Community paramedic hospital reduction and mitigation program: study protocol for a randomized pragmatic clinical trial.

BACKGROUND: New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization. METHODS: This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment. DISCUSSION: This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability. TRIAL REGISTRATION: ClinicalTrials.gov NCT05232799. Registered on 10 February 2022.

Moving Forward in the Next Decade: Radiation Oncology Sciences for Patient-Centered Cancer Care.

In a time of rapid advances in science and technology, the opportunities for radiation oncology are undergoing transformational change. The linkage between and understanding of the physical dose and induced biological perturbations are opening entirely new areas of application. The ability to define anatomic extent of disease and the elucidation of the biology of metastases has brought a key role for radiation oncology for treating metastatic disease. That radiation can stimulate and suppress subpopulations of the immune response makes radiation a key participant in cancer immunotherapy. Targeted radiopharmaceutical therapy delivers radiation systemically with radionuclides and carrier molecules selected for their physical, chemical, and biochemical properties. Radiation oncology usage of "big data" and machine learning and artificial intelligence adds the opportunity to markedly change the workflow for clinical practice while physically targeting and adapting radiation fields in real time. Future precision targeting requires multidimensional understanding of the imaging, underlying biology, and anatomical relationship among tissues for radiation as spatial and temporal "focused biology." Other means of energy delivery are available as are agents that can be activated by radiation with increasing ability to target treatments. With broad applicability of radiation in cancer treatment, radiation therapy is a necessity for effective cancer care, opening a career path for global health serving the medically underserved in geographically isolated populations as a substantial societal contribution addressing health disparities. Understanding risk and mitigation of radiation injury make it an important discipline for and beyond cancer care including energy policy, space exploration, national security, and global partnerships.

An 'Ayurveda-Biology' platform for integrative diabetes management.

ETHNOPHARMACOLOGICAL RELEVANCE: Diabetes is a multifactorial disease with complex multi-organ-multi-target crosstalk in the body. Currently, the theoretical assumptions framing the diabetes management strategies are reductionist and largely focus on reducing hyperglycemia through targeted molecular drugs. While they effectively reduce hyperglycemia, they are inadequate to address the multifactorial etiopathology, chronicity and systemic complications of diabetes. Therefore, a holistic and systemic approach is essential for its successful management. We hypothesize an integrative diabetes management strategy, combining holistic principles of diabetes management with its molecular understandings, would be more appropriate to fill this gap. The holistic disease management principles of Ayurveda, the Indian system of medicine, can play a pivotal role in this context. This narrative review discusses the scope of a trans-disciplinary ' Ayurveda-Biology ' approach for deepening the holistic understanding of the pathophysiology of diabetes as well as designing novel integrative strategies for managing diabetes and restoring whole body glucose homeostasis. METHODOLOGY: The article analyses the Ayurveda scheme of diabetes management and correlates it with the molecular understanding of its pathophysiology and management. The sources of information used in this article include classical texts of Ayurveda , medical books, published research articles and scientific databases like PubMed, Google Scholar, Science-Direct, etc. RESULTS: While Ayurveda and modern biomedicine uses different epistemology and ontology for describing diabetes, both the systems recognize the central role of gut and gut derived factors in postprandial glucose disposal and whole body glucose homeostasis. Essentially, the principles of both Ayurveda and modern biomedicine overlap at a gut centred view of diabetes management; and Gastro-intestinal mediated glucose disposal , a holistic concept of glucose metabolism, is emerging as a converging node for designing innovative integrative diabetes management strategies. CONCLUSIONS: An integrative disease management strategy, combining holistic and reductionist perspectives of traditional medicine and biology respectively, would be the prerogative for successful management of diabetes. Creating an ' Ayurveda-Biology' knowledge framework integrating the patient centred holistic management principles of Ayurveda and the molecular approaches of modern biology can give better insights into the biology of whole body glucose homeostasis and offer novel strategies for cost effective, holistic and multi-targeted management of diabetes.

