Implementing an advanced team-based care model in a federally qualified health center (FQHC): Assessing implementation facilitators and challenges.

OBJECTIVE: The objective of this paper is to assess implementation facilitators and challenges for advanced team-based care (aTBC) in a federally qualified health center (FQHC). In aTBC, care team coordinators room patients, perform vitals and agenda setting during patient intake, and remain present alongside providers during patient visits. METHODS: The authors conducted a qualitative post-hoc analysis of the aTBC implementation using data from several sources. They used content analysis to code items as facilitators or challenges and thematic analysis to group those into larger themes. Finally, they applied a priori codes from the revised consolidated framework for implementation research (CFIR) to organize the facilitators and barriers into subdomains. RESULTS: The existing evidence-base around aTBC, the FQHC's ability to pilot and adapt it, and strong implementation leads were key facilitating factors. Challenges included an external shock (i.e., the COVID-19 pandemic), aTBC complexity, and uncertainty about whether success required implementation of the full model versus easier-to-integrate smaller components. CONCLUSIONS: FQHCs that wish to implement aTBC models need strong champions and internal structures for piloting, adapting, and disseminating interventions. FQHC leaders must think strategically about how to build support and demonstrate success to improve an FQHC's chances of expanding and sustaining aTBC.

The imperative of collaboration: Lived experience perspectives on team approaches in outpatient eating disorder treatment.

BACKGROUND: Across healthcare broadly, team treatment approaches range from siloed multidisciplinary treatment to synergistic Interprofessional Collaborative Practice (IPCP), with IPCP increasingly favored. In eating disorders, clinical practice guidelines endorse team outpatient treatment, and these approaches are widely used in clinical practice. However, there is limited evidence to describe attitudes toward and experiences of team approaches, including IPCP, among individuals with a lived experience. METHOD: Twenty-seven participants (aged 20-51 years) with a formal eating disorder diagnosis were recruited. Each had received outpatient eating disorder treatment from a team or teams comprising a mental health professional, dietitian, and general practitioner (GP) in the past 2 years. Qualitative data were collected via semi-structured interviews and analyzed using Braun and Clarke's reflexive thematic analysis. RESULTS: Four themes were derived from the qualitative analysis. Themes included: (1) working together is better; (2) the linchpin of teamwork is communication; (3) teams should foster autonomy with limit-setting; and (4) systemic failures negatively affect team treatment. Participants favored highly collaborative treatment from a team including a mental health professional, dietitian, and GP at a minimum, where the team engaged in high-quality communication and fostered autonomy with limit-setting. Systemic failures negatively affecting team treatment were reported across the care continuum. DISCUSSION: Findings endorse the application of IPCP to outpatient eating disorder treatment as a strategy to improve treatment satisfaction, engagement, and outcomes. Given the paucity of evidence exploring IPCP in this field, however, the development and evaluation of interprofessional education and treatment models is a foundational necessity. PUBLIC SIGNIFICANCE: Team eating disorder treatment is widely used in clinical practice, although there is limited evidence to guide interventions. This study explores attitudes toward and experiences of team outpatient eating disorder treatment among individuals with a lived experience. Understanding preferred team treatment characteristics delivers important information to improve treatment satisfaction, engagement, and outcomes for individuals receiving outpatient eating disorder treatment.

Impact of a multi-disciplinary team-based care model for patients living with diabetes on health outcomes: a mixed-methods study.

