Integrated Care: A Person-Centered and Population Health Strategy for the COVID-19 Pandemic Recovery and Beyond.

The COVID-19 pandemic has mandated a re-imagination of how healthcare is administered and delivered, with a view towards focusing on person-centred care and advancing population health while increasing capacity, access and equity in the healthcare system. These goals can be achieved through healthcare integration. In 2019, the University Health Network (UHN), a consortium of four quaternary care hospitals in Ontario, Canada, established the first stage of a pilot program to increase healthcare integration at the institutional level and vertically with other primary, secondary and tertiary institutions in the Ontario healthcare system. Implementation of the program was accelerated during the COVID-19 pandemic and demonstrated how healthcare integration improves person-centred care and population health; therefore serving as the foundation for a health system response for the COVID-19 pandemic recovery and beyond.

Preliminary Results of the Adoption and Application of the Integrated Comprehensive Care Bundle Care Program When Treating Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: St. Joseph's Health System has implemented an integrated comprehensive care bundle care (ICC) program with the hopes that it would improve patients' care while reducing overall costs. The aim of this analysis was to evaluate the performance of the ICC program within patients admitted with chronic pulmonary obstructive disease (COPD). METHODS: We conducted a retrospective observational cohort study comparing ICC patients to non-ICC patients admitted to St. Joseph's Healthcare Hamilton for COPD being discharged with support services between June 2012 and March 2015, using administrative data. Confounding adjustment was achieved through the use of propensity score matching. Medical resource utilizations during the initial hospitalization and within the 60 days following discharge were compared using regression models. RESULTS: All 76 patients who entered the ICC program (100.0%) were matched 1 : 1 to 76 eligible non-ICC patients (28.4%). Length of stay (6.47 [7.29] versus 9.55 [10.21] days) and resource intensity weights (1.16 [0.80] versus 1.64 [1.69]) were lower in the ICC group within the initial hospitalization but, while favoring the ICC program, healthcare resource use tended not to differ statistically following discharge. INTERPRETATION: The ICC program was able to reduce initial medical resource utilization without increasing subsequent medical resource use.

Integrated Comprehensive Care - A Case Study in Nursing Leadership and System Transformation.

Calls for transformational change of our healthcare system are increasingly clear, persuasive and insistent. They resonate at all levels, with those who fund, deliver, provide and receive care, and they are rooted in a deep understanding that the system, as currently rigidly structured, most often lacks the necessary flexibility to comprehensively meet the needs of patients across the continuum of care. The St. Joseph's Health System (SJHS) Integrated Comprehensive Care (ICC) Program, which bundles care and funding across the hospital to home continuum, has reduced fragmentation of care, and it has delivered improved outcomes for patients, providers and the system. This case study explores the essential contribution of nursing leadership to this successful transformation of healthcare service delivery.

Management of Hospital Formularies in Ontario: Challenges within a Local Health Integration Network.

BACKGROUND: Expenditures on drugs dispensed and administered to patients in Canadian hospitals have been estimated at $2.4 billion per year. Pharmacy and therapeutics (P&T) committees play a key role in the evaluation and management of drug therapies in this setting. Hospitals differ with respect to the composition of these committees, their members' expertise, and the processes used for making formulary decisions. OBJECTIVES: To examine the current processes for formulary drug review from the perspective of P&T committees and their individual members, and to examine the needs and preferences of these stakeholders related to evidence review and potential collaborative drug review processes within a large Local Health Integration Network (LHIN) in Ontario. METHODS: Twenty-three sites within 10 hospital corporations in LHIN 4 (Hamilton Niagara Haldimand Brant) were recruited. A 2-part questionnaire was developed and pretested for clarity and comprehensiveness. The institution profile section of the questionnaire was to be completed by pharmacy directors and the P&T section by committee members. RESULTS: Ten pharmacy directors and 28 committee members representing 10 P&T committees responded. A mean of 6.4 new drug requests were reviewed annually by each P&T committee. Across the LHIN, the workload associated with reviewing submissions for new drugs to be added to the formulary represented 0.84 full-time equivalent. The quality of clinical evidence in the drug submissions was rated more favourably than the quality of economic evidence; furthermore, the use of economic evidence was limited by a lack of health economics expertise within the committees. A centralized review process for the LHIN was perceived as beneficial to improve efficiency, the quality of review, and standardization, and also to reduce costs. CONCLUSIONS: Across the Hamilton Niagara Haldimand Brant LHIN, considerable time and resources are spent on the review of potential new drugs for addition to the hospitals' formularies. A standardized formulary review process, with greater use of provincial and national drug reviews, would likely benefit all LHINs.

