The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Pharmacist involved education program in a multidisciplinary team for oral mucositis: Its impact in head-and-neck cancer patients.

OBJECTIVES: This retrospective study examined how a pharmacist-involved education program in a multidisciplinary team (PEMT) for oral mucositis (OM) affected head-and-neck cancer (HNC) patients receiving concurrent chemoradiotherapy (CCRT). MATERIALS AND METHODS: Total samples data of 53 patients during the stipulated timeframe were retrospectively collected from electronic medical records from February 2017 to January 2019. We compared the presence/absence of OM (OM: yes/no) between patients with and without PEMT (PEMT: yes/no) as the primary endpoint and OM severity as the secondary endpoint. The following information was surveyed: age, gender, weight loss, steroid or immunosuppressant use, hematological values (albumin, white blood cell count, blood platelets, and neutrophils), cancer grade, primary cancer site, type and use of mouthwash and moisturizer, opioid use (yes/no, days until the start of opioid use, and dose, switch to tape), and length of hospital day (LOD). The two groups were compared using Fisher's exact test for qualitative data and the Mann-Whitney U test for quantitative data, and a significance level of p<0.05 was set. RESULTS: The group managed by PEMT had significantly lower weight loss and a significantly lower incidence of local anesthetic and opioid use and switch to tape compared with the group not managed by PEMT (p<0.05). The two groups showed no significant difference in OM (yes/no) or OM severity. The PEMT group had significantly shorter LOD at 57 (53-64) days compared with the non-PEMT group at 63.5 (57-68) days (p<0.05). CONCLUSIONS: Our results showed that PEMT did not improve OM (yes/no) or OM severity in HNC patients undergoing CCRT. However, the PEMT group had a lower incidence of grades 3 and 4 OM than the non-PEMT group, although not significantly. In addition, PEMT contributed to oral pain relief and the lowering of the risk for OM by reduction in weight loss.

Access and Delivery of Adult Congenital Heart Disease Care in the United States: Quality-Driven Team-Based Care.

The landscape of congenital heart disease has changed rapidly over the past few decades. The shift from pediatric to adult congenital heart disease care has stretched resources and the ability to provide high-quality access and delivery of care for the more than 1.5 million adults with congenital heart disease in the United States. Meeting the demand for delivering high-quality care requires a team-based approach, with each member highly specialized. This review describes the deficits and deficiencies in providing care for adults with congenital heart disease in the United States and a team-based approach to improving access and delivery 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.

Multiprofessional team perception of a music therapeutic workshop developed by nurses.

OBJECTIVE: To understand the perception of a multiprofessional team regarding the use of music in a therapeutic workshop developed by nurses. METHOD: Qualitative study, of the exploratory type. Data were collected through semi-structured interviews, with the participation of 13 professionals from a Psychosocial Care Center in a municipality of Minas Gerais' Zona da Mata, and analyzed according to Michel Maffesoli's comprehensive sociology approach. RESULTS: The testimonies revealed that the use of music in the nurse's activities in mental health represents a re-signification of nursing care and favors the user's subjectivity. FINAL CONSIDERATIONS: This study allowed us to show that nurses need to listen to the music that comes from the heart, from the soul, and to the truths that are not always stated in the scenarios of therapeutic practices with individuals going through psychic suffering. Therefore, the care offered should be centered on the human history, which wants to be unveiled and understood.

Multiprofessional team perception of a music therapeutic workshop developed by nurses / Percepción del equipo multiprofesional sobre el taller terapéutico de música desarrollado por enfermero / Percepção da equipe multiprofissional sobre oficina terapêutica de música desenvolvida pelo enfermeiro

ABSTRACT Objective: To understand the perception of a multiprofessional team regarding the use of music in a therapeutic workshop developed by nurses. Method: Qualitative study, of the exploratory type. Data were collected through semi-structured interviews, with the participation of 13 professionals from a Psychosocial Care Center in a municipality of Minas Gerais' Zona da Mata, and analyzed according to Michel Maffesoli's comprehensive sociology approach. Results: The testimonies revealed that the use of music in the nurse's activities in mental health represents a re-signification of nursing care and favors the user's subjectivity. Final considerations: This study allowed us to show that nurses need to listen to the music that comes from the heart, from the soul, and to the truths that are not always stated in the scenarios of therapeutic practices with individuals going through psychic suffering. Therefore, the care offered should be centered on the human history, which wants to be unveiled and understood.

