Colorectal cancer survivorship care plans: Variations in documentation and posttreatment surveillance recommendations.

BACKGROUND: Survivorship care plans (SCP) should outline pertinent information about cancer treatment and follow-up. METHODS: We descriptively analyzed the content of 74 colorectal cancer SCPs completed as part of a randomized, controlled trial of SCPs at an academic and community cancer center. Surveillance recommendations were compared with American Cancer Society, American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines. RESULTS: SCP information provided in >80% of the plans included participant age, cancer diagnosis, details, and side-effects of treatment (surgery, chemotherapy, radiation) and health promotion recommendations. SCP content documented less frequently included predisposing conditions, genetic counseling/testing information and staging. Posttreatment surveillance recommendations were documented in >90% SCPs. For stage 2-3 cancer, rates of guideline concordant recommendations were 100% for colonoscopy surveillance (Year 1 only), 87% for imaging surveillance, 65% for carcinoembryonic antigen surveillance, and 33% for follow-up visits. Excluding colonoscopy, >15 unique recommendations were listed for each modality across stages and sites, with more variation at the academic site. CONCLUSIONS: SCPs consistently recorded information about cancer diagnosis and treatment but omitted critical information about cancer-specific details denoting risk. Surveillance recommendations varied considerably between cancer centers. Future work to improve the consistency of surveillance recommendations documented in SCPs may be needed.

Examining the hurdles in defining the practice of Nurse Navigators.

BACKGROUND: Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care. PURPOSE: A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident. DISCUSSION: Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance. CONCLUSION: Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

Addressing Care Continuity and Quality Challenges in the Management of Hypertension: Case Study of the Private Health Care Sector in Kenya.

BACKGROUND: Hypertension is a major risk factor of cardiovascular disease and a leading cause of morbidity and mortality globally. In Kenya, the rise of hypertension strains an already stretched health care system that has traditionally focused on the management of infectious diseases. Health care provision in this country remains fragmented, and little is known about the role of health information technology in care coordination. Furthermore, there is a dearth of literature on the experiences, challenges, and solutions for improving the management of hypertension and other noncommunicable diseases in the Kenyan private health care sector. OBJECTIVE: The aim of this study is to assess stakeholders' perspectives on the challenges associated with the management of hypertension in the Kenyan private health care sector and to derive recommendations for the design and functionality of a digital health solution for addressing the care continuity and quality challenges in the management of hypertension. METHODS: We conducted a qualitative case study. We collected data using in-depth interviews with 18 care providers and 8 business leads, and direct observations at 18 private health care institutions in Nairobi, Kenya. We analyzed the data thematically to identify the key challenges and recommendations for technology-enabled solutions to support the management of hypertension in the Kenyan private health sector. We subsequently used the generated insights to derive and describe the design and range of functions of a digital health wallet platform for enabling care quality and continuity. RESULTS: The management of hypertension in the Kenyan private health care sector is characterized by challenges such as high cost of care, limited health care literacy, lack of self-management support, ineffective referral systems, inadequate care provider training, and inadequate regulation. Care providers lack the tools needed to understand their patients' care histories and effectively coordinate efforts to deliver high-quality hypertension care. The proposed digital health platform was designed to support hypertension care coordination and continuity through clinical workflow orchestration, decision support, and patient-mediated data sharing with privacy preservation, auditability, and trust enabled by blockchain technology. CONCLUSIONS: The Kenyan private health care sector faces key challenges that require significant policy, organizational, and infrastructural changes to ensure care quality and continuity in the management of hypertension. Digital health data interoperability solutions are needed to improve hypertension care coordination in the sector. Additional studies should investigate how patients can control the sharing of their data while ensuring that care providers have a holistic view of the patient during any encounter.

Real-world Compliance With Percutaneous Tibial Nerve Stimulation Maintenance Therapy in an American Population.

