipes for resistance: Practical applications of restorative food justice in New Haven, Connecticut

In the United States, many people of color recently released from prison are likely to be food insecure. The intersections between race, food security, and release from prison are starting to be recognized. However, food justice should be informed by the perspectives and work being done by returning citizens and people of color. With the help of EMERGE CT, a transitional employment social enterprise for returning citizens in New Haven, Connecticut, I collected food access survey data and narratives of crewmembers at EMERGE to explore these issues. I merged restorative justice and food justice frame­works into one framework to develop an initiative that focuses on the availability of healthy, sustainable, and culturally appropriate food for returning citizens and addresses the social trauma that is perpetuated through both the food and prison systems. Further, I write about the importance of compensating food system leaders of color. I provide insight on the challenges in planning such a program. I discuss why we need to amplify the voices of returning citizens in food justice work. Lastly, I consider how these collaborative, cross-movement coalitions develop creative ways to re-envision equity.

Implementation of large-system transformation initiatives in the New Zealand health system

<p><b>Health systems worldwide are trying to shift towards a learning system to deliver people-centred, holistic and equitable health care. Large-system transformation (LST) initiatives that capitalise on key features of complex adaptive systems may be more likely to achieve the desired shift.</b></p> <p>By LST initiatives, I mean “interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes” (p 422) [1].</p> <p>This research had three aims: (1) to identify the key elements that support successful implementation of LST initiatives; (2) to construct a maturity matrix that describes different stages of maturity for each of these elements; and (3) to investigate and report on contextual factors that influence successful implementation of LST initiatives. Collectively, the three aims revealed the programme architecture that underpins efforts to successfully implement LST initiatives in the New Zealand health system.</p> <p>The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research. This research used insights from a New Zealand LST initiative (the System Level Measures programme), evidence from literature, and evidence from knowledge of those working in the health system, to analyse and describe this programme architecture. </p> <p>The research resulted in three key sets of findings.</p> <p>First, the research found that a set of 10 key elements needs to be present in the New Zealand health system and work in harmony to increase the chances of successful implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to Te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) an integrated health information; (ix) analytic capability; and (x) dedicated resources and time.</p> <p>Second, a self-assessment maturity matrix for the key elements was developed with New Zealand health system leaders to provide a practical tool for them and informal trust-based networks (such as Alliances) to improve their understanding of the different stages of maturity for the key elements, to assess their readiness for change, and to develop capacity and capability needed for system transformation. </p> <p>Third, a realist logic of enquiry was used to investigate how the key elements work in different contexts to influence the successful implementation of LST initiatives. At a local level, (i) the history of working together and quality of relationships, (ii) distributed leadership from commissioners of health services, and (iii) the maturity of informal trust-based networks, such as Alliances, emerged as key contextual factors that influenced successful implementation of these initiatives. The key mechanism of trust was triggered with a positive history of working together, which built strong relationships and facilitated a distributed leadership style among health system agents through informal networks. The high-trust environment built and nurtured over time strengthened relationships among health system agents, which then provided the foundation for health system transformation.</p> <p>At a national level, the distributed health system leadership, the application of ‘new power’ approach to design and implementation of LST initiatives, and the system accountability environment emerged as key contextual factors. The existing accountability framework, which solely focussed on financial performance of District Health Boards and outputs, suffocated the notion of a learning system as health system leaders placed more effort on achieving targets and outputs rather than on continuous improvement. A culture of continuous improvement supported the notion of a learning system; it encouraged iterative learning using methods such as plan-do-study-act cycles and fostered innovation. Use of ‘new power’ values such as collaborative policy design and implementation harnessed the intrinsic motivation of health system agents and built trust between policy makers and health service providers, which lead to sustained collective engagement with transformation efforts. A collective engagement to achieve a shared vision built strong and resilient health system leadership.</p> <p>The research concluded that transformation of health systems depended on senior system leaders’ understanding of the programme architecture that underpins efforts to successfully implement LST initiatives.</p>

Implementation of large-system transformation initiatives in the New Zealand health system

