Pandemic Hastens Cleveland Clinic's Unified Well-Being Strategy.

SUMMARY: Across the healthcare landscape, the COVID-19 pandemic has been incredibly challenging. It also has been a catalyst for change. It has ignited a redesign of the US health system and presented opportunities in areas such as caregiver and patient communication, digital practice, telehealth and virtual care, and more. Notably, the pandemic also has shined a new light on caregiver well-being. As executive leaders of Cleveland Clinic's Caregiver Office, our top priority throughout the pandemic has been to support our caregivers professionally and personally-to help them be their best for themselves and for their fellow caregivers, our patients, our organization, and our communities. Today, Cleveland Clinic is realizing the profound impact of many of the strategies put in place during the pandemic and seeing how COVID-19 accelerated our organization's unified vision for caregiver well-being. This article offers insight into Cleveland Clinic's commitment to caregiver well-being, highlights actions we undertook during the pandemic, shares the resulting lessons we learned, and showcases how those lessons are shaping our future caregiver well-being strategy.

Scaling-Up Stage 4 Pediatric Obesity Clinics: Identifying Barriers and Future Directions Using Implementation Science.

Nearly one-fifth of the pediatric population in the United States has obesity. Comprehensive behavioral interventions, with at least 26 contact hours, are the recommended treatment for pediatric obesity; however, there are various barriers to implementing treatment. This Perspective applies the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to address barriers to implementing multidisciplinary pediatric weight management clinics and identify potential solutions and areas for additional research. Lack of insurance coverage and reimbursement, high operating costs, and limited access to stage 4 care clinics with sufficient capacity were among the main barriers identified. Clinicians, researchers, and patient advocates are encouraged to facilitate conversations with insurance companies and hospital and clinic administrators, increase telehealth adoption, request training to improve competency and self-efficacy discussing and implementing obesity care, and advocate for more stage 4 clinics.

Different models of pharmaceutical services and care in primary healthcare clinics in the Eastern Cape, South Africa: Challenges and opportunities for pharmacy practice.

BACKGROUND: Primary health care (PHC) re-engineering forms a crucial part of South Africa's National Health Insurance (NHI), with pharmaceutical services and care being crucial to treatment outcomes. However, owing to a shortage of pharmacists within PHC clinics, task-shifting of the dispensing process to pharmacist's assistants and nurses is common practice. The implications of this task-shifting process on the provision of pharmaceutical services and care remains largely unstudied. AIM: The study aimed to explore the pharmacist-based, pharmacist's assistant-based and nurse-based dispensing models within the PHC setting. SETTING: The Nelson Mandela Bay Health District, South Africa. METHODS: A mixed methods approach was utilised comprising of Phase 1: a pharmaceutical services audit to analyse pharmaceutical service provision and Phase 2: semi-structured interviews to describe the pharmaceutical care provision within each dispensing model thematically. RESULTS: Pharmaceutical services partially fulfilled minimum standards within all models, however, challenges exist that limit the quality of these services. Phase 2 showed that the provision of pharmaceutical care within all models was restricted by context-related constraints, thus patient-centred activities to underpin pharmaceutical services were limited. CONCLUSION: Although pharmaceutical services may have been available for all models, compromised quality of these services impacted overall quality of care. Limited pharmaceutical care provision was evident within each dispensing model. The results raised concerns about the current utilisation of pharmacy personnel, including the pharmacist, within the PHC setting. Further opportunities exist, if constraints allow, for the pharmacist to contribute to better patient-centred care.

Nutrition services offered to pregnant women attending antenatal clinics in Dar es Salaam, Tanzania: A qualitative study.

OBJECTIVES: To provide an overview of the qualifications of nurses working in antenatal clinics, and to identify current nutrition services and information provided to pregnant women. To explore barriers and enablers to the provision of nutrition services by nurses to pregnant women attending antenatal clinics mapped against the Theoretical Domains Framework. DESIGN AND SETTING: Cross-sectional qualitative study, conducted in three municipal hospitals (Temeke, Mwananyamala and Ilala) in Dar es Salaam, Tanzania. PARTICIPANTS: Fourteen nurses currently providing health services to pregnant women, with at least two months' work experience within in the selected facility were purposively selected. METHOD: In-depth interviews were carried out with the participants by three trained research assistants using guides prepared in Swahili. Transcripts were translated into English and imported to NVivo 12 software. Data was analysed using qualitative content analysis principles. RESULTS: Five nutrition services commonly provided to pregnant women at antenatal clinics were nutrition education, iron and folic acid supplementation, weight measurements, dietary assessment and haemoglobin level monitoring. Domains included knowledge, skills, beliefs about capabilities, in addition to memory, attention and decision processes, and the environmental context and resources domains had both barriers and enablers identified by participants. The three remaining domains of the social/professional role and identity, optimism, and beliefs about consequences had only enablers reported. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Nurses deliver nutrition care to pregnant women during routine antenatal clinic visits. However, the information delivered to pregnant women varied among nurses, and a number of barriers and enablers to provision of nutrition care to pregnant women were identified. This data can inform future improvement to strategies for implementing nutrition services to pregnant women attending antenatal clinics. In-service training to nurses working with pregnant women and availability of tailored nutrition education materials, such as a food guide in these health facilities could improve nutrition care during this important period.