RESUMEN Objetivo: Comprender la percepción de los profesionales del equipo multiprofesional sobre el uso de la música en un taller terapéutico desarrollado por enfermero. Método: Estudio cualitativo de tipo exploratorio. Los datos fueron recolectados por medio de entrevistas semiestructuradas, con la participación de 13 profesionales de un Centro de Atención Psicosocial en un municipio de la Zona de la Mata de Minas Gerais, y después analizados desde la sociología comprensiva de Michel Maffesoli. Resultados: Los testimonios demostraron que el uso de la música en las actividades del enfermero en salud mental representa una resignificación de las líneas de cuidados de enfermería y le favorece la subjetividad del usuario. Consideraciones finales: Este estudio señala que el enfermero necesita oír la música que viene del corazón, del alma y de las verdades que ni siempre se dicen en los escenarios de prácticas terapéuticas con individuos en sufrimiento psíquico. Por lo tanto, el cuidado ofrecido debe ser centrado en la historia humana que nos invita a desvelarla y comprenderla.

RESUMO Objetivo: Compreender a percepção dos profissionais da equipe multiprofissional sobre o uso da música em oficina terapêutica desenvolvida pelo enfermeiro. Método: Estudo qualitativo, do tipo exploratório. Os dados foram coletados por meio de entrevistas semiestruturadas, com a participação de 13 profissionais de um Centro de Atenção Psicossocial em um município da Zona da Mata Mineira, e analisados seguindo-se o referencial da sociologia compreensiva, de Michel Maffesoli. Resultados: Os depoimentos revelaram que o uso da música nas atividades do enfermeiro em saúde mental representa uma ressignificação das linhas de cuidados de enfermagem e favorece a subjetividade do usuário. Considerações finais: Este estudo possibilitou evidenciar que o enfermeiro precisa ouvir a música que vem do coração, da alma e das verdades nem sempre proferidas nos cenários de práticas terapêuticas com indivíduos em sofrimento psíquico. Portanto, o cuidado ofertado deve ser centrado na história humana que convida a ser desvelada e compreendida. Descritores: Enfermeiros; Música; Saúde Mental; Serviços de Saúde Mental; Cuidados de Enfermagem.

Process outcomes of a multifaceted, interdisciplinary knowledge translation intervention in aged care: results from the vitamin D implementation (ViDAus) study.

BACKGROUND: Vitamin D supplement use is recommended best practice in residential aged care facilities (RACFs) for the prevention of falls, however has experienced delays in uptake. Following successful international efforts at implementing this evidence into practice, the ViDAus study sought to replicate this success for the Australian context. The aim of this paper is to report on the process outcomes of implementing this intervention. METHODS: Forty-one RACFs were engaged in a multifaceted, interdisciplinary knowledge translation intervention. This focused on raising awareness to improve knowledge on vitamin D, and supporting facilities to identify barriers and implement locally devised strategies to improve the uptake of evidence based practice (EBP). RESULTS: Staff members of participating facilities (n = 509 including nursing, care and allied health staff) were well engaged and accepting of the intervention, though engagement of servicing general practitioners (GPs) (n = 497) and pharmacists (n = 9) was poor. Facilities each identified between three and eight strategies focused on raising awareness, identifying residents to target for vitamin D and creating referral pathways depending upon their own locally identified barriers and capacity. There was variable success at implementing these over the 12-month intervention period. Whilst this study successfully raised awareness among staff, residents and their family members, barriers were identified that hindered engagement of GPs. CONCLUSIONS: The intervention was overall feasible to implement and perceived as appropriate by GPs, pharmacists, facility staff, residents and family members. More facilitation, higher-level organisational support and strategies to improve RACF access to GPs however were identified as important improvements for the implementation of vitamin D supplement use. TRIAL REGISTRATION: Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ) on 15 June 2016.

Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short-term outcomes.

AIM: Significant recent changes in management of locally advanced rectal cancer (LARC) include preoperative staging, use of extended neoadjuvant therapies and minimally invasive surgery (MIS). This study was aimed at characterizing these changes and associated short-term outcomes. METHOD: We retrospectively analysed treatment and outcome data from patients with T3/4 or N+ LARC ≤ 15 cm from the anal verge who were evaluated at a comprehensive cancer centre in 2009-2015. RESULTS: In total, 798 patients were identified and grouped into five cohorts based on treatment year: 2009-2010, 2011, 2012, 2013 and 2014-2015. Temporal changes included increased reliance on MRI staging, from 57% in 2009-2010 to 98% in 2014-2015 (P < 0.001); increased use of total neoadjuvant therapy, from 17% to 76% (P < 0.001); and increased use of MIS, from 33% to 70% (P < 0.001). Concurrently, median hospital stay decreased (from 7 to 5 days; P < 0.001), as did the rates of Grade III-V complications (from 13% to 7%; P < 0.05), surgical site infections (from 24% to 8%; P < 0.001), anastomotic leak (from 11% to 3%; P < 0.05) and positive circumferential resection margin (from 9% to 4%; P < 0.05). TNM downstaging increased from 62% to 74% (P = 0.002). CONCLUSION: Shifts toward MRI-based staging, total neoadjuvant therapy and MIS occurred between 2009 and 2015. Over the same period, treatment responses improved, and lengths of stay and the incidence of complications decreased.

When a Child Needs a Transplant but Lacks Familial Social Support.

We present the case of a 19-month-old boy with complex congenital heart disease. His single father is skeptical of traditional medicine and does not offer the social support needed to make heart transplantation successful for his son. After the father demonstrates commitment to transplant success and provides enhanced social support, doctors place the child on a Berlin Heart (a biventricular assist device) as a bridge to transplantation and list him for transplant. When the child is matched to a donor heart, the father refuses transplantation, despite that it is the child's only chance for survival. His doctors report the case to child protective services, but they decline to take protective custody. The father then changes his mind and asks that the child be put back on the waiting list for transplant. By this time, the social supports the father implemented are no longer in place. This case raises a number of issues. First, should courts order heart transplantation when doctors believe that it is in the child's best interest and parents do not consent? Second, once parents refuse a transplant, can they change their minds? Third, if there are uncertainties regarding whether the child has the social support to make transplantation successful, should the child be relisted? Finally, should a child who is not currently a transplant candidate but who may become one in the future be supported with ventricular assist devices?

What Is New in Obstetric Anesthesia: The 2017 Gerard W. Ostheimer Lecture.

The Gerard W. Ostheimer lecture is given each year at the Society for Obstetric Anesthesia and Perinatology annual meeting and is intended to summarize important new scientific literature relevant to practicing obstetric anesthesiologists. This review highlights some of the most consequential papers covered in this lecture. It discusses landmark clinical trials that are likely to change the practice of obstetrics and obstetric anesthesia. It summarizes several articles that focus on how to optimize the provision of neuraxial anesthesia and postoperative pain control. Finally, it reviews studies aimed at identifying systems-based interventions that can improve obstetrical outcomes. A proposed "to-do" list focused on quality improvement initiatives that can be implemented on labor and delivery units is provided.

The Team Based Biopsychosocial Model: Having a Clinical Ethicist as a Facilitator and a Bridge Between Teams.