<p><b>Health systems worldwide are trying to shift towards a learning system to deliver people-centred, holistic and equitable health care. Large-system transformation (LST) initiatives that capitalise on key features of complex adaptive systems may be more likely to achieve the desired shift.</b></p> <p>By LST initiatives, I mean “interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes” (p 422) [1].</p> <p>This research had three aims: (1) to identify the key elements that support successful implementation of LST initiatives; (2) to construct a maturity matrix that describes different stages of maturity for each of these elements; and (3) to investigate and report on contextual factors that influence successful implementation of LST initiatives. Collectively, the three aims revealed the programme architecture that underpins efforts to successfully implement LST initiatives in the New Zealand health system.</p> <p>The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research. This research used insights from a New Zealand LST initiative (the System Level Measures programme), evidence from literature, and evidence from knowledge of those working in the health system, to analyse and describe this programme architecture. </p> <p>The research resulted in three key sets of findings.</p> <p>First, the research found that a set of 10 key elements needs to be present in the New Zealand health system and work in harmony to increase the chances of successful implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to Te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) an integrated health information; (ix) analytic capability; and (x) dedicated resources and time.</p> <p>Second, a self-assessment maturity matrix for the key elements was developed with New Zealand health system leaders to provide a practical tool for them and informal trust-based networks (such as Alliances) to improve their understanding of the different stages of maturity for the key elements, to assess their readiness for change, and to develop capacity and capability needed for system transformation. </p> <p>Third, a realist logic of enquiry was used to investigate how the key elements work in different contexts to influence the successful implementation of LST initiatives. At a local level, (i) the history of working together and quality of relationships, (ii) distributed leadership from commissioners of health services, and (iii) the maturity of informal trust-based networks, such as Alliances, emerged as key contextual factors that influenced successful implementation of these initiatives. The key mechanism of trust was triggered with a positive history of working together, which built strong relationships and facilitated a distributed leadership style among health system agents through informal networks. The high-trust environment built and nurtured over time strengthened relationships among health system agents, which then provided the foundation for health system transformation.</p> <p>At a national level, the distributed health system leadership, the application of ‘new power’ approach to design and implementation of LST initiatives, and the system accountability environment emerged as key contextual factors. The existing accountability framework, which solely focussed on financial performance of District Health Boards and outputs, suffocated the notion of a learning system as health system leaders placed more effort on achieving targets and outputs rather than on continuous improvement. A culture of continuous improvement supported the notion of a learning system; it encouraged iterative learning using methods such as plan-do-study-act cycles and fostered innovation. Use of ‘new power’ values such as collaborative policy design and implementation harnessed the intrinsic motivation of health system agents and built trust between policy makers and health service providers, which lead to sustained collective engagement with transformation efforts. A collective engagement to achieve a shared vision built strong and resilient health system leadership.</p> <p>The research concluded that transformation of health systems depended on senior system leaders’ understanding of the programme architecture that underpins efforts to successfully implement LST initiatives.</p>

Master teachers as system leaders of professional learning: master teacher studios in China

PurposeThis study aims to describe and analyze an innovative mechanism of teacher-led, system-wide professional learning that has been widely adopted since the beginning of the twenty-first century in China – the Master Teacher Studio (MTS).Design/methodology/approachThis paper drew from policy documents, published Chinese literature relating to MTSs and personal fieldwork experience in Shanghai, Guangdong and Zhejiang province.FindingsThe article first outlines the context framing the system change, including its policy background and evolution, and then the MTS's purpose, formative process and structure. It finally examines major teacher learning activities and the leadership roles of the MTS hosts (leaders).Research limitations/implicationsThis study contributed to the knowledge base of system teacher leaders and how they lead cross-school leading.Practical implicationsThe MTS initiative described in this article shows the power of central system leadership to spread and embed effective teacher learning practices at schools.Originality/valueThis article provides implications for understanding and practicing teacher system leadership to support teacher professional learning in different societies.

Characteristics of the ideal hospitalist inpatient care program: perceptions of Canadian health system leaders

Background Despite the growing prevalence of hospitalist programs in Canada, it is not clear what program features are deemed desirable by administrative and medical leaders who oversee them. We aimed to understand perceptions of a wide range of healthcare administrators and frontline providers about the implementation and necessary characteristics of a hospitalist service. Methods We conducted semi-structured interviews with a range of administrators, medical leaders and frontline providers across three hospital sites operated by an integrated health system in British Columbia, Canada. Results Most interviewees identified the hospitalist model as the ideal inpatient care service line, but identified a number of challenges. Interviewees identified the necessary features of an ideal hospitalist service to include considerations for program design, care and non-clinical processes, and alignment between workload and physician staffing. They also identified continuity of care as an important challenge, and underlined the importance of communication as an important enabler of implementation of a new hospitalist service. Conclusions Most hospital administrators and frontline providers in our study believed the hospitalist model resulted in improvements in clinical processes and work environment.