A framework to increase prescription capture from health-system clinics.

PURPOSE: To develop and implement an interprofessional framework to increase the capture of health system-generated prescriptions within health system-owned pharmacies. SUMMARY: Low prescription capture rates within a health system's internal pharmacies led to an interdisciplinary process improvement effort. A framework was developed to assess the baseline prescription capture rate, select clinics for improvement, understand clinic workflows and key drivers of pharmacy selection, design strategies to increase prescription capture, implement targeted efforts, and measure the effectiveness of the intervention(s). Employing this framework provided revised workflows for nursing and medical assistant staff scripting and for referral of patients to internal pharmacies. These workflows were pilot tested at 3 system clinics. Results indicated that overall prescription capture increased by 2.9 to 4.1 percentage points (range, 10 to 86 prescriptions per month) and specialty prescription capture increased by 11.6 to 26.7 percentage points (range, 4 to 26 prescriptions per month) for each clinic within the first 2 months. A total of 99 new patients were referred to internal pharmacies within the first month. CONCLUSION: Development and implementation of a framework to increase prescription capture from health system clinics helped increase capture, enhanced clinic engagement and knowledge about pharmacy services, and supported positive clinic-pharmacy relationships.

Development of a Resource Impact Model for Clinics Treating Pre-Operative Iron Deficiency Anemia in Ireland.

INTRODUCTION: Intravenous (IV) iron is typically the preferred treatment for patients with iron deficiency anemia (IDA) who cannot tolerate or absorb oral iron, or who require fast replenishment of iron stores pre-operatively. Several IV iron formulations are available with different dosing characteristics affecting infusion speed and maximum dose. The aim was to develop a resource impact model to calculate the cost of establishing an IV iron clinic and model resource impact of different IV irons to inform clinicians and service providers implementing innovative pre-operative IV iron services in Ireland. METHODS: A resource impact tool was developed to model resource utilization and IDA treatment costs. Two fast-administration, high-dose formulations of IV iron are available in Ireland: iron isomaltoside 1000/ferric derisomaltose (IIM) and ferric carboxymaltose (FCM). The tool modeled clinic throughput based on their different dosing characteristics in a specific IDA population, capturing fixed overheads, variable costs, clinic income from private and publicly-funded patients, and savings associated with IV iron. RESULTS: Based on a 70:30 split between public and private patients in a new pre-operative service with capacity for 12 infusion slots weekly, IIM would facilitate correction of iron deficits in 474 patients annually, resulting in a net annual clinic balance of €42,736 on income of €159,887 and net costs of €117,151. FCM would facilitate treatment of 353 patients, resulting in a net annual clinic balance of €36,327 on income of €116,050 and costs of €79,722, a difference of €6408 and 121 patients treated in favor of using IIM over FCM. CONCLUSION: Based on this provider-perspective analysis, IIM would maximize clinic throughput relative to other IV iron formulations, allowing clinicians in Ireland to optimize their current service provision and expenditure, and model the impact of introducing IV iron clinics for pre-operative patients with IDA.

Integrated Care: Provider referrer perceptions of occupational therapy services for homeless adults in an integrated primary care setting.

