Financial reimbursement and productivity metrics for pharmacist-led chronic care management services in rural practice settings.

BACKGROUND: The implementation of chronic care management (CCM) services has often been hindered by issues with reimbursement, raising concerns about sustainability. To date, little if any literature has examined the financial feasibility and sustainability of CCM services in rural practice settings. OBJECTIVE: Assess financial reimbursement and productivity metrics for pharmacist-led CCM services at a rural, medically underserved family medicine clinic. METHODS: This study retrospectively examined data from the clinic's CCM program from October 2020 through May 2021 and included total clinical encounters, minutes of pharmacist time spent on calls, CCM claims, work relative value units (wRVU), financial reimbursement, and overall personnel costs. RESULTS: Over an 8-month period, 46 patients were enrolled in CCM services. Of the 49 CCM calls placed during this time, 31 (63.3%) were billable, though only 20 (64.5% of billable calls) were ultimately reimbursed. Approximately 37% of pharmacist "time-on-task" was not billable. Compared to the $643 required to cover pharmacist time on CCM calls, $822 of reimbursement was collected. This $179 profit, or 27.8% return-on-investment, is similar to results from more urbanized practices. Furthermore, services were "net productive" in wRVU generation, which may appeal to physician stakeholders interested in such targets. CONCLUSIONS: Concerns about profitability and sustainability have prevented more widespread CCM implementation. In the present study, pharmacist-led CCM services achieved a 27.8% return-on-investment. Though rural-based CCM services may never attain significant profit margins, this data suggests they can still be financially self-sustaining and "net productive," all while providing high-quality patient care.

Trauma informed occupational therapy school practice with adolescents with social emotional and behavioural difficulties: findings of standardised measures / Trauma informando práticas escolares em terapia ocupacional com adolescentes em dificuldades socioemocionais e comportamentais: achados a partir de medidas padronizadas

Abstract Introduction Although non-standardized qualitative and quantitative reports from 39 Irish students aged 12 to 14 years, with complex social and emotional needs and their 13 teachers had established benefits of 'Movement Matters', an occupational therapy designed participatory curriculum for learning self-regulation in mainstream schools (National Behaviour Support Service, 2015a), standardized measures were required for quality assurance by the Irish Government funded service. Objective The relevance of findings of standardized attitude measurements on the impacts of an occupation focused intervention with a discrete school population in areas of social disadvantage are discussed. Method Findings of the 'Pupil Attitude to Self and School' (PASS) (Granada Learning, 2021) and 'Strengths and Difficulties Questionnaire' (SDQ) (Youth in Mind, 2021), both well-established standardized measures of attitude and behaviours completed (pre and post intervention) by teachers, parents and students are presented. Results No statistically significant differences were found between the standardized pre and post intervention measures. However, findings indicate a disparity between how these students in complex environments experience school in comparison to large UK study populations. Conclusion This paper discusses the use of these standardized measures for capturing impacts of an occupation focused intervention in a school environment. It calls for an increased appreciation on outcomes measurement related to the intervention's aim of providing experiences of meaningful participation and well-being. Further collaborative research on outcome measurement of participation of students in complex mainstream school environments is required.

