coordinated care
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2022 ◽  
pp. 1-11
Author(s):  
Madhumitha Manivannan ◽  
Julia Heunis ◽  
Sarah M. Hooper ◽  
Alissa Bernstein Sideman ◽  
Kristi P. Lui ◽  
...  

Background: Financial mismanagement and abuse in dementia have serious consequences for patients and their families. Vulnerability to these outcomes reflects both patient and contextual factors. Objective: Our study aimed to assess how multidisciplinary care coordination programs assist families in addressing psychosocial vulnerabilities and accessing needed resources. Methods: Our study was embedded in a clinical trial of the Care Ecosystem, a telephone- and internet-based supportive care intervention for patients with dementia and caregivers. This program is built around the role of the Care Team Navigator (CTN), an unlicensed dementia care guide who serves as the patient and caregiver’s primary point of contact, screening for common problems and providing support. We conducted a qualitative analysis of case summaries from a subset of 19 patient/caregiver dyads identified as having increased risk for financial mismanagement and abuse, to examine how Care Ecosystem staff identified vulnerabilities and provided support to patients and families. Results: CTNs elicited patient and caregiver needs using templated conversations to address common financial and legal planning issues in dementia. Sources of financial vulnerability included changes in patients’ behavior, caregiver burden, intrafamily tension, and confusion about resources to facilitate end-of-life planning. The Care Ecosystem staff’s rapport with their dyads helped them address these issues by providing emotional support, information on how to access financial, medical, and legal resources, and improving intra-familial communication. Conclusion: The Care Ecosystem offers a scalable way to address vulnerabilities to financial mismanagement and abuse in patients and caregivers through coordinated care by unlicensed care guides supported by a multidisciplinary team.


2022 ◽  
pp. 9-25
Author(s):  
Steve Berta ◽  
Howard Blonsky ◽  
James Wogan
Keyword(s):  

BMC Nursing ◽  
2022 ◽  
Vol 21 (1) ◽  
Author(s):  
Alessandra Schirin Gessl ◽  
Angela Flörl ◽  
Eva Schulc

Abstract Background The number of people with complex nursing and care needs living in their own homes is increasing. The implementation of Case and Care Management has shown to have a positive effect on unmet care needs. Research on and implementation of Case and Care Management in the community setting in Austria is limited. This study aimed to understand the changes and challenges of changing care needs by mobile nurses and to evaluate the need for Case Management in mobile care organizations by investigating the evolution of mobile care nurses‘task profiles and the challenges in working in a dynamic field with changing target groups and complexifying care needs. Methods A qualitative study with reductive-interpretative data analysis consisting of semi-structured focus groups was conducted. Community care nurses, head nurses, and managers of community mobile care units as well as discharge managers of a community hospital (n = 24) participated in nine qualitative, semi-structured focus groups. The recorded focus groups were transcribed and analyzed using qualitative content analysis. Results The analysis revealed three main categories: the complexity of the case, innerinstitutional frameworks, and interinstitutional collaboration, which influence the perception of need for further development in the direction of Case and Care Management. Feelings of overwhelmedness among nurses were predominantly tied to cases that presented with issues beyond healthcare such as legal, financial, or social that necessitated communication and collaboration across multiple care providers. Conclusions Care institutions need to adapt to changing and increasingly complex care needs that necessitate cooperation between organizations within and across the health and social sectors. A key facilitator for care coordination and the adequate service provision for complex care needs are multidisciplinary institutional networks, which often remain informal, leaving nurses in the role of petitioner without equal footing. Embedding Case and Care Management in the community has the potential to fill this gap and facilitate flexible, timely, and coordinated care across multiple care providers.