BACKGROUND: Occupational therapists have a long history of addressing community performance and participation challenges faced by individuals with complex, chronic conditions, including those with serious mental illnesses (SMI) and cognitive issues that present with a traumatic brain injury (TBI). Healthcare reform has shifted incentives to support practices that promote successful community life for people with complex medical conditions. Community based care models emphasizing integrated primary care, such as Federally Qualified Health Centers (FQHC) are emerging, and a generalist role for occupational therapy is being defined. Those with complex comorbid conditions such as mental illness, substance abuse and traumatic brain injury are at risk for negative health outcomes that are further compounded by homelessness. There is a critical need to understand effective treatment options for this population to reduce the negative effects of chronic health conditions. As occupational therapists further define a role serving traditional clients in less traditional settings, such as the FQHC, it is helpful to explore the perceptions of the utility of OT services on the part of provider referrers. OBJECTIVE: This study explored provider referrer perceptions of a new occupational therapy service for homeless adults in an FQHC to assist effective allocation of scarce resources. METHODS: Twelve provider referrers at an FQHC were interviewed regarding their perception of the role and utility of occupational therapy in this setting. Interviews were then coded for themes. RESULTS: Providers identified the unique value of occupational therapy, emphasizing critical information gleaned from the performance-based assessment of functional cognition, and the positive impact on team interactions and subsequent care decisions. CONCLUSION: Occupational therapy provides a distinct perspective on client performance in FQHC settings indicating benefit for inclusion of services.

Evaluation of pharmacist interventions in a head and neck medical oncology clinic.

INTRODUCTION: Head and neck cancers (HNC) are a complex and heterogeneous group of cancers, often necessitating a multidisciplinary approach across the care continuum. Oncology pharmacists are uniquely qualified to play a vital role on a multidisciplinary team and provide specialized care to optimize medication therapy. METHODS: This was a retrospective chart review evaluating the role of a board-certified oncology pharmacist in the head and neck oncology clinic at an academic, comprehensive cancer center from April 2017 through March 2018. The primary objective of the study was to describe the types of interventions made by the oncology pharmacists. Secondary objectives included quantifying time spent on patient education and number of prescriptions sent to pharmacies. RESULTS: The pharmacist had 873 encounters with 151 patients, resulting in 2080 interventions. Approximately 57% of the interventions were performed in the clinic. Patient education (58%), facilitation of new prescriptions or refill requests (49.9%), and supportive care management (32.6%) were the most frequent interventions. The oncology pharmacist spent 154.1 h on patient education and sent 811 prescriptions to pharmacies, with 63.6% of prescriptions sent to the institution's cancer center pharmacy. CONCLUSION: The incorporation of an oncology pharmacist in the HNC team optimized patient care through comprehensive and timely interventions across the care continuum. Our study is the first to highlight the vital role oncology pharmacists have in improving the overall quality of care of HNC patients. Future directions include exploring the impact of oncology pharmacist interventions on select Quality Oncology Practice Initiative measures by the American Society of Clinical Oncology.

Nurturing autonomy in student midwives within a student led antenatal clinic.

BACKGROUND: A clinical environment that provides meaningful and productive learning experiences is essential for students of all health care professions. To support the learning needs of undergraduate midwifery students and facilitate the continuity of care experiences a student led clinic was established in one South East Queensland maternity unit. AIM: This study explored the experiences and learning processes of previous and current midwifery students undertaking clinical practice within a student led clinic. METHOD: Qualitative descriptive. Ten students that elected to work in the midwifery student led clinic were invited to participate in a one off digitally recorded face to face or telephone interview. Thematic analysis was used to analyse the data set. University ethical approval was granted (NRS/17/15/HREC). FINDINGS: Findings suggest the student led clinic positioned students in the 'driver's seat'. Overwhelmingly students described the clinic as providing them with an array of opportunities to 'lead' care rather than being forced to 'sit and watch'. Students believed the experience of working in the clinic increased their midwifery knowledge, skills, confidence, critical thinking, and the ability to advocate for and empower women. CONCLUSION: High quality and supportive clinical teaching and learning experiences are vital for ensuring the student midwife develops into a competent practitioner who is fit for registration. The evidence from this small study highlights the benefits afforded to students of working in partnership not only with pregnant women but also with their university midwifery lecturer. The student's continuity of care learning experiences appeared to foster and cultivate their capability, identity, purpose, resourcefulness and connection; all the five senses of success.

Decision space and participation of primary healthcare facility managers in the Ideal Clinic Realisation and Maintenance programme in two South African provinces.