OBJECTIVE: To evaluate percutaneous tibial nerve stimulation (PTNS) maintenance therapy dropout rates and identify factors associated with compliance in an American population. METHODS: We retrospectively queried our PTNS database for patients from 2014-2019. Demographic, relevant clinical, and visit data were collected. Maintenance therapy was patient-driven and frequency of sessions was tapered based on symptomology. Upon completion of 12 initial sessions, we assessed dropout from maintenance at 3, 6, 9, and 12 months. Multiple variables were tested for correlation with dropout in patients continuing maintenance therapy for 1 year vs those who dropped out. RESULTS: One hundred and sixty-three PTNS patients were identified, of which 104 completed initial therapy and 81 proceeded with maintenance therapy. At 3, 6, 9, and 12 months, maintenance continuation rates were 77.8% (63/81), 58.0% (47/81), 45.6% (37/81), and 39.5% (32/41), respectively. Primary reasons for dropout were worsening of urinary symptoms/lack of efficacy (n = 21), time commitment (n = 9), loss of insurance (n = 5), medical comorbidities (n = 4), request for alternative OAB treatment (n = 2), and unknown (n = 8). On both univariate and multivariate analysis, perceived symptom improvement (P<.01; HR = 0.02, P< .01) was associated with continuing maintenance therapy. On only univariate analysis, neurological history (P = .02) and multiple sclerosis history (0.02) were associated with continuing therapy. CONCLUSION: Only 39.5% of patients continue to undergo maintenance PTNS therapy after 1 year. Future studies are required to understand and ameliorate factors for low compliance in PTNS maintenance therapy.

Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development?

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.

Process lessons from evaluating a combined continuity of carer and home birth scheme.

INTRODUCTION: Continuity of midwifery carer improves outcomes, but there is significant variation in how such schemes are implemented and evaluated cross-culturally. The Angus home birth scheme in Scotland incorporates continuity of carer throughout pregnancy, labor, birth, and the postnatal period. METHODS: Manual maternity case note review to evaluate the 80% continuity of carer and 3% planned home birth rate targets. RESULTS: Of 1466 women booking for maternity care, 69 joined the scheme. Forty-four had a planned home birth (3% overall), of whom seven were originally deemed ineligible. Of the 44, eight (18%) also achieved 80% continuity of carer with the primary midwife; by including a home birth team colleague, the continuity rate rose to 73%. Women whose care achieved home birth and continuity targets had lower deprivation scores. Eligibility issues, women's changing circumstances, and data recording lapses were complicating issues. CONCLUSIONS: Targets must be both feasible and meaningful and should be complemented by assessing a broad range of outcomes while viewing the scheme holistically. By expanding eligibility criteria, the home birth rate target was met; including input from a home birth team colleague in the calculation meant the continuity target was nearly met. With dedicated and competent staff, adequate resource and political support, and when considered in the round, the scheme's viability within local services was confirmed. Other generalizable learning points included the need to standardize definitions and data recording methods. Comparability across schemes helps grow the evidence base so that the links between processes and outcomes can be identified.

Better continuity of care improves the quality of end-of-life care among elderly patients with end-stage renal disease.

Continuity of care (COC) has been emphasized in research on terminal cancer patients to increase the quality of end-of-life care; however, limited research has been conducted on end-stage renal disease patients. We applied a retrospective cohort design on 29,095 elderly patients with end-stage renal disease who died between 2005 and 2013. These patients were identified from the National Health Insurance Research Database of Taiwan. The provider Continuity of Care Index (COCI) and site COCI were calculated on the basis of outpatient visits during the 6-12 months before death. We discovered that increases in the provider COCI were significantly associated with reductions in health expenditures after adjusting for confounders, especially in inpatient and emergency departments, where the treatment intensity is high. Higher provider and site COC were also associated with lower utilization of acute care and invasive treatments in the last month before death. Provider COC had a greater effect on end-of-life care expenditures than site COC did, which indicated significant care coordination gaps within the same facility. Our findings support the recommendation of prioritizing the continuity of end-of-life care, especially provider continuity, for patients with end-stage renal disease.

Longitudinal continuity of care during antenatal and delivery in the Volta Region of Ghana.

OBJECTIVE: To determine the extent of longitudinal continuity of care (CoC) during pregnancy and delivery in the Volta Region of Ghana. METHODS: Longitudinal data were used from the National Health Insurance Claims Dataset for the period January to December 2013 for pregnant women who sought antenatal and delivery care in the region. Pregnant women who delivered at a health facility with at least three visits were included in the study. Five CoC indices were calculated for each pregnant woman. RESULTS: Of the 14 474 pregnant women included in the study, 58.4% had perfect CoC. Mean CoC indices were: most frequent provider continuity (MFPC) 0.82 ± 0.25; modified, modified continuity index (MMCI) 0.86 ± 0.20; continuity of care index (COCI) 0.76 ± 0.30; sequential continuity index (SECON) 0.80 ± 0.28; and place of delivery continuity (PDC) 0.68 ± 0.41. CONCLUSION: There are relatively medium to high levels of CoC indices during pregnancy and delivery, with place of delivery CoC having the lowest score, an indication that more pregnant women switched providers during delivery. There is a need for policy to ensure CoC during pregnancy.