2021 ◽  
Author(s):  
Agnieszka Pluta ◽  
Alicja Marzec ◽  
Edyta Kobus

Abstract BackgroundDiabetes is a lifestyle disease which can cause many complications and organ-related disorders. The aim of the study was to analyze selected aspects of preparing patients with diabetes for self-care.MethodsThe study group consisted of 190 people diagnosed with type 1 and type 2 diabetes, including 101 women and 89 men. The mean age of the respondents was 42.2 ± 13.4 years. The study was conducted using an anonymous self-designed questionnaire containing 50 questions.ResultsAmong the respondents, 23.2% did not control their glucose levels at home. The respondents most often measured glucose once a day (33.6%) or three times a day (26.7%). 64.7% of the respondents declared that they kept a self-monitoring diary. The knowledge of the symptoms of hypoglycemia and the ability to properly manage it was declared by 64.8% of the respondents. 52.1% of the patients did not undertake any activity lasting more than 30 minutes at least 3 times a week. 75.2% described their condition as very good and good. Independent participation in therapy, i.e. taking hypoglycemic drugs or insulin, was declared by 63.7% of the respondents.ConclusionsDespite undergoing therapeutic education, the study population diagnosed with diabetes still show deficiencies in terms of awareness of proper health behaviors. Objective results showed that the patients had insufficient knowledge and skills in terms of self-care and self-observation, blood glucose and blood pressure measurements, physical activity, diet therapy and adherence to pharmacotherapy recommendations. Despite the good general preparation for self-care as declared by the respondents, these patients require further systematic, individual educational activities.Study implicationsThe results of the present study have implications for nursing practice, patient therapeutic education, and the functioning of the public health and healthcare systems. The number of diabetic patients is constantly increasing. Patients require coordinated care and individualized therapeutic education in order to be prepared for self-care and self-management, thus reducing the risk of complications. Delaying the occurrence of potential complications provides patients with a chance to live an active private and professional life, and protects the health care system from carrying the cost burden of expensive highly specialized services.


2021 ◽  
pp. 107755872110646
Author(s):  
Jennifer Gutberg ◽  
Jenna M. Evans ◽  
Sobia Khan ◽  
Reham Abdelhalim ◽  
Walter P. Wodchis ◽  
...  

How does leadership emerge and function when multiple health care organizations come together to form a network? In this qualitative comparative case study, we draw on distributed leadership theory to examine the leadership practices that manifested during the implementation of three coordinated care networks. Thirty leaders and care providers participated in semistructured interviews. Interview data were inductively analyzed using thematic analysis. Although established in response to the same policy initiative, each case differed in its leadership approach and implementation strategy. We found that manifestation of distributed leadership was contingent on the presence of an individual leader who acted as a unifying force across their respective network. Our findings suggest that policies to encourage the development of interorganizational networks should include sufficient resources to support an individual leader who enables distributed leadership.


Author(s):  
Amanda E. Garver ◽  
Salini Mohanty ◽  
Brad E. Dicianno ◽  
Renee M. Turchi

PURPOSE: The objective of this study was to describe the knowledge, attitudes, and practices related to caring for youth with SB within a statewide pediatric primary care medical home network. METHODS: Health care professionals who were members of the PA MHP statewide network were surveyed on sociological demographics, confidence in and knowledge of topics that impact the SB population, education on SB, designating responsibility of care, tasks completed in the office, and transition from pediatric to adult care from October 2016 through November 2016. RESULTS: Among 67 respondents, 78%believed counseling families/caregivers about the impact of SB on everyday life was a shared responsibility between PCPs and SB clinics. Eighty five percent of participants indicated they had exposure to SB through clinical courses or didactics in training but only 54%of participants felt knowledgeable on the impact of SB on everyday life. CONCLUSION: Findings suggest a need for increased educational efforts, improved awareness of SB, and access to evidence-based guidelines for PCPs to promote accessible and coordinated care to individuals with SB.


2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 829-829
Author(s):  
Sweta Tewary ◽  
Denise Kruszynski ◽  
Naushira Pandya ◽  
Nicole Cook ◽  
Sashah Damier ◽  
...  

