Assessing patient work system factors for medication management during transition of care among older adults: an observational study.

OBJECTIVE: To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults. DESIGN, SETTINGS AND PARTICIPANTS: Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 years) discharged home from medical units of two US hospitals from August 2018 to July 2019. MAIN MEASURES: Patient work system factors for managing medications were assessed during hospital stays using six capacity indicators, four task indicators and three medication management practice indicators. Main outcomes were assessed at participants' homes approximately a week after discharge for (1) Medication discrepancies between the medications taken at home and those listed in the medical record, and (2) Patient experiences with new medication regimens. RESULTS: 274 of the 376 recruited participants completed home assessment (72.8%). Among capacity indicators, most older adults (80.6%) managed medications during transition without a caregiver, 41.2% expressed low self-efficacy in managing medications and 18.3% were not able to complete basic medication administration tasks. Among task indicators, more than half (57.7%) had more than 10 discharge medications and most (94.7%) had medication regimen changes. Having more than 10 discharge medications, more than two medication regimen changes and low self-efficacy in medication management increased the risk of feeling overwhelmed (OR 2.63, 95% CI 1.08 to 6.38, OR 3.16, 95% CI 1.29 to 7.74 and OR 2.56, 95% CI 1.25 to 5.26, respectively). Low transportation independence, not having a home caregiver, low medication administration skills and more than 10 discharge medications increased the risk of medication discrepancies (incidence rate ratio 1.39, 95% CI 1.01 to 1.91, incidence rate ratio 1.73, 95% CI 1.13 to 2.66, incidence rate ratio 1.99, 95% CI 1.37 to 2.89 and incidence rate ratio 1.91, 95% CI 1.24 to 2.93, respectively). CONCLUSIONS: Patient work system factors could be assessed before discharge with indicators for increased risk of poor patient experience and medication discrepancies during older adults' care transition from hospital to home.

Feasibility of and Experience with Free State Funded Telehealth Based Patient Self-referral for COVID-19 Monoclonal Antibody Therapy.

BACKGROUND: Monoclonal antibody (mAb) treatment for COVID-19 has been underutilized due to logistical challenges, lack of access and variable treatment awareness among patients and healthcare professionals. The use of telehealth during the pandemic provides an opportunity to increase access to COVID-19 care. METHODS: This is a single-center descriptive study of telehealth-based patient self-referral for mAb therapy between March 1, 2021, to October 31, 2021 at Baltimore Convention Center Field Hospital (BCCFH). RESULTS: Among the 1001 self-referral patients, the mean age was 47, and most were female (57%) white (66%), and had a primary care provider (62%). During the study period, self-referrals increased from 14 per month in March to 427 in October resulting in a 30-fold increase. About 57% of self-referred patients received a telehealth visit, and of those 82% of patients received mAb infusion therapy. The median time from self-referral to onsite infusion was 2 days (1-3 IQR). DISCUSSION: Our study shows the integration of telehealth with a self-referral process improved access to mAb infusion. A high proportion of self-referrals were appropriate and led to timely treatment. This approach helped those without traditional avenues for care and avoided potential delay for patients seeking referral from their PCPs.

Comparison of hospitalist morale in a COVID-19 alternate care site (ACS) to hospitalist morale in conventional hospitals in Maryland.

BACKGROUND: Morale and burnout were concerns for hospitalists prior to the COVID-19 pandemic; these concerns were amplified as COVID-19 spread and hospitals experienced unprecedented stress. In contrast to prior literature, our study assesses both satisfaction and the importance of various factors. This study examines morale of hospitalists early in the COVID-19 pandemic in two settings: conventional hospitals and a COVID-19 Alternate Care site (ACS) in the same geographic region in Maryland. Multiple studies published early in the pandemic show low morale in COVID-19 hospitals. METHODS: In a cross-sectional survey study, we analyze data from the Hospitalist Morale Index (HMI) administered between September 2020 and March 2021 to determine the pandemic's impact on hospitalist morale. RESULTS: Surprisingly, our study found morale in the ACS was better than morale at the conventional hospitals. ACS hospitalists and conventional hospitalists were demographically similar. Our results show that a significantly higher proportion of conventional hospitalists reported burnout compared to the ACS hospitalists. General quality of life was rated significantly higher in the ACS group than the conventional group. Significantly more ACS hospitalists were invested in making their group outstanding. Five main HMI domains were examined with questions on a 5-point rating scale: Clinical Factors, Workload, Material Rewards, Leadership, and Appreciation/Acknowledgement. ACS hospitalists rated most measures higher than conventional hospitalists; largest differences were observed in Clinical Factors and Appreciation/Acknowledgement domains. Narrative comments from ACS hospitalists revealed strong identification with the mission of the ACS and pride in contributing during a crisis. One key difference between the two groups explains these findings: provider autonomy. The ACS staff chose the position and the assignment, while conventional hospitalists caring for COVID-19 patients could not readily opt out of this work. CONCLUSION: Our data suggest that autonomy in assignments with risk has implications for morale and burnout.