Project 20: Midwives' insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how.

INTRODUCTION: Continuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems. OBJECTIVE: To explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women's outcomes. DESIGN: Realist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London. FINDINGS: Three main themes were identified: 'Perceptions of the model of care, 'Tailoring the service to meet women's needs', 'Going above and beyond'. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women's outcomes, and how women with different social risk factors respond to these mechanisms. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Overall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women's outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.

Moving forward after cancer: successful implementation of a colorectal cancer patient-centered transitions program.

PURPOSE: Cancer survivors transitioning between academic comprehensive cancer systems and community general practice settings are vulnerable to discontinuity, inconsistency and variation in care, inappropriate surveillance testing, and a sense of isolation and loss. Though these issues have been well recognized for over a decade and a half in the survivorship, oncologic, and health services literature, there remains a dearth of positive examples of models that have been well received by both the transitioned patient and the providers on either side of the handoff. We herein describe a sustained positive example of a transitions program. This program centers on standardized and personalized survivorship care plans (SCP) to guide follow-up care and recovery. METHODS: Following the province-wide introduction of a transitions program for treated stages II and III colorectal cancer (CRC) patients, a post-implementation survey was mailed to transitioned patients with the primary outcome evaluated the patients' perception of improved continuity of care and the main instrument used the Patient Continuity of Care Questionnaire. This was compared against a previously published pre-implementation historical control. RESULTS: The data presented comparing pre- and post-implementation patient cohorts reflect significantly improved patient-reported perceptions regarding the enhanced continuity and coordination of their follow-up and survivorship care after the province-wide introduction of a formal transitions process. This SCP intervention has been sustained post implementation. CONCLUSIONS: Using, as a starting-point, a standardized electronically SCP, CancerCare Manitoba has successfully facilitated a jurisdiction-wide implementation of a scalable, reproducible, and adaptable transitions program. IMPLICATIONS FOR CANCER SURVIVORS: This intervention at the time of transition back to the community has enhanced CRC survivor perception of continuity and coordination of follow-up care.

Initial Outcomes of an Online Continuing Education Series Focused on Post-treatment Cancer Survivorship Care.

There is a growing number of post-treatment cancer survivors in the USA. Cancer survivors can have a variety of care needs and health care professionals must be prepared to meet these needs. The American Cancer Society (ACS) and the George Washington University (GW) Cancer Center developed The Cancer Survivorship E-Learning Series for Primary Care Providers (E-Learning Series) to address the need for cancer survivorship training and education among health care professionals with a focus on primary care. The GW Cancer Center analyzed evaluation data from 1341 learners who voluntarily completed a module pre- and post-assessment between April 15, 2013, and December 31, 2017, to assess differences in self-rated confidence, on a five-point Likert scale, to meet learning objectives. Descriptive statistics characterize the sample and paired samples t tests were used to assess any statistically significant differences from pre to post (p < 0.05). Most learners were nurses (75.19%) and a majority of learners worked in oncology (74.68%) followed by primary care (11.60%). At pre-assessment, the module with the lowest mean self-confidence rating was 3.16 (SD = 0.81) and the highest was 3.60 (SD = 0.73). At post-assessment, module means in self-confidence rating ranged from 4.08 (SD = 0.46) to 4.26 (SD = 0.56). All differences were statistically significant (p < 0.0001). Results highlight gaps in confidence among health care professionals regarding cancer survivorship care and the need for continuing education. There is also a need for additional uptake of the E-Learning Series among primary care providers. Results suggest that the E-Learning Series is an effective educational tool that increases learners' confidence in providing cancer survivorship care.

Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework.

PROBLEM: Midwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow. BACKGROUND: It is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services. AIM: We aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings. METHODS: Data were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework. FINDINGS: Good quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes. DISCUSSION: Midwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework. CONCLUSION: The QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care.

Acknowledging the primacy of continuity of care experiences in midwifery education.