Abstract Age Friendly Health Systems (AFHS) commit to evidence-based, low-risk, coordinated care that is centered on what matters most to older adults, their families and caregivers. Nova Southeastern University South Florida Geriatric Workforce Enhancement Program (NSU SFGWEP) has partnered with multiple primary care clinics to provide dedicated AFHS training and support to increase AFHS transformation in Broward and Miami-Dade Counties. As part of the initiative, SFGWEP provide didactic training, clinic on-site brief demonstration, and infographic guidance for EHR documentation. NSU SFGWEP activities are conducted through training surveys, provider feedback, and e-clinical measures that align with CMS MIPS measures. Three participating health systems report annually on seven e-clinical measures that, collectively, provide indicators of the 4Ms of AFHS (what matters, medication management, mentation and mobility.) From baseline to Year 1, NSU SFGWEP saw improvement in controlled hypertension (54% to 94%), opioid screening (<1% to 11%), advance care planning (21% to 35%) and falls risk assessment (45% to 59%). Results demonstrate the need to continue and expand AFHS interventions for sustainability. In Year 2, SFGWEP will continue to expand awareness of best practices and benefits of the AFHS through education and training at NSU and at the various primary care sites. As mutual collaboration and implementation methods are shared among participating members, the expectation is that quality healthcare of our elder community adults will measurably improve.


2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 453-454
Author(s):  
Katherine Abbott ◽  
Athena Koumoutzis ◽  
Jennifer Heston-Mullins

Abstract MyCare Ohio is a prospective blended managed care payment model program tasked to provide comprehensive and coordinated care to Ohio residents who are dully eligible for Medicare and Medicaid. To understand the administration and day-to-day implementation of care management within MyCare Ohio, n=75 interviews with a total of n=331 personnel from Area Agencies on Aging, Managed Care Plans, and service providers were conducted. Interviews were audio recorded, transcribed, and checked for accuracy. Data were analyzed by iterative reviews and deductive coding in Dedoose. Respondents provided insights on how care management activities are affected by program design features (e.g., ability to opt-out of the Medicare component), transitions between acute and long-term care settings, documentation systems and data-sharing, and high numbers of beneficiaries with behavioral health diagnoses. Implications for practice and policy will be discussed.


OBJECTIVE As the care of patients with spina bifida continues to evolve, life expectancy is increasing, leading to a critical need for transition planning from pediatric-based to adult-based care. The burden of neurosurgical care for adults with spina bifida remains unknown. In this study, the authors sought to use a large national data set to estimate the prevalence of neurosurgical interventions in adults with spina bifida. METHODS This study utilized Health Facts, which is a de-identified proprietary data set abstracted from all Cerner electronic health records. It includes 69 million unique patients with > 500 million encounters in 580 centers. Validation, technical exclusions, and data filters were applied to obtain an appropriate cohort of patients. The ICD-9 and ICD-10 codes for all types of spinal dysraphism, as well as the Current Procedural Terminology (CPT) codes for hydrocephalus procedures, spinal cord untethering, and Chiari decompression, were queried and records were retrieved. Demographic variables along with differences in age groups and temporal trends were analyzed. RESULTS Overall, 24,764 unique patients with ≥ 1 encounter with a spinal dysraphism diagnosis between 2000 and 2017 were identified. The pediatric cohort included 11,123 patients with 60,027 separate encounters, and the adult cohort included 13,641 patients with 41,618 separate encounters. The proportion of females was higher in the adult (62.9%) than in the pediatric (51.4%) cohort. Annual encounters were stable from 2 to 18 years of age, but then decreased by approximately half with a precipitous drop after age 21 years. The sex distribution of adults and children who underwent procedures was similar (54.6% female adults vs 52.4% female children). Surgical interventions in adults were common. Between 2013 and 2017, there were 4913 procedures for hydrocephalus, with 2435 (49.6%) adult patients. Similarly, 273 (33.3%) of the 819 tethered cord procedures were performed in adults, as were 307 (32.9%) of 933 Chiari decompressions. CONCLUSIONS The Health Facts database offered another option for studying care delivery and utilization in patients aging with spina bifida. The median age of this population has now reached early adulthood, and a significant number of neurosurgical procedures were performed in adults. An abrupt drop in the rate of encounters occurred at 21 years of age, possibly reflecting transition issues such as access-to-care problems and lack of coordinated care.


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