BACKGROUND: Individuals facing socioeconomic hardship experience higher than average rates of chronic disease, such as diabetes, with less access to evidence-based treatment. One solution to address these inequities is a team-based care (TBC) model, defined as one in which at least two providers work collaboratively with a patient and their caregiver(s) to make healthcare decisions. This paper seeks to describe the implementation of a TBC model within a safety-net healthcare setting and determine the extent to which it can be an effective, patient-centered approach to treating individuals with diabetes. METHODS: Semi-structured interviews were conducted with staff (n = 15) and patients (n = 18). Clinical data were extracted from the electronic medical record of patients (n = 1,599) seen at a safety-net health system in Chicago, Illinois, United States. The mixed methods study was guided by implementation science and participatory research principles. Staff interviews were 60 min and covered patient care activities, work flow, perceived patient experience, and facilitators/barriers to care coordination. Patient interviews were 60 min and covered satisfaction, attitudes about diabetes management, quality of life, and technology. Patient interviews were co-analyzed by research staff and members of a patient advisory committee. Clinical data were collected at an index visit, two years prior and at one-year follow up (n = 1,599). RESULTS: Four themes emerged from the interviews: (1) patients perceived the TBC model to be patient centered and of high quality; (2) technology can be an innovative tool, but barriers exist; (3) diabetes management is a complex process; and (4) staff communication enhances care coordination, but misinterpreting roles reduces care coordination. From pre-enrollment to the follow-up period, we found a statistically significant increase in missed visits, decrease in hemoglobin A1c (HbA1c), decrease in body mass index, and decrease in the percent of patients with high blood pressure. We found that each medical visit during the follow-up period was associated with an HbA1c decrease of 0.26 points. CONCLUSIONS: A TBC model is a patient-centered approach to providing care to patients with complex health needs, such as diabetes, patients were satisfied with the care they were receiving, and the model was associated with an improvement in clinical outcomes.

Perceptions and outcomes of an embedded Alzheimer Society First Link Coordinator in rural primary health care memory clinics.

BACKGROUND: Primary health care has a central role in dementia detection, diagnosis, and management, especially in low-resource rural areas. Care navigation is a strategy to improve integration and access to care, but little is known about how navigators can collaborate with rural primary care teams to support dementia care. In Saskatchewan, Canada, the RaDAR (Rural Dementia Action Research) team partnered with rural primary health care teams to implement interprofessional memory clinics that included an Alzheimer Society First Link Coordinator (FLC) in a navigator role. Study objectives were to examine FLC and clinic team member perspectives of the impact of FLC involvement, and analysis of Alzheimer Society data comparing outcomes associated with three types of navigator-client contacts. METHODS: This study used a mixed-method design. Individual semi-structured interviews were conducted with FLC (n = 3) and clinic team members (n = 6) involved in five clinics. Data were analyzed using thematic inductive analysis. A longitudinal retrospective analysis was conducted with previously collected Alzheimer Society First Link database records. Memory clinic clients were compared to self- and direct-referred clients in the geographic area of the clinics on time to first contact, duration, and number of contacts. RESULTS: Three key themes were identified in both FLC and team interviews: perceived benefits to patients and families of FLC involvement, benefits to memory clinic team members, and impact of rural location. Whereas other team members assessed the patient, only FLC focused on caregivers, providing emotional and psychological support, connection to services, and symptom management. Face-to-face contact helped FLC establish a relationship with caregivers that facilitated future contacts. Team members were relieved knowing caregiver needs were addressed and learned about dementia subtypes and available services they could recommend to non-clinic clients with dementia. Although challenges of rural location included fewer available services and travel challenges in winter, the FLC role was even more important because it may be the only support available. CONCLUSIONS: FLC and team members identified perceived benefits of an embedded FLC for patients, caregivers, and themselves, many of which were linked to the FLC being in person.

The Community Primary Care Champions Fellowship: a mixed methods evaluation of an interprofessional fellowship for physician assistants and physicians.