A Call to Action to Address Disparities in Palliative Care Access: A Conceptual Framework for Individualizing Care Needs.

Palliative care is a values-driven approach for providing holistic care for individuals and their families enduring serious life-limiting illness. Despite its proven benefits, access and acceptance is not uniform across society. The genesis of palliative care was developed through a traditional Western lens, which dictated models of interaction and communication. As the importance of palliative care is increasingly recognized, barriers to accessing services and perceptions of relevance and appropriateness are being given greater consideration. The COVID-19 pandemic and recent social justice movements in the United States, and around the world, have led to an important moment in time for the palliative care community to step back and consider opportunities for expansion and growth. This article reviews traditional models of palliative care delivery and outlines a modified conceptual framework to support researchers, clinicians, and staff in evaluating priorities for ensuring individualized patient needs are addressed from a position of equity, to create an actionable path forward.

Applying a Client-centered Approach to Maternal and Neonatal Networks of Care: Case Studies from Urban and Rural Nigeria.

In Nigeria, two maternal and neonatal health Networks of Care (NOC) focus on extending the reach and quality of routine and emergency maternal and neonatal health services tailored to the different contexts. This paper uses the four domains of the NOC framework-Agreements and Enabling Environment, Operational Standards, Quality, Efficiency and Responsibility, and Learning and Adaptation-to describe the NOC, highlighting how each developed to address specific local needs. In Northern Nigeria, the NOC were established in collaboration among Clinton Health Access Initiative and the government to reduce maternal and neonatal morbidity and mortality. Health centers and communities in the network were supported to be better prepared to provide maternal and neonatal care, while birth attendants at all levels were empowered and equipped to stabilize and treat complications. The approach brought services closer to the community and facilitated rapid referrals. The NOC in Lagos State extended the reach of routine and emergency maternal and neonatal health services through organically developed linkages among registered traditional birth attendant clinics, private and public sector facilities, the Primary Healthcare Board, and the Traditional Medicine Board. Traditional birth attendants are registered, trained, and monitored by Apex Community Health Officers, whose responsibilities include collection and review of data and ensuring linkages to postpartum services, such as family planning and immunizations. While differing in their approaches, both NOC provide locally appropriate, pragmatic approaches to supporting women birthing in the community and encouraging institutional delivery to ensure that women and their babies have access to timely, appropriate, and safe services.

Dementia Care in Times of COVID-19: Experience at Fundació ACE in Barcelona, Spain.

BACKGROUND: Fundació ACE is a non-profit organization providing care based on a holistic model to persons with cognitive disorders and their families for 25 years in Barcelona, Spain. Delivering care to this vulnerable population amidst the COVID-19 pandemic has represented a major challenge to our institution. OBJECTIVE: To share our experience in adapting our model of care to the new situation to ensure continuity of care. METHODS: We detail the sequence of events and the actions taken within Fundació ACE to swiftly adapt our face-to-face model of care to one based on telemedicine consultations. We characterize individuals under follow-up by the Memory Unit from 2017 to 2019 and compare the number of weekly visits in 2020 performed before and after the lockdown was imposed. RESULTS: The total number of individuals being actively followed by Fundació ACE Memory Unit grew from 6,928 in 2017 to 8,147 in 2019. Among those newly diagnosed in 2019, most patients had mild cognitive impairment or mild dementia (42% and 25%, respectively). Weekly visits dropped by 60% following the suspension of face-to-face activity. However, by April 24 we were able to perform 78% of the visits we averaged in the weeks before confinement began. DISCUSSION: We have shown that Fundació ACE model of care has been able to successfully adapt to a health and social critical situation as COVID-19 pandemic. Overall, we were able to guarantee the continuity of care while preserving the safety of patients, families, and professionals. We also seized the opportunity to improve our model of care.

Exploring Current Evidence on the Past, the Present, and the Future of the Heart Team: A Narrative Review.