Resumo Introdução Embora relatórios qualitativos e quantitativos não padronizados de 39 estudantes irlandeses, de 12 a 14 anos, com necessidades sociais e emocionais complexas e seus 13 professores tenham estabelecido benefícios de 'Movement Matters', uma terapeuta ocupacional projetou um currículo participativo para aprender autorregulação no ensino regular (National Behaviour Support Service, 2015a), tendo sido necessárias medidas padronizadas para garantia de qualidade do serviço financiado pelo governo Irlandês. Objetivo Discutir a relevância dos resultados das medidas de atitudes padronizadas sobre os impactos de uma intervenção focada na ocupação com uma população escolar em áreas de desvantagem social. Método São apresentados dados do 'Pupil Attitude to Self and School' (PASS) (Granada Learning, 2021) e 'Strengths and Difficulties Questionnaire' (SDQ) (Youth in Mind, 2021), ambas medidas padronizadas bem estabelecidas de atitude e comportamentos (pré e pós-intervenção) por professores, pais e alunos. Resultados Não foram encontradas diferenças estatisticamente significativas entre as medidas padronizadas pré e pós-intervenção. No entanto, os resultados indicam uma disparidade sobre como esses alunos vivenciam a escola em ambientes complexos, em comparação com estudos de grandes populações no Reino Unido. Conclusão Este artigo discute o uso dessas medidas padronizadas para compreender os impactos de uma intervenção focada na ocupação em um ambiente escolar. Observa-se a necessidade de uma maior apreciação da medição de resultados relacionados ao objetivo da intervenção ao fornecer experiências de participação e bem-estar significativos. São necessárias mais investigações colaborativas sobre a medição dos resultados da participação dos alunos em ambientes complexos de escolas regulares.

Humanitarian Surgical Missions: Guidelines for Successful Anesthesia Support.

Many anesthesiologists and CRNAs are provided little training in preparing for a humanitarian surgical mission. Furthermore, there is very little published literature that outlines how to plan and prepare for anesthesia support of a humanitarian surgical mission. This article attempts to serve as an in-depth planning guide for anesthesia support of humanitarian surgical missions. Recommendations are provided on planning requirements that most anesthesiologists and CRNAs do not have to consider on routinely, such as key questions to be answered before agreeing to support a mission, ordering and shipping supplies and medications, travel and lodging arrangements, and coordinating translators in a host nation. Detailed considerations are included for all the phases of mission planning: advanced, mission-specific, final, mission-execution, and postmission follow-up planning, as well as a timeline in which to complete each phase. With the proper planning and execution, the anesthetic support of humanitarian surgical missions is a very manageable task that can result in an extremely satisfying sense of accomplishment and a rewarding experience. The authors suggest this article should be used as a reference document by any anesthesia professional tasked with planning and supporting a humanitarian surgical mission.

Deprivation status and the hospital costs of an emergency medical admission.

BACKGROUND: Deprivation has been shown to adversely affect health outcomes. However, whether deprivation increases hospitalisation costs is uncertain. We have examined the relationship between deprivation and the costs of emergency medical admissions in a single centre between 2008-2014. METHODS: We calculated the total hospital costs of emergency admissions related to their deprivation status, based on area of residence (Electoral Division - small census area). We used truncated Poisson and quantile regression methods to examine relationships between predictor variables and total hospital episode costs. RESULTS: Over the study period, 29,508 episodes were recorded in 15,932 patients. Compared with the least deprived (Q1), the incidence rate ratios (IRR) for annual costs were increased to Q3 1.15 (95% CI: 1.12, 1.19), Q4 2.39 (95% CI: 2.30, 2.49) and Q5 2.76 (95% CI: 2.68, 2.85). The margin statistic cost estimate per thousand population increased from 183.8 K€ in Q1 to 507.9 K€ in Q5. The total bed days/1000 population increased as follows (compared with Q1): Q3 IRR 1.41 (95% CI: 1.37, 1.45), Q4 1.96 (95% CI: 1.89, 2.03) and Q5 3.04 (95% CI: 2.96, 3.12). The margin statistic bed day estimate (/1000 population) increased from 218.7 in Q1 to 664.0 in Q5. CONCLUSION: Deprivation status had a profound impact on total hospital costs for emergency medical admissions. This was primarily mediated through a tripling of total bed days in the most deprived groups.

An Occupational Therapy and Teaching Partnership: Applying a Scholarship of Practice Model.

Occupational therapists must generate knowledge and evidence that relates specifically to their practice context especially when there is a paucity of literature for emerging areas of practice. This paper describes the process of adopting a scholarship of practice approach with other professionals to generate evidence for practice in mainstream post primary school settings with students with social, emotional and behavioral difficulties (SEBD). Scholarship of practice and clinical reasoning are closely intertwined as therapists generate evidence on their practice to make informed decisions and judgments. In this paper, there are a number of important concepts needing to be highlighted for their meaning in this specific context.