BACKGROUND: Primary care in the US faces challenges with clinician recruitment, retention, and burnout, with further workforce shortages predicted in the next decade. Team-based care can be protective against clinician burnout, and opportunities for interprofessional education (IPE) on professional development and leadership could encourage primary care transformation. Despite an increasingly important role in the primary care workforce, IPE initiatives training physician assistants (PAs) alongside physicians are rare. We describe the design, curriculum, and outcomes from an interprofessional primary care transformation fellowship for community-based primary care physicians and PAs. METHODS: The Community Primary Care Champions (CPCC) Fellowship was a one-year, part-time fellowship which trained nine PAs, fourteen physicians, and a behavioralist with at least two years of post-graduate clinical experience in six content pillars: quality improvement (QI), wellness and burnout, mental health, social determinants of health, medical education, and substance use disorders. The fellowship included a recurring schedule of monthly activities in self-study, lectures, mentoring, and community expert evening discussions. Evaluation of the fellowship included pre, post, and one-year follow-up self-assessments of knowledge, attitudes, and confidence in the six content areas, pre- and post- wellness surveys, lecture and discussion evaluations, and midpoint and exit focus groups. RESULTS: Fellows showed significant improvement in 24 of 28 self-assessment items across all content areas post-fellowship, and in 16 of 18 items one-year post-fellowship. They demonstrated reductions in emotional exhaustion and depersonalization post-fellowship and increased confidence in working in interprofessional teams post-fellowship which persisted on one-year follow-up assessments. All fellows completed QI projects and four presented their work at national conferences. Focus group data showed that fellows experienced collaborative, meaningful professional development that was relevant to their clinical work. They appreciated the flexible format and inclusion of interprofessional community experts in evening discussions. CONCLUSIONS: The CPCC fellowship fostered an interprofessional community of practice that provided an effective IPE experience for physicians and PAs. The learning activities, and particularly the community expert discussions, allowed for a flexible, relevant experience, resulting in personal and professional growth along with increased confidence working within interprofessional teams.

Revisiting the Time Needed to Provide Adult Primary Care.

BACKGROUND: Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care. OBJECTIVE: To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. DESIGN: Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels. PARTICIPANTS: Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017-2018 National Health and Nutrition Examination Survey. MAIN MEASURES: The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care. KEY RESULTS: PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management). CONCLUSIONS: PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.

Team-Based Diabetes Care in Ontario and Hong Kong: a Comparative Review.

PURPOSE OF REVIEW: There are gaps in implementing and accessing team-based diabetes care. We reviewed and compared how team-based diabetes care was implemented in the primary care contexts of Ontario and Hong Kong. RECENT FINDINGS: Ontario's Diabetes Education Programs (DEPs) were scaled-up incrementally. Hong Kong's Multidisciplinary Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) evolved from a research-driven quality improvement program. Each jurisdiction had a mixture of non-team and team-based primary care with variable accessibility. Referral procedures, follow-up processes, and financing models varied. DEPs used a flexible approach, while the RAMP-DM used structured assessment for quality assurance. Each approach depended on adequate infrastructure, processes, and staff. Diabetes care is most accessible and functional when integrated team-based services are automatically initiated upon diabetes diagnosis within a strong primary care system, ideally linked to a register with supports including specialist care. Structured assessment and risk stratification are the basis of a well-studied, evidence-based approach for achieving the standards of team-based diabetes care, although flexibility in care delivery may be needed to meet the unique needs of some individuals. Policymakers and funders should ensure investment in skilled health professionals, infrastructure, and processes to improve care quality.

Needs of persons living with ALS at home and their family caregivers: A scoping review.

INTRODUCTION/AIMS: Most persons with amyotrophic lateral sclerosis (ALS) live at home with support of family caregivers, with escalating complexity of care over the trajectory of the disease requiring resources and support to mitigate negative physical, social, and emotional outcomes. METHODS: This scoping review identifies the home health/home care needs of persons with ALS and their caregivers as a basis for creating a home health medical standard. We used the PRISMA Extension for Scoping Reviews (PRISMA-ScR) to examine studies describing home care needs published between 2011 and 2021. RESULTS: Our search yielded 481 articles, of which 44 were included with a total of 3592 (9-273) participants. Most studies used a cross-sectional design and 20 (45%) were rated as high quality. We grouped the needs identified as emotional/psychological, assistive devices and technology, information and education, and human resources and professional services. Most studies demonstrated persistent unmet needs and that available interventions were helpful while needs generally were not met proactively, despite the predictable trajectory. DISCUSSION: This review describes biopsychosocial and equipment interventions over the trajectory of ALS with implications for anticipatory planning by clinicians, as well as policy for coverage of necessary services and supports. Interdisciplinary expert teams could develop consensus around needs across the trajectory and recommended services and supports. To make knowledge more accessible, encourage availability of services, and clarify the need for coverage of services, we aim to develop an expert consensus-based ALS home health medical standard guidance document in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine.