INTRODUCTION: Including healthcare professionals dealing with cardiovascular diseases, Heart Team is a concept/structure designed for selecting diagnostic strategies, facilitating therapeutic decisions, and improving cardiovascular outcomes in patients with complex heart pathologies, requiring input from different subspecialties and the necessity of a multidisciplinary approach. The aim of this narrative review is to search for and to summarize current evidence regarding Heart Team and to underline the future directions for the development of this concept. METHODS: We searched the electronic database of PubMed, SCOPUS, and Cochrane CENTRAL for studies including Heart Team. Forty-eight studies were included, if reference was made to Heart Team structure and functionality. RESULTS: We depicted the structure and the timeline of Heart Team, along with actual evidence-based recommendations from European Guidelines. We underlined the importance of quality of knowledge-sharing and decision-making inside the Team, analyzing bad decisions which did not reflect members' true beliefs due to "uniformity pressure, closed mindedness, and illusion of invulnerability." The observation that Guidelines' indications regarding Heart Team carry a level C indication underlines the very future of this Team: randomized controlled trials proving solid benefits in an evidence-based world. CONCLUSIONS: Envisioned as a tool for optimizing the management of various complex cardiovascular pathologies, Heart Team should simplify and facilitate the activity in the cardiovascular ward. Finally, these facts should be translated into better cardiovascular outcomes and a lower psychological distress among Team participants. Despite all future changes, there must always be a constant part: the patient should remain at the very center of the Team.

Creating World-Class Care and Service for Our Nation's Finest: How Veterans Health Administration Diffusion of Excellence Initiative Is Innovating and Transforming Veterans Affairs Health Care.

As the largest integrated health care system in the US, the Veterans Health Administration is dedicated to continually innovating its systems, technology, and practices to provide high-quality care to US veterans. In this article, I describe the Veterans Health Administration's Diffusion of Excellence Initiative, which involves an annual, systemwide competition to recognize Department of Veterans Affairs employees and identify promising practices for implementation in other Department of Veterans Affairs facilities or Veterans Integrated Service Networks. To demonstrate the reach and impact of the initiative, I highlight practices that are being implemented in 4 areas: 1) direct scheduling, 2) access to health care in rural areas, 3) access to mental health care, and 4) interactive and patient-centered care. In addition, I outline the primary components of the current transition plan to elevate lessons learned and transform the initiative from a nascent start-up to a sustainable part of the Veterans Health Administration's culture.

Evolving Changes in the Delivery of Health Services: A Place for Urological Homecare?

The ongoing pressure to improve quality while reducing costs is leading to increased uptake of various urological homecare models. Urological homecare can involve reductions in hospital usage and costs, traveling time for the patient, and hospital deaths and can improve patient experience and satisfaction.

Merging current health care trends: innovative perspective in aging care.

Current trends in health care delivery and management such as predictive and personalized health care incorporating information and communication technologies, home-based care, health prevention and promotion through patients' empowerment, care coordination, community health networks and governance represent exciting possibilities to dramatically improve health care. However, as a whole, current health care trends involve a fragmented and scattered array of practices and uncoordinated pilot projects. The present paper describes an innovative and integrated model incorporating and "assembling" best practices and projects of new innovations into an overarching health care system that can effectively address the multidimensional health care challenges related to aging patient especially with chronic health issues. The main goal of the proposed model is to address the emerging health care challenges of an aging population and stimulate improved cost-efficiency, effectiveness, and patients' well-being. The proposed home-based and community-centered Integrated Healthcare Management System may facilitate reaching the persons in their natural context, improving early detection, and preventing illnesses. The system allows simplifying the health care institutional structures through interorganizational coordination, increasing inclusiveness and extensiveness of health care delivery. As a consequence of such coordination and integration, future merging efforts of current health care approaches may provide feasible solutions that result in improved cost-efficiency of health care services and simultaneously increase the quality of life, in particular, by switching the center of gravity of health delivery to a close relationship of individuals in their communities, making best use of their personal and social resources, especially effective in health delivery for aging persons with complex chronic illnesses.

Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System.

Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.

The Role of Integrated Care in a Medical Home for Patients With a Fetal Alcohol Spectrum Disorder.

Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe preventable birth defects and intellectual and/or developmental disabilities resulting from prenatal alcohol exposure. The American Academy of Pediatrics has a previous clinical report in which diagnostic criteria for a child with an FASD are discussed and tools to assist pediatricians with its management can be found. This clinical report is intended to foster pediatrician awareness of approaches for screening for prenatal alcohol exposure in clinical practice, to guide management of a child with an FASD after the diagnosis is made, and to summarize available resources for FASD management.

Patient-Centered Care: Nursing Knowledge and Policy.

There has been much written about the importance of care that is centered on persons and their loved ones. Patient-centered care has been central to nursing practice and unique nursing knowledge. This central focus provides an opportunity for nurses to develop policies that may affect practice so that practice is consistent with a distinctive knowledge base. The purpose of this paper is to discuss patient-centered care and nursing theory.

Understanding care in the past to develop caring science of the future: a historical methodological approach.

In this paper, we explore how the development of historical research methodologies during the last centuries can contribute to more diverse and interdisciplinary research in future caring science, especially towards a care focus that is more person-centred. The adding of a historical approach by professional historians to the theory of person-centredness and person-centred care can develop knowledge that enables a more holistic understanding of the patient and the development of the patient perspective from the past until today. Thus, the aim was to show how developments within historical methodology can help us to understand elements of care in the past to further develop caring science in future. Historical research methodologies have advocated a "history from below" perspective, and this has enabled the evolution of systematic approaches to historical research that can be explored and critically analysed. Linked with this, the development of a more social and cultural oriented understanding of historical research has enabled historians to explore and add knowledge from a broader societal perspective. By focusing on the life of ordinary people and taking social and cultural aspects into account when trying to reconstruct the past, we can get a deeper understanding of health, care and medical development. However, an interdisciplinary research focus on person-centredness and person-centred care that includes professional historians can be challenging. In this paper, we argue that a historical perspective is necessary to meet the challenges we face in future delivery of health care to all people, in all parts of society in an ever more global world.

A computer template to enhance patient-centredness in multimorbidity reviews: a qualitative evaluation in primary care.

BACKGROUND: Computer templates for review of single long-term conditions are commonly used to record care processes, but they may inhibit communication and prevent patients from discussing their wider concerns. AIM: To evaluate the effect on patient-centredness of a novel computer template used in multimorbidity reviews. DESIGN AND SETTING: A qualitative process evaluation of a randomised controlled trial in 33 GP practices in England and Scotland examining the implementation of a patient-centred complex intervention intended to improve management of multimorbidity. A purpose-designed computer template combining long-term condition reviews was used to support the patient-centred intervention. METHOD: Twenty-eight reviews using the intervention computer template and nine usual-care reviews were observed and recorded. Sixteen patient interviews, four patient focus groups, and 23 clinician interviews were also conducted in eight of the 12 intervention practices. Transcripts were thematically analysed based on predefined core components of patient-centredness and template use. RESULTS: Disrupted communication was more evident in intervention reviews because the template was unfamiliar, but the first template question about patients' important health issues successfully elicited wide-ranging health concerns. Patients welcomed the more holistic, comprehensive reviews, and some unmet healthcare needs were identified. Most clinicians valued identifying patients' agendas, but some felt it diverted attention from care of long-term conditions. Goal-setting was GP-led rather than collaborative. CONCLUSION: Including patient-centred questions in long-term condition review templates appears to improve patients' perceptions about the patient-centredness of reviews, despite template demands on a clinician's attention. Adding an initial question in standardised reviews about the patient's main concerns should be considered.