The Relationship between Resource Utilization, Clinical Risk and Hospital Costs for Emergency Medical Admissions.

There has been little study of the relationship between resource utilisation, clinical risks and hospital costs in acute medicine with the question remaining as to whether current funding models reflect patient acuity. We examined the relationship between resource use for investigations/allied professional and patient episode costs in all emergency medical admissions admitted to our institution during 2008-2013. Univariate estimates were compared with a multivariate model adjusted for major cost predictors. Interestingly, the model adjusted cost estimates changed considerably when compared with univariate analysis. We used both linear and non-linear (quantile regression) methods due to the highly skewed nature of hospital costs. The data suggested that hospital episode costs were predictable and driven by objective measures of clinical complexity. The use of expensive investigations and healthcare professional time was secondary to the clinical acuity. Thus, cost was heavily weighted towards higher complexity, and lower resource utilisation associated with lower risk patient groups. However, the non-linear nature of the costings would caution against simple predictor models and non-linear techniques such as quantile regression may, as we have demonstrated, prove superior in defining the underlying relationships.

Factors predicting the hospital episode costs of emergency medical admissions.

BACKGROUND: Important outcome predictor variables for emergency medical admissions are the Manchester Triage Category, Acute Illness Severity, Chronic Disabling Disease and Sepsis Status. We have examined whether these are also predictors of hospital episode costs. METHODS: All patients admitted as medical emergencies between January 2008 and December 2012 were studied. Costs per case were adjusted by reference to the relative cost weight of each diagnosis related group (DRG) but included all pay costs, non-pay costs and infra-structural costs. We used a multi-variate logistic regression with generalized estimating equations (GEE), adjusted for correlated observations, to model the prediction of outcome (30-day in-hospital mortality) and hospital costs above or below the median. We used quantile regression to model total episode cost prediction over the predictor distribution (quantiles 0.25, 0.5 and 0.75). RESULTS: The multivariate model, using the above predictor variables, was highly predictive of an in-hospital death-AUROC of 0.91 (95% CI: 0.90, 0.92). Variables predicting outcome similarly predicted hospital episode cost; however predicting costs above or below the median yielded a lower AUROC of 0.73 (95% CI: 0.73, 0.74). Quantile regression analysis showed that hospital episode costs increased disproportionately over the predictor distribution; ordinary regression estimates of hospital episode costs over estimated the costs for low risk and under estimated those for high-risk patients. CONCLUSION: Predictors of outcome also predict costs for emergency medical admissions; however, due to costing data heteroskedasticity and the non-linear relationship between dependant and predictor variables, the hospital episode costs are not as easy to predict based on presentation status.

Milestone-specific, Observed data points for evaluating levels of performance (MODEL) assessment strategy for anesthesiology residency programs.

BACKGROUND: Anesthesiology residency programs will be expected to have Milestones-based evaluation systems in place by July 2014 as part of the Next Accreditation System. METHODS: The San Antonio Uniformed Services Health Education Consortium (SAUSHEC) anesthesiology residency program developed and implemented a Milestones-based feedback and evaluation system a year ahead of schedule. It has been named the Milestone-specific, Observed Data points for Evaluating Levels of performance (MODEL) assessment strategy. RESULTS: The "MODEL Menu" and the "MODEL Blueprint" are tools that other anesthesiology residency programs can use in developing their own Milestones-based feedback and evaluation systems prior to ACGME-required implementation. Data from our early experience with the streamlined MODEL blueprint assessment strategy showed substantially improved faculty compliance with reporting requirements. CONCLUSIONS: The MODEL assessment strategy provides programs with a workable assessment method for residents, and important Milestones data points to programs for ACGME reporting.