Facilitation of team-based care to improve HTN management and outcomes: a protocol for a randomized stepped wedge trial.

BACKGROUND: There are well-established guidelines for treating hypertension (HTN), yet only half of patients with HTN meet the defined target of < 140/90. Team-based care (TBC) is an evidence-based strategy for improving blood pressure (BP) management and control. TBC is defined as the provision of health services by at least two health professionals "who work collaboratively with patients and their caregivers to accomplish shared goals to achieve coordinated, high-quality care". However, primary care practices experience challenges to implementing TBC principles and care processes; these are more pronounced in small independent practice settings (SIPs). Practice facilitation (PF) is an implementation strategy that may overcome barriers to adopting evidence-based TBC to improve HTN management in SIPs. METHODS: Using a stepped wedge randomized controlled trial design, we will test the effect of PF on the adoption of TBC to improve HTN management in small practices (< 5 FTE clinicians) in New York City, and the impact on BP control compared with usual care. We will enroll 90 SIPs and randomize them into one of three 12-month intervention waves. Practice facilitators will support SIPs to adopt TBC principles to improve implementation of five HTN management strategies (i.e., panel management, population health, measuring BP, supporting medication adherence, self-management). The primary outcome is the adoption of TBC for HTN management measured at baseline and 12 months. Secondary outcomes include the rate of BP control and sustainability of TBC and BP outcomes at 18 months. Aggregated data on BP measures are collected every 6 months in all clusters so that each cluster provides data points in both the control and intervention conditions. Using a mixed methods approach, we will also explore factors that influence the effectiveness of PF at the organization and team level. DISCUSSION: This study will provide much-needed guidance on how to optimize adoption and sustainability of TBC in independent primary care settings to reduce the burden of disease related to suboptimal BP control and advance understanding of how facilitation works to improve implementation of evidence-based interventions. TRIAL REGISTRATION: ClinicalTrials.gov; NCT05413252 .

Letter to the Editor In Response to: "Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners" (Suh et al. 2022).

The authors present a Letter to the Editor in response to the recently published article: "Referring Provider Opinions of Pediatric Cardiology Evaluations Performed by Nurse Practitioners" by Suh et al. (Pediatr Cardiol, https://doi.org/10.1007/s00246-022-02959-0 , 2022).

A Mixed-Methods Approach for Evaluating Implementation Processes and Program Costs for a Hypertension Management Program Implemented in a Federally Qualified Health Center.

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.

Preparing future physicians for complexity: a post-graduate elective in HIV psychiatry.

BACKGROUND: Patients with complex care needs have multiple concurrent conditions (medical, psychiatric, social vulnerability or functional impairment), interfering with achieving desired health outcomes. Their care often requires coordination and integration of services across hospital and community settings. Physicians feel ill-equipped and unsupported to navigate uncertainty and ambiguity caused by multiple problems. A HIV Psychiatry resident elective was designed to support acquisition of integrated competencies to navigate uncertainty and disjointed systems of care - necessary for complex patient care. METHODS: Through qualitative thematic analysis of pre- and post-interviews with 12 participants - residents and clinic staff - from December 2019 to September 2022, we explored experiences of this elective. RESULTS: This educational experience helped trainees expand their understanding of what makes patients complex. Teachers and trainees emphasize the importance of an approach to "not knowing" and utilizing integrative competencies for navigating uncertainty. Through perspective exchange and collaboration, trainees showed evidence of adaptive expertise: the ability to improvise while drawing on past knowledge. CONCLUSIONS: Postgraduate training experiences should be designed to facilitate skills for caring for complex patients. These skills help residents fill in practice gaps, improvise when standardization fails, and develop adaptive expertise. Going forward, findings will be used to inform this ongoing elective.