Recruitment, Readiness, and Retention of Providers at a Field Hospital During the Pandemic.

In response to the coronavirus disease (COVID-19) pandemic, the State of Maryland established a 250-bed emergency response field hospital at the Baltimore Convention Center to support the existing health care infrastructure. To operationalize this hospital with 65 full-time equivalent clinicians in less than 4 weeks, more than 300 applications were reviewed, 186 candidates were interviewed, and 159 clinicians were credentialed and onboarded. The key steps to achieve this undertaking involved employing multidisciplinary teams with experienced personnel, mass outreach, streamlined candidate tracking, pre-interview screening, utilizing all available expertise, expedited credentialing, and focused onboarding. To ensure staff preparedness, the leadership developed innovative team models, applied principles of effective team building, and provided "just in time" training on COVID-19 and non-COVID-19-related topics to the staff. The leadership focused on staff safety and well-being, offered appropriate financial remuneration, and provided leadership opportunities that allowed retention of staff.

Treating an Epidemic During a Pandemic: Experience Treating Opioid Use Disorder at the Baltimore Convention Center Field Hospital.

During the COVID-19 pandemic, access to addiction treatment has plummeted. At the same time, patients with opioid use disorder are at higher risk of COVID-19 infection and experience worse outcomes. The Baltimore Convention Center Field Hospital (BCCFH), a state-run COVID-19 disaster hospital operated by Johns Hopkins Medicine and the University of Maryland Medical System, continues to operate 14 months into the pandemic to serve as an overflow unit for the state's hospitals. BCCFH staff observed the demand for opioid use disorder care and developed admission criteria, a pharmacy formulary, and case management procedures to meet this need. This article describes generalized lessons from the BCCFH experience treating substance use disorder during a pandemic.

Lessons Learned From Implementing Rehabilitation at a COVID-19 Field Hospital.

ABSTRACT: Rehabilitation experts play an important role in preventing hospital-acquired debility, increasing patients' abilities to safely perform activities of daily living, and facilitating discharge to the home setting for patients with COVID-19. Surges in COVID-19 hospitalization rates combined with increases in length of hospital stay and decreases in postacute care placements have necessitated the opening of COVID-19 field hospitals around the country. Most field hospitals lack the resources to offer a full suite of rehabilitation services, but there are opportunities for small teams of rehabilitation experts to increase their reach by using innovative strategies. This article describes the implementation of a small team of rehabilitation experts in a COVID-19 field hospital and strategies used by this team to maximize patient activity and mobility, facilitate timely discharge, and maximize the number of patients discharged to the home setting. Strategies include training nonclinical staff to assist with activity and mobility promotion and using a rehabilitation triage system to determine needs of individual patients and facilitate efficient resource utilization. The authors reflect on successful aspects of these strategies, as well as barriers to rehabilitation implementation, and make recommendations for other field hospitals seeking to implement rehabilitation during the COVID-19 pandemic or future health crises.

Capturing the Rest: Inpatient Mammography for Nonadherent Hospitalized Women.

INTRODUCTION: More than a third of hospitalized women are overdue or nonadherent to breast cancer screening guidelines, and almost a third of them are also at high risk for developing breast cancer. The purpose of this study is to evaluate the feasibility of coordinating inpatient breast cancer screening mammography for these women before their discharge from the hospital. METHODS: A prospective intervention study was conducted among 101 nonadherent women aged 50-74 years who were hospitalized to a general medicine service. Sociodemographic, reproductive history, family history of breast cancer, and medical comorbidities data were collected for all patients from January 2015 to October 2016. The data were analyzed in March 2018. Fisher's exact tests and unpaired t-tests were utilized to compare the characteristics of the study population. RESULTS: Of the 101 women enrolled who were nonadherent to breast cancer screening recommendations, their mean age was 59.3 (SD=6) years, the mean 5-year Gail risk score was 1.63 (SD=0.69), and 29% of the women were African American. Almost 80% (n=79) underwent inpatient screening mammography. All women who underwent screening mammography during their inpatient stay were extremely satisfied with the experience. The convenience of having screening mammography while hospitalized was reported to be a major facilitator of completing the overdue screening. All nurses (100%) taking care of these women believed that this practice should become part of the standard of care, and most hospitalist physicians (66%) agreed that this practice is feasible. CONCLUSIONS: This study shows that it is possible to coordinate mammography for hospitalized women who were overdue for screening and at high risk for developing breast cancer. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT04164251.