In South Africa, the introduction of a national health insurance (NHI) system is the most prominent health sector reform planned to achieve universal health coverage in the country. Primary health care (PHC) is the foundation of the proposed NHI system. This study draws on policy implementation theory and Bossert's notion of decision space to analyse PHC facility managers' decision space and their participation in the implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme. We conducted a cross-sectional survey among 127 PHC facility managers in two districts in Gauteng and Mpumalanga provinces. A self-administered questionnaire elicited socio-demographic information, the PHC managers' participation in the conceptualization and implementation of the ICRM programme, their decision space and an optional open-ended question for further comments. We obtained a 100% response rate. The study found that PHC facility managers reported lack of involvement in the conceptualization of the ICRM programme, high levels of participation in implementation [mean score 5.77 (SD ±0.90), and overall decision space mean score of 2.54 (SD ±0.34)]. However, 17 and 21% of participants reported narrow decision space on the critical areas of the availability of essential medicines and on basic resuscitation equipment respectively. The qualitative data revealed the unintended negative consequences of striving for 'ideal clinic status', namely that of creating an illusion of compliance with the ICRM standards. The study findings suggest the need for greater investment in the health workforce, special efforts to involve frontline managers and staff in health reforms, as well as provision of adequate resources, and an enabling practice environment.

Evaluating time in health care: What are we busy about?

At the end of the day, there are both economic and less tangible benefits to having predictable clinic operations in which people's medical and behavioral health needs are met. These different benefits, stemming from changes in how time is used, are relevant to a wide range of stakeholders including administrators, clinicians, and patients. In short, time is one of our most important resources in health care. Therefore, time studies have a crucial role to play in advancing the implementation of integrated care. In this editorial we describe several methods for measuring time and invite readers to consider which of these (or another method you're aware of) balances your needs for precision and feasibility of measurement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Indigenous mothers' experiences of using acute care health services for their infants.

AIMS AND OBJECTIVES: To develop an understanding of how Indigenous mothers experience selecting and using health services for their infants can assist nurses in improving their access to care. This understanding may ultimately lead to improved health outcomes for Indigenous infants and their families. BACKGROUND: Access to acute care services is important to minimise morbidity and mortality from urgent health issues; however, Indigenous people describe difficulties accessing care. Indigenous infants are known to use the emergency department frequently, yet little is known about the facilitators and barriers their mothers experience when accessing these services. DESIGN: This study undertook a qualitative, interpretive description design. METHODS: This article adheres to the reporting guidelines of COREQ. Data collection methods included interviews and a discussion group with Indigenous mothers (n = 19). Data analysis was collaborative and incorporated both Indigenous and Western ways of knowing, through the application of Two-Eyed Seeing. RESULTS: A thematic summary resulted in six themes: (a) problematic wait times; (b) the hidden costs of acute care; (c) paediatric care; (d) trusting relationships; (e) racism and discrimination; and (f) holistic care. CONCLUSIONS: The experiences of Indigenous mothers using acute care services for their infants suggest a role for culturally safe and trauma and violence-informed care by health providers in the acute care context. RELEVANCE TO CLINICAL PRACTICE: Nurses can improve access to acute care services for Indigenous mothers and infants through the provision of culturally safe and trauma and violence-informed approaches care, by building rapport with families, providing care that is respectful and nonjudgemental, eliminating fees associated with using acute care services and linking families with cultural resources both in hospital and within the community.

Challenges and strategies for contraceptive care in independent abortion clinics in the United States, 2017.

OBJECTIVE: Many patients may wish to receive contraceptive counseling and services during an abortion visit, but a 2009 study documented challenges faced by abortion clinics, especially independent ones, in providing contraceptive care. Since then, the Affordable Care Act (ACA) has made contraception more accessible by expanding coverage to millions of individuals and by eliminating out of pocket costs. This paper aims to update this previous work and describe recent challenges in providing contraceptive care in independent abortion settings following the ACA, as well as the strategies used to address these challenges. METHODS: We conducted two focus groups and 19 semi-structured interviews with clinic administrators and directors at independent abortion clinics. RESULTS: Challenges to providing contraceptive care in independent abortion clinics included navigating new guidelines under the Affordable Care Act for establishing coverage agreements with health insurance plans and receiving timely and sufficient reimbursement for services provided. Study respondents described strategies related to adjusting clinic flow and protocols to address patient needs regarding receiving contraception during abortion care. CONCLUSION: Staff working in independent abortion clinics in the United States experience a tension between trying to provide holistic, patient-centered care - including contraceptive care - and navigating restrictive political and healthcare contexts for the delivery of abortion care.

Massage Chair Sessions: Favorable Effects on Ambulatory Cancer Center Nurses' Perceived Level of Stress, Blood Pressure, and Heart Rate.