Developing an interprofessional team to support patients prescribed long-term high-dose opioid therapy.

Despite decreases in US opioid prescribing rates, daily morphine milligram equivalents (MME) prescribed per person remains three times higher than in 1999. An interprofessional team (IPT) was developed to support pain management for patients prescribed long-term high-dose opioids (HDO) in a Federally Qualified Health Center. The IPT utilized a clinical pharmacist, addiction nurse, medical director, and another physician or nurse practitioner to manage adults prescribed long-term HDO, defined as exceeding 50 daily MME. Visits focused on patient education including risks associated with long-term HDO use and effective pain management. The IPT engaged in supportive, individualized care planning for safer, evidence-based pain management, which included, but was not limited to opioid tapers, adjuvant non-opioid pain medications (NOPM), non-pharmacological therapy (NPT), and naloxone co-prescribing. The IPT saw 90% (n = 19) of eligible patients. Excluding outliers, the cohort demonstrated an average 18% ± 24.9 decrease in daily MME. The most common NOPM were acetaminophen, NSAIDs, and pregabalin, and the most common NPT were physical, aquatic, and behavioral therapy. Shared decision-making, collaborative teamwork, and simple patient-centered goals are key to moving patients toward safer, evidence-based therapy.

Two-year outcomes following the HIDOC program: expanding outpatient care delivery to meet the needs of medically complex, high-utilizing patients with a broader interprofessional care team.

This article describes the Highly Individualized Dedicated Onsite Care (HIDOC) intensive primary care program implemented at a university clinic, comprising (a) care by an interprofessional team, (b) new logistical capacity, and (c) clinician skills training. Measured outcomes include Emergency Department (ED) visits and hospitalizations at a university and a community hospital over 2 years, using a within-subjects design. We demonstrate decreased hospitalizations at the University Hospital, and a decrease in ED visits at both sites. Team-based strategies to provide intensive primary care can decrease utilization, allowing for greater continuity of care.

Prevalence and predictors of team-based care activities between primary care providers and embedded behavioral health providers: a national survey.

Primary care (PC) settings increasingly use team-based care activities with embedded behavioral health providers (BHPs) to enhance patient care via group medical visits, conjoint appointments, team huddles, and warm handoffs. Aim 1 was to describe the variation of team-based care activities within integrated PC clinics. Aim 2 was to explore whether factors associated with the BHP (e.g., gender, training, and experience) and the PC setting (e.g., perceived teamwork) predict engagement in team-based activities. A national sample of eligible BHPs (n = 345; 14.2% response rate) completed an anonymous survey assessing the presence/intensity of team-based care activities. 90% of BHPs reported regularly engaging in team-based care activities with PC teams. Most engagement occurred when providing feedback to PC providers (90.4% at least daily) and during warm handoffs (90.4% at least once daily). Engagement in team-based care was predicted by the level of teamwork occurring within the PC clinic (ßs = .41-.47; ps < .001) and BHP characteristics, such as the number of years spent in PC (ßs = .24-.26, ps < .001). Although these data are promising, with many BHPs reportedly engaging in team-based activities with PC teams, there is significant variation. Researchers should continue to explore whether the engagement in these team-based care activities enhances patient care.

Interprofessional care in a retirement and assisted living community: the complexity of teamwork.