The biopsychosocial model is characterized by the systematic consideration of biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery. This model opposes the biomedical model, which is the foundation of most current clinical practice. In the biomedical model, quest for evidence based medicine, the patient is reduced to molecules, genes, organelles, systems, diseases, etc. This reduction has brought great advances in medicine, but it lacks a holistic view of the person. To solve the problem, we propose an early team based approach where the primary care physician leads a group of people that can help her/him address the psychosocial issues while she/he attends to the biomedical issues. This article addresses one case where the clinical ethicist facilitating a team based biopsychosocial model for the care of a patient worked as a bridge between the primary team, the critical care team, and the psychosocial team to advance the argument that good communication among the groups can lead to a true biopsychosocial model where the collaboration of the social worker, psychologist, chaplain, ethicist and the different medical teams can improve the overall patient experience.

Integrated primary care could play a starring role in the Amazon-JP Morgan-Buffet health care enterprise.

Earlier this year, Amazon, J. P. Morgan, and Berkshire Hathaway announced plans to launch a joint health care company with more than a million covered lives. Dr. Atul Gawande, the prominent Boston-based surgeon and health care thought leader, will become the first chief executive officer of this health care venture, with a mission to get the best results at the lowest costs and remain free from profit-making incentives and constraints. In this presidential column, the author explores what this has to do with the mission in the Collaborative Family Health care Association (CFHA) and the promulgation of integrated health care. (PsycINFO Database Record

Introduction to the Special Issue on Neuropsychology Practices in Integrated Care Teams.

This special issue on neuropsychology practices in integrated healthcare teams demonstrates how neuropsychologists have transformed their practices in an evolving healthcare landscape. These contributions are an overview of the many ways in which neuropsychologists function in integrated care teams. The experiences of integrated neuropsychologists serve as a model for those seeking new practice opportunities by providing highly practical, clinically relevant information. Included in this volume are articles on education and reimbursement issues, information about clinical practices that address diagnostic issues, prognostics and clinical management, as well as surgical treatment planning and outcome prediction. Authors highlight the value of their services, their contribution to improving team and patient communication, as well as the biopsychosocial understanding of the patient. Several unexpected challenges are detailed among the pearls and pitfalls of these practices.

[Paradigm Shift in the Quality of Regional Medical Care: Cooperative Treatment of Onychomycosis].

　In a superaging society, the medical paradigm should include both less coverage of medical-care work flow by human resources and high-quality care for patients. Strategies such as establishing medical-care teams and community medicine systems mainly for home medical care should be implemented. However, a well-organized system for home-based medical treatment of elderly patients is not yet in place, as evidenced by the lack of care, problems with long-term polypharmacy resulting from visits to multiple healthcare providers, and declines in their physical strength. It is assumed that care might not be provided in association with treatment because planning based on the paradigm of "home medical care" has not been fully established. Therefore, in this study, we aimed to determine the "paradigm shift in home medical care" based on the treatment of onychomycosis. We also hoped to identify the types of medical support required to improve the general well-being of individuals and what needs to be done to ensure a high quality of life for patients. All those (including patients themselves) involved in patient care should together formulate a protocol for medical treatment and cooperate based on the role each can play. Although it may be difficult to maintain cooperation among healthcare workers, improvements in the medical quality of an entire region can be achieved by planning a life design including medical treatment for each patient.

A Survey of Current Anesthesia Trends for Electrophysiology Procedures.

BACKGROUND: There has been a dramatic shift in recent years in anesthesia coverage for electrophysiology (EP) procedures. An anesthesiologist and electrophysiologist at our institution jointly developed a survey, which was distributed to the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society. Its goal was to document current practice patterns and examine perceived variability in coverage. METHODS: On approval of the leadership from the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society, an online survey was administered to the membership. The survey included demographic data, anesthetic type, and perceptions of the respondents. RESULTS: Four hundred seventy-nine surveys were completed. Thirty-eight percent were completed by electrophysiologists and 63% by anesthesiologists, giving a response rate of 8.24% for anesthesiologists and 13.6% for electrophysiologists. Of these, 57% of respondents worked in an academic setting. Over the past 2 years, 66.5% of respondents reported anesthesia involvement in EP cases increasing. These cases are reportedly covered by all anesthesiologists in a group 55% of the time, cardiac anesthesia 32.5%, and a designated team at the remainder of the institutions. Seventy-six percent of respondents reported having designated EP block time in the schedule. Ninety-two percent of respondents reported that patient satisfaction has increased with the involvement of anesthesia services. CONCLUSIONS: Anesthesia coverage for EP procedures has continued to increase with an increase in patient satisfaction. Anesthesiologists have had to adapt and provide designated block time to accommodate this increase and also, in some instances, form teams that go beyond simply cardiac anesthesiologists to care for these patients during their procedures.