CONTEXTE: Les dépenses pour les médicaments distribués et administrés aux patients dans les hôpitaux canadiens ont été évaluées à 2,4 milliards de dollars par année. Les comités de pharmacologie et de thérapeutique jouent un rôle central dans l'analyse et la prise en charge des pharmacothérapies dans ce milieu. La composition de ces comités et l'expertise de leurs membres varient d'un hôpital à l'autre, tout comme les processus qui y sont employés pour prendre des décisions à propos de la liste des médicaments. OBJECTIFS: Étudier les processus actuels d'ajout de médicaments à la liste locale du point de vue des comités de pharmacologie et de thérapeutique et de leurs membres. Examiner les besoins et préférences de ces parties prenantes quant à l'analyse des données probantes et aux potentiels processus collaboratifs d'évaluation des médicaments au sein d'un important réseau local d'intégration des services de santé (RLISS) ontarien. MÉTHODES: Vingt-trois établissements dans 10 organisations hospitalières du RLISS 4 (Hamilton Niagara Haldimand Brant) ont été retenus. On a élaboré un questionnaire de deux parties qui a été testé au préalable pour en vérifier la clarté et l'exhaustivité. La section sur le profil de l'établissement devait être remplie par les directeurs de pharmacie et celle sur la pharmacologie et la thérapeutique devait l'être par les membres des comités. RÉSULTATS: Dix directeurs de pharmacie et 28 membres représentant 10 comités de pharmacologie et de thérapeutique ont répondu. En moyenne, 6,4 nouvelles demandes d'ajout de médicament étaient analysées annuellement par chaque comité. Dans l'ensemble du RLISS, la charge de travail nécessaire à l'analyse des demandes d'ajout de nouveaux médicaments à la liste locale représentait 0,84 d'un poste équivalent temps plein. La qualité des données cliniques probantes dans les demandes d'ajout était considérée plus favorablement que celle des données économiques. De plus, comme les membres des comités ne possédaient pas l'expertise nécessaire en économie de la santé, l'utilisation des données probantes à ce sujet était limitée. Un processus centralisé d'analyse pour le RLISS était perçu comme avantageux pour améliorer l'efficience, la qualité de l'analyse et la normalisation ainsi que pour réduire les coûts. CONCLUSIONS: Dans l'ensemble du RLISS de Hamilton Niagara Haldimand Brant, beaucoup de ressources et de temps sont accordés à évaluer l'ajout de médicaments à la liste locale. Tous les RLISS tireraient sûrement profit d'un processus normalisé d'ajout à la liste locale des médicaments ainsi que d'une meilleure utilisation des évaluations réalisées par les organismes provinciaux et national.

The Integrated Comprehensive Care Program: A Novel Home Care Initiative After Major Thoracic Surgery.

The objective of the study was to evaluate the Integrated Comprehensive Care (ICC) program, a novel health system integration initiative that coordinates home care and hospital-based clinical services for patients undergoing major thoracic surgery relative to traditional home care delivery. Methods included a pilot retrospective cohort analysis that compared the intervention cohort (ICC), composed of all patients undergoing major thoracic surgery in the 2012-2013 fiscal year with a control cohort, who underwent surgery in the year before the initiation of ICC. Length of stay, hospital costs, readmission, and emergency room visit data were stratified by degree and approach of resection and compared using univariate logistic regression analysis. A total of 331 patients under ICC and 355 control patients were enrolled. Hospital stay was significantly shorter in patients under video-assisted thoracoscopic surgery (VATS) ICC (sublobar median 3 vs 4 days, P = 0.013; lobar median 4 vs 5 days, P = 0.051) but not for open resections. The frequency of emergency room visits within 60 days of surgery was lower for all stratification groups in the ICC cohort, except for VATS sublobar (25.7% control vs 13.9% ICC, P = 0.097). There were no significant differences in 60-day readmission frequency in any subcohort. The mean inpatient case cost was significantly lower for ICC VATS sublobar resections ($8505.39 vs $11,038.18, P = 0.007), with the other resection types trending lower for ICC but nonsignificant. In conclusion, a hospital-based, postdischarge, patient-centered program could potentially result in shorter hospital stay, fewer readmission and emergency room visits, costsavings, and no increase in adverse postdischarge outcomes after major thoracic surgery.

Response to a Serious Flood: The St Joseph's Healthcare Experience.

Water spread like liquid fire damaging more than 60,000 sq. ft. of clinical and support space, bringing the emergency department (ED) and operating rooms at St Joe's to an abrupt halt. Staff mobilized immediately, calling a hospital-wide Code Aqua (flood) and Code Green (evacuation) for the ED, and launching into action to save equipment and supplies worth millions of dollars. Our path to recovery has been difficult, but we have emerged stronger as an organization. The urgent necessity of rethinking care led to radical innovation, particularly in the flow and care of patients admitted through the ED.

Overlap in speech-language and reading services for kindergartners and first graders.