BACKGROUND: Continuity of midwifery care is the best maternity care model for women at any risk level, and there is a global imperative to improve access to midwifery-led care. However, diverse perspectives about how best to prepare graduates for working in midwifery continuity of care models persist. The continuity of care experience standard in Australia was anticipated to address this. AIM: To challenge the dearth of published information about the structures and processes in midwifery education programs by identifying: the educational value and pedagogical intent of the continuity of care experience; issues with the implementation, completion and assessment of learning associated with continuity of care experience; and discuss curriculum models that facilitate optimal learning outcomes associated with this experience. We discuss the primacy of continuity of care experience in midwifery education programs in Australia. DISCUSSION: The inclusion of continuity of care experience in midwifery programs in Australia became mandatory in 2010 requiring 20, however this number was reduced to 10 in 2014. Research has shown the beneficial outcomes of continuity of care experience to both students and women. Continuity of care experience builds mutual support and nurturing between women and students, fosters clinical confidence, resilience, and influences career goals. We require curriculum coherence with both structural and conceptual elements focusing on continuity of care experience. IMPLICATIONS AND RECOMMENDATIONS: Education standards that preference continuity of care experience as the optimal clinical education model with measurable learning outcomes, and alignment to a whole of program philosophy and program learning outcomes is required.

Hospital transition care for the elderly: an integrative review.

OBJECTIVE: to identify evidence of scientific production on hospital transition care provided to the elderly. METHOD: an integrative review, with publications search in the MEDLINE, PubMed, LILACS, BDENF, Index Psychology and SciELO databases, with keywords and Mesh terms: elderly, hospitalization, patient discharge, health of the elderly, and transitional care, between 2013 and 2017 in English, Portuguese and Spanish. The 14 selected articles analysis was carried out through exploratory and critical reading of titles, abstracts and results of the researches. RESULTS: transitional care can prevent re-hospitalizations as they enable rehabilitation, promotion and cure of illnesses in the elderly. FINAL CONSIDERATIONS: transitional care implies the improvement of the quality of life of the elderly person, requiring skilled health professionals who involve the family through accessible communication.

Impact of improved primary care on patient satisfaction: Results of a pilot study in the University of the Philippines.

Primary care is generally perceived by the public as an inefficient, low-quality source of health care in the Philippines. Taking a toll on local health policies, the repercussions of these views warrant a more holistic approach in understanding patient experience. This paper evaluates the impact of strengthening primary care services on patient satisfaction at the University of the Philippines Health Service (UPHS). A prevalidated 16-item, 5-scale questionnaire was distributed to 200 eligible patients at the start of the study in 2016 and then again in 2017. A significant increase of highly satisfied patients in 13 of 16 questionnaire items was recorded after primary care services in the facility were strengthened. The highest satisfaction scores were reported for overall wait times, coordination of care, and health advice. Our findings suggest that improvements in primary care services through digitalizing health records, financing laboratory and pharmaceutical services, and retraining staff accounts for significant improvements in patient satisfaction. This ultimately bears potential for better clinical outcomes in form of patient retention and long-term care.

Development of Phase-Specific Breast Cancer Survivorship Care Plans.

INTRODUCTION: Phase-specific survivorship care plans (SCPs) have the potential to be powerful tools in providing individualized, comprehensive survivorship care, particularly in terms of care coordination and transition, if used as dynamic documents. MATERIALS AND METHODS: We designed an initial follow-up care plan (FCP) to be used at the conclusion of curative therapy, as well as distinct, phase-specific FCPs for periodic use at 5-year and 10-year time points in the survivorship course. These FCPs incorporate the 4 essential components of survivorship care outlined by the Institute of Medicine: prevention, surveillance, intervention for consequences of cancer treatment, and coordination among health care providers. RESULTS: Phase-specific SCPs were designed by a multidisciplinary team with expertise in breast health, survivorship, and cancer care delivery across diverse practice settings. The FCPs were formulated to align with national guidelines and emergent, peer-reviewed literature, and reflect evolving recommendations regarding the duration of adjuvant hormone therapy. The SCPs were pilot-tested and successfully integrated into the existing work flow of the electronic medical records at each practice site. CONCLUSION: Phase-specific SCPs were developed to incorporate new knowledge about evolving treatment recommendations, screening guidelines, and updated genetic information to encourage timely discussions relevant to the specific stage of survivorship.

Handover of care and of information by community midwives, maternity care assistants and Preventive Child Healthcare professionals, a qualitative study.