Teamwork is an aspiration in the delivery of interprofessional care to older adults, but how does it play out in residential settings that combine independent living, assisted living, and skilled nursing care? This study investigated teamwork as an organic part of a retirement and assisted living community immersed in mission-driven care. Drawing on 44 in-depth interviews, 62 meeting observations, and five years of immersion in the setting by the first author, we explored the complex dynamics of teamwork. Our overarching findings showed that co-location aided by physical design and a mission-driven investment in care may not be sufficient to effect teamwork in a complex care environment, and that the organizational context was potentially damaging to teamwork. Our study highlights opportunities to improve teamwork and interprofessional collaboration in organizational settings that combine the provision of health and social care. Increasing expectations for teamwork outcomes may prove essential as retirement and assisted living care settings offer supportive and therapeutic environments for older adults who move between different levels of care.

Team-based care: an expanded medical assistant role - enhanced rooming and visit assistance.

Primary care practices face significant challenges as they pursue the Quadruple Aim. Redistributing care across the interprofessional primary care team by expanding the role of the medical assistant (MA) is a potential strategy to address these challenges. Two sequential, linked processes to expand the role of the MA, called Enhanced Rooming and Visit Assistance, were implemented in four family medicine residency clinics in Minnesota. In Enhanced Rooming, MAs addressed preventive services, obtained a preliminary visit agenda, and completed a warm hand-off to the provider. In Visit Assistance, MAs stayed in the room the entire visit to assist with the visit workflow. Enhanced Rooming and Visit Assistance processes were successfully implemented and sustained for over one year. MAs and providers were satisfied with both processes, and patients accepted the expanded MA roles. Mammogram ordering rates increased from 10% to 25% (p < 0.0001). After Visit Summary (AVS) print rates increased by 12% (p < 0.0001). Visit Turn-Around-Time (TAT) decreased 3.1 minutes per visit (p = 0.0001). Expanding the MA role in a primary care interprofessional team is feasible and a potentially useful tool to address the Quadruple Aim.

[Delegation of medical duties to qualified rheumatology assistants : Effect on depression and anxiety in patients with rheumatoid arthritis]. / Delegation ärztlicher Leistungen an rheumatologische Fachassistenten : Effekte auf Depression und Angst bei Patienten mit rheumatoider Arthritis.

BACKGROUND: At least 1 comorbidity occurs in 80% of patients with rheumatoid arthritis (RA). In addition to cardiovascular comorbidities psychological comorbid conditions are common. The prevalence of depression and anxiety is higher in patients than in the general population. Screening for comorbidities is crucial. A shortage of outpatient specialist care barely allows resources for this. The implementation of team-based care holds the potential to improve the standard of care while simultaneously working against the shortage of care. OBJECTIVE: The aim of the study was to examine the effects of care on the course of depression and anxiety in patients with seropositive RA and active disease. MATERIAL AND METHODS: A multicenter pragmatic randomized controlled trial was conducted over the course of 1 year with 224 patients. After baseline, five more visits followed. In the intervention group (IG), three were initially carried out by qualified rheumatological assistants. Depression, anxiety and patient satisfaction with outpatient care were looked at in detail. RESULTS: In the IG the anxiety symptoms significantly improved over 12 months (p = 0.036). The proportions of patients with anxiety also significantly changed in the IG (p < 0.001), while there was no change in the control group between baseline and month 12. The values of the depression scale did not differ significantly (p = 0.866). In terms of the information dimension of the satisfaction questionnaire, patients in the IG felt significantly better informed after 6 months (p = 0.013) and 12 months (p = 0.003). CONCLUSION: A positive effect of team-based care on the course of depression and anxiety in patients with seropositive RA and active disease could be shown.

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis.

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

Endocrine Prehabilitation.

We conceptualize and define endocrine and metabolic prehabilitation as enhancement of physical, psychosocial and social health, prior to a planned medical, surgical or radiotherapeutic endocrine/metabolic intervention, in order to ensure optimal therapeutic outcomes during and after the procedure. This is similar to, but different from the process of endocrine rehabilitation, which follows endocrine therapy. All health care professionals, working as a team, should take responsibility of endocrine prehabilitation.