The free spirit: spiritualism meanings by a Nursing team on psychiatry / El espíritu suelto: significados de espiritualidad por equipo de enfermería en psiquiatría / O espírito solto: significados de espiritualidade por equipe de enfermagem em psiquiatria

ABSTRACT Objective: To analyze the meanings attributed by nursing professionals in psychiatry to spirituality and its relationship with care. Method: Clinical-qualitative, with appreciation of symbolic meanings. We interviewed 18 individuals for a semi-structured script of open questions and the data were analyzed in the light of psychoanalytic hermeneutics. The discussion was undertaken with the overlap of understanding of the sacred symbol, psychological and the meaning of life. Results: Different spiritualities are interposed by personal restlessness and the experience of transience. Spirituality aids in social functions, personal balance and commitment to endure the anguish of transience. Among professionals, it has been shown as an ethical-combative attitude to evil forms, but there is a restriction in dealing with patients' spirituality. Final considerations: The meanings pointed to the limits of human reason, resembling caregivers and patients in subjective conditions by which they avoid spirituality in psychiatry. It is suggested that spiritual attention be given to professionals.

RESUMEN Objetivo: Analizar los significados atribuidos por profesionales de enfermería en psiquiatría a la espiritualidad y su relación con el cuidado. Método: Clínico-cualitativo, con estimación de los significados simbólicos. Fueron entrevistados 18 sujetos por un itinerario semiestructurado de preguntas abiertas y los datos analizados a la luz de la hermenéutica psicoanalítica. La discusión se emprendió con la superposición del entendimiento del símbolo sagrado, psicológico y del sentido de la vida. Resultados: Distintas espiritualidades se interponen por la inquietud personal y la experiencia con la transitoriedad. La espiritualidad ayuda en las funciones sociales, en el equilibrio personal y en el empeño en soportar las angustias de la transitoriedad. Entre los profesionales se mostró como una actitud ético-combativa a las formas maléficas, pero hay restricción en trabajar con la espiritualidad de los pacientes. Consideraciones finales: Los significados señalaron los límites de la razón humana, asemejando cuidadores y pacientes en condiciones subjetivas por las que evitan la espiritualidad en la psiquiatría. Se sugiere atención espiritual para los profesionales.

RESUMO Objetivo: Analisar os significados atribuídos por profissionais de enfermagem em psiquiatria à espiritualidade e sua relação com o cuidado. Método: Clínico-qualitativo, com apreciação dos significados simbólicos. Entrevistou-se 18 sujeitos por um roteiro semiestruturado de questões abertas e os dados foram analisados à luz da hermenêutica psicanalítica. A discussão se empreendeu com a sobreposição do entendimento do símbolo sagrado, psicológico e do sentido da vida. Resultados: Distintas espiritualidades se interpõem pela inquietação pessoal e a experiência com a transitoriedade. A espiritualidade ajuda nas funções sociais, no equilíbrio pessoal e no empenho em suportar as angústias da transitoriedade. Entre os profissionais, se mostrou como uma atitude ético-combativa às formas maléficas, mas há restrição em lidar com a espiritualidade dos pacientes. Considerações finais: Os significados apontaram para os limites da razão humana, assemelhando cuidadores e pacientes em condições subjetivas pelas quais evitam a espiritualidade em psiquiatria. Sugere-se atenção espiritual para os profissionais.