INTRODUCTION: Handover of care has been internationally acknowledged as an important aspect in patient safety. Families who are vulnerable due to low socio-economic status, a language barrier or poor health skills, benefit especially from a decent handover of care from one healthcare professional to another. The handover from primary midwifery care and maternity care to Preventive Child Healthcare (PCHC) is not always successful, especially not in case of vulnerable families. AIM: Obtaining insight in and providing recommendations for the proces of handover of information by primary midwifery care, maternity care and PCHC in the Netherlands. METHODS: A qualitative research through semi-structured interviews was conducted. Community midwives, maternity care nurses and PCHC nurses from three municipalities in the Netherlands were invited for interviews with two researchers. The interviews took place from February to April 2017. The qualitative data was analyzed using NVivo11 software (QSR International). RESULTS: A total of 18 interviews took place in three different municipalities with representatives of the three professions involved with the handover of care and of information concerning antenatal, postnatal and child healthcare: six community midwives, six maternity care assistants and six PCHC nurses. All those interviewed emphasized the importance of good information transfer in order to provide optimum care, especially when problems within the family ar present. In order to improve care, a large number of healthcare professionals prefered a fully digitized handover of information, providing the privacy of the client is warrented and the system works efficiently. To provide high quality care, it is considered desirable that healthcare workers get to know each other and more peer agreements are prepared. The 'obstetric collaborative network' or another structured meeting was considered most suitable for this exchange. CONCLUSION: This study shows that the handover of care and of information between professionals in the fields of antenatal, postnatal and child healthcare is gaining awareness, but a more rigorous chain of care and collaboration between these disciplines is desired. Digitizing seems important to improve the handover of information.

The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk.

BACKGROUND: The measurement and interpretation of patient experience is a distinct dimension of health care quality. The Midwives @ New Group practice Options (M@NGO) randomized control trial of caseload midwifery compared with standard care among women regardless of risk reported both clinical and cost benefits. This study reports participants' perceptions of the quality of antenatal care within caseload midwifery, compared with standard care for women of any risk within that trial. METHODS: A trial conducted at two Australian tertiary hospitals randomly assigned participants (1:1) to caseload midwifery or standard care regardless of risk. Women were sent an 89-question survey at 6 weeks postpartum that included 12 questions relating to pregnancy care. Ten survey questions (including 7-point Likert scales) were analyzed by intention to treat and illustrated by participant quotes from two free-text open-response items. RESULTS: From the 1748 women recruited to the trial, 58% (n = 1017) completed the 6-week survey. Of those allocated to caseload midwifery, 66% (n = 573) responded, compared with 51% (n = 444) of those allocated to standard care. The survey found women allocated to caseload midwifery perceived a higher level of quality care across every antenatal measure. Notably, those women with identified risk factors reported higher levels of emotional support (aOR 2.52 [95% CI 1.87-3.39]), quality care (2.94 [2.28-3.79]), and feeling actively involved in decision-making (3.21 [2.35-4.37]). CONCLUSIONS: Results from the study show that in addition to the benefits to clinical care and cost demonstrated in the M@NGO trial, caseload midwifery outperforms standard care in perceived quality of pregnancy care regardless of risk.

Facilitating holistic continuity of care for older patients: Home care nurses' experiences using checklists.

AIMS AND OBJECTIVES: To explore home care nurses' experiences of implementation and use of checklists developed for improving continuity of care for older patients (65+ years). BACKGROUND: The Norwegian Coordination Reform was implemented to improve coordination between hospitals and communities and facilitate a quicker return to home community after hospital discharge. To follow-up, national learning networks were initialised to improve pathways for chronically ill older patients, including the development and use of standardised checklists. DESIGN: An explorative qualitative design was chosen. METHODS: Three focus group interviews were conducted, including 18 registered nurses from eight municipalities in southern Norway. Systematic text condensation was used to analyse the interview texts. The COREQ checklist was followed. RESULTS: Three categories emerged from the analysis. (a) "The implementation process" included the experiences of a chaotic beginning, the importance of involvement, the leaders' role and resource allocation. (b) "Pros and cons of checklists in use" included the informants' experiences of checklists' usefulness for nurses and the patients. (c) "Competence needed" included the need for a comprehensive set of formal, experiential and social competences. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: The leaders' role, support and engagement are decisive for a successful implementation. To succeed and establish solid routines, allocating resources when implementing new laborious routines, such as checklists, is important. To improve holistic continuity of care to chronically ill older patients, checklists should be customisable to each patient's needs, be comprehensive enough to grasp the essence in what to be done at several time points, but at the same time brief enough to be operational. Checklists can be a useful tool for home care nurses, if customised to the individual municipality and the staffs' working routines. It is important that the staff have versatile and extensive competencies enabling them to use the checklists appropriately.