PURPOSE: Speech-language pathologists (SLPs) and reading professionals provide educational services to children who are at risk for reading difficulties, although these professions do not necessarily coordinate efforts. To date, there is limited evidence regarding the proportion of children who receive services from both professionals. The current study reports the prevalence and overlap of speech-language and reading services provided to kindergartners and first graders in Virginia. METHOD: This study analyzed a population-level database of reading screening scores from 74,730 kindergartners and 75,088 first graders. Information regarding the speech-language services received by these children was obtained. Prevalence rates of speech-language impairment, reading risk, and comorbidity were calculated. The distribution of children receiving speech-language services across categories of reading competence was examined. RESULTS: Findings indicated that ∼6% of the children received speech-language services and 11.1% of the kindergartners and 13.7% of the first graders received reading services. One-quarter of the children receiving speech-language services also received reading services. Furthermore, children receiving speech-language services received reading services at twice the rate of children who were not receiving speech-language services in both kindergarten (23.1% vs. 9.1%) and first grade (25.2% vs. 11.3%). CLINICAL IMPLICATIONS: This study provides empirical support for improving coordination between SLPs and reading professionals.

Shared-reading dynamics: mothers' question use and the verbal participation of children with specific language impairment.

PURPOSE: In this study, the authors used sequential analysis to explore bidirectional and dynamic dependencies between mothers' question use and children's verbal participation during shared reading. METHOD: The sample was composed of mothers and their preschool-age children with specific language impairment (SLI; n = 14). Each mother and child extratextual utterance was transcribed and coded. Mother utterances were coded as "questions" or "other"; in turn, questions were coded for cognitive challenge and topic directiveness. Child utterances were coded as "verbal participation" (related to the book) or "other"; utterances designated as verbal participation were also coded for level of production (minimal, low, high) on the basis of their mean length of utterance. RESULTS: Descriptive data show variability in mothers' question use and some variability in the level of children's verbal participation during shared reading. However, mothers' question use did not facilitate higher levels of verbal participation by children. Furthermore, the level of children's verbal participation did not influence the cognitive challenge and topic directiveness of mothers' question use. CONCLUSIONS: The findings were contrary to hypotheses and collectively suggest potentially unique and challenging verbal dynamics between mothers and their young children with SLI during shared-reading experiences. Future directions for research are discussed.

Achieving environmental excellence through a multidisciplinary grassroots movement.

St. Joseph's Healthcare Hamilton (SJHH) supports a grassroots green team, called Environmental Vision and Action (EVA). Since the creation of EVA, a healthy balance between corporate projects led by corporate leaders and grassroots initiatives led by informal leaders has resulted in many successful environmental initiatives. Over a relatively short period of time, environmental successes at SJHH have included waste diversion programs, energy efficiency and reduction initiatives, alternative commuting programs, green purchasing practices, clinical and pharmacy greening and increased staff engagement and awareness. Knowledge of social movements theory helped EVA leaders to understand the internal processes of a grassroots movement and helped to guide it. Social movements theory may also have broader applicability in health care by understanding the passionate engagement that people bring to a common cause and how to evolve sources of opposition into engines for positive change. After early successes, as the limitations of a grassroots movement began to surface, the EVA team revived the concept of evolving the grassroots green program into a corporate program for environmental stewardship. It is hard to quantify the importance of allowing our staff, physicians, volunteers and patients to engage in changes that they feel passionately about. However, at SJHH, the transformation of a group of people unsatisfied with the organization's environmental performance into an 'engine for change' has led to a rapid improvement in environmental stewardship at SJHH that is now regarded as a success.

Pneumonia observational incidence and treatment: a multidisciplinary process improvement study.

BACKGROUND: Little information is available on the types, causes, and treatment of pneumonia in intensive care unit patients in usual clinical practice. OBJECTIVE: To characterize treatment of patients with presumed pneumonia in a tertiary care intensive care unit and to identify potential areas for improvement in care. METHODS: In a prospective, cohort study, the sample consisted of all consecutive patients treated in an intensive care unit during a 3-month period. For patients with presumed pneumonia, data were collected on incidence of pneumonia, diagnostic investigations, microbial isolates, and antibiotics prescribed. RESULTS: Of 194 admissions, 73 patients were treated for pneumonia: 47 had community-acquired pneumonia; 12 had hospital-acquired pneumonia; 12 had ventilator-associated pneumonia, both early (7) and late (5); and 2 had intensive care unit-acquired pneumonia. Approximately 71% of patients had microbiological tests performed. Among 54 microbial isolates, 51.9% were gram-positive bacteria, 31.5% were gram-negative bacteria, and 9.3% were Candida species. The most commonly used antimicrobials were quinolones (54 of 192 prescriptions) and cephalosporins (33); each patient received a median of 3 antibiotics. CONCLUSIONS: Most cases of pneumonia were community acquired. The most common causative organisms were gram-positive cocci. Four quality improvement strategies were rationalization of antibiotic use during rounds, nurses' reporting of culture results, review of antibiotic appropriateness by a pharmacist, and redesign of the clinical information system.