BACKGROUND: High stress levels over time can contribute to compassion fatigue and burnout and negatively affect individual health and well-being. OBJECTIVES: A pre-/post-test initiative was implemented to determine the effects of massage chair sessions on ambulatory cancer center nurses (RNs and advanced practice providers) based on their perceived stress, blood pressure (BP), and heart rate (HR). METHODS: A mechanical massage chair was available for 20-minute sessions in a secure room, and nurses self-recorded perceived stress using a visual analog scale, as well as BP and HR using a wrist cuff device. Descriptive statistics and paired t tests were used to assess nurse characteristics and differences before and after massage chair sessions. FINDINGS: Nurses participated in 200 massage chair sessions during a six-month period. Significant reductions were noted in perceived stress, systolic and diastolic BP, and HR. These data indicate that providing a relaxing room with chair massage has favorable effects on nurses' perceived stress, BP, and HR.

Implementing integrated behavioral health: Testing associations between shared clinical time and space and provider referrals.

INTRODUCTION: Behavioral health provider (BHP) availability is widely acknowledged as an important factor in the effectiveness of an integrated care approach within primary care. However, there is little research providing evidence of the impact of BHP availability on physician uptake of integrated behavioral health (IBH) services. METHOD: This quasi-experimental study examines whether shared clinical time and space with a BHP is associated with providers' number of standard IBH referrals and proportion of warm handoffs within total behavioral health (BH) referrals. Data are from 2 family medicine outpatient clinics with 1 shared, part-time BHP and were gathered across 4 months (2,847 unique patients served) using electronic health record chart review of patients referred for BH services. RESULTS: Results of a Poisson regression indicated greater shared time and space between BHP and providers is significantly associated with a greater number of providers' standard IBH referrals, χ²(df = 1, N = 15) = 13.67, p = .000. Results of general linear modeling indicate greater shared time and space is also associated with a greater proportion of warm handoffs (percentage of total referrals). A 1-unit increase in percentage of schedule overlap was associated with a 110% increase in likelihood of a family medicine provider making a warm handoff, Exp(ß) = 2.10, p = .007. DISCUSSION: This exploratory study provides initial evidence to support the notion that shared time and space between BHPs and physicians is an essential component of effective integrated care. Future research is needed to evaluate how shared time and space impact the accessibility, adoption, and effectiveness of the BHP. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Design and Implementation of a Group Prenatal Care Model for Somali Women at a Low-Resource Health Clinic.

OBJECTIVE: To design and implement group prenatal care (GPC) for Somali women and to evaluate participants' satisfaction, knowledge, and care engagement. DESIGN: Quality improvement project. SETTING/LOCAL PROBLEM: A federally qualified health center in an urban Midwestern setting, which serves a largely East African immigrant and refugee population. PARTICIPANTS: Pregnant Somali women at more than 20 weeks gestation receiving prenatal care at the project site. Many participants were non-English speaking. INTERVENTION/MEASUREMENTS: While honoring the 13 essential elements of CenteringPregnancy, the model was adapted to the East African population at the project site and offered to all eligible women receiving individual prenatal care at the clinic. Women attended biweekly sessions, including individual assessment and education, exposure to integrative health therapies, and group discussion. Pre- and postintervention data were collected in surveys and in-depth interviews from March through August 2017. RESULTS: Seventeen Somali women attended a median of two sessions (range = 1-7). Self-reported results for knowledge of safe exercise in pregnancy (p = .02), exclusive breastfeeding (p = .04), what happens in the hospital (p = .02), and stress management (p = .03) increased after GPC participation. Ninety-three percent of women preferred GPC to individual care. CONCLUSION: When adapted to meet the needs of Somali women, GPC has the potential to improve care satisfaction, increase knowledge, and reduce stress during pregnancy and the postpartum period. This model may interest women and care providers in similar community health care settings.

Transfer of primary care patients receiving chronic care: the next step in the continuum of care.

The burden of chronic conditions is increasing rapidly in low- and middle-income countries. Chronic conditions require long-term and continuous care, including for patients transferring between facilities. Patient transfer is particularly important in the context of health service decentralization, which has led to increasing numbers of primary care facilities at which patients can access care, and high levels of migration, which suggest that patients might require care at multiple facilities. This article provides a critical review of existing evidence regarding transfer of stable patients receiving primary care for chronic conditions. Patient transfer has received limited consideration in people living with HIV, with growing concern that patients who transfer are at risk of poor outcomes; this appears similar for people with TB, although studies are few. There are minimal data on transfer of patients with non-communicable diseases, including diabetes. Patient transfer for chronic conditions has thus received surprisingly little attention from researchers; considering the potential risks, more research is urgently required regarding reasons for and outcomes of transfers, transfer processes and interventions to optimize transfers, for different chronic conditions. Ultimately, it is the responsibility of health systems to facilitate successful transfers, and this issue requires increased attention from researchers and policy-makers.