Infection Prevention Considerations for a Multi-Mission Convention Center Field Hospital in Baltimore, Maryland, During the COVID-19 Pandemic.

The state of Maryland identified its first case of coronavirus disease 2019 (COVID-19) on March 5, 2020. The Baltimore Convention Center (BCCFH) quickly became a selected location to set up a 250-bed inpatient field hospital and alternate care site. In contrast to other field hospitals throughout the United States, the BCCFH remained open throughout the pandemic and took on additional COVID-19 missions, including community severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnostic testing, monoclonal antibody infusions for COVID-19 outpatients, and community COVID-19 vaccinations.To prevent the spread of pathogens during operations, infection prevention and control guidelines were essential to ensure the safety of staff and patients. Through multi-agency collaboration, use of infection prevention best practices, and answering what we describe as PPE-ESP, an operational framework was established to reduce infection risks for those providing or receiving care at the BCCFH during the COVID-19 pandemic.

Racial Disparities are Present in the Timing of Radiographic Assessment and Surgical Treatment of Hip Fractures.

BACKGROUND: Hip fractures are associated with 1-year mortality rates as high as 19% to 33%. Nonwhite patients have higher mortality and lower mobility rates at 6 months postoperatively than white patients. Studies have extensively documented racial disparities in hip fracture outcomes, but few have directly assessed racial disparities in the timing of hip fracture care. QUESTIONS/PURPOSES: Our purpose was to assess racial disparities in the care provided to patients with hip fractures. We asked, (1) do racial disparities exist in radiographic timing, surgical timing, length of hospital stay, and 30-day hospital readmission rates? (2) Does the hospital type modify the association between race and the outcomes of interest? METHODS: We retrospectively reviewed the records of 1535 patients aged 60 years or older who were admitted to the emergency department and treated surgically for a hip fracture at one of five hospitals (three community hospitals and two tertiary hospitals) in our health system from 2015 to 2017. Multivariable generalized linear models were used to assess associations between race and the outcomes of interest. RESULTS: After adjusting for patient characteristics, we found that black patients had a longer mean time to radiographic evaluation (4.2 hours; 95% confidence interval, -0.6 to 9.0 versus 1.2 hours; 95% CI, 0.1-2.3; p = 0.01) and surgical fixation (41 hours; 95% CI, 34-48 versus 34 hours 95% CI, 32-35; p < 0.05) than white patients did. Hospital type only modified the association between race and surgical timing. In community hospitals, black patients experienced a 51% (95% CI, 17%-95%; p < 0.01) longer time to surgery than white patients did; however, there were no differences in surgical timing between black and white patients in tertiary hospitals. No race-based differences were observed in the length of hospital stay and 30-day hospital readmission rates. CONCLUSIONS: After adjusting for patient characteristics, we found that black patients experienced longer wait times to radiographic evaluation and surgical fixation than white patients. Hospitals should consider evaluating racial disparities in the timing of hip fracture care in their health systems. Raising awareness of these disparities and implementing unconscious bias training for healthcare providers may help mitigate these disparities and improve the timing of care for patients who are at a greater risk of delay. LEVEL OF EVIDENCE: Level III, therapeutic study.

Coordination of care in breast cancer survivors: an overview.

The number of breast cancer survivors in the United States is increasing. With longer survival, there has been an increase in the complexity and duration of posttreatment care. Multidisciplinary care teams are needed to participate across the broad spectrum of issues that breast cancer survivors face. In this setting, the need for well-established patterns of communication between care providers is increasingly apparent. We have created a multidisciplinary approach to the management of breast cancer survivors to improve communication and education between providers and patients. This approach could be extended to the care and management of survivors of other types of cancer.

Comparing care for breast cancer survivors to non-cancer controls: a five-year longitudinal study.

BACKGROUND: Deficiencies in care for cancer survivors may result from unclear roles for primary care providers (PCPs) and oncology specialists in follow-up. OBJECTIVES: To compare cancer survivors' care to non-cancer controls. DESIGN: Retrospective, longitudinal, controlled study starting 366 days post-diagnosis. SUBJECTS: Stage 1-3 breast cancer survivors age 65+ diagnosed in 1998 (n = 1961) and matched non-cancer controls (n = 1961). MEASUREMENTS: Using the SEER-Medicare database, we examined the number of visits to PCPs, oncology specialists, and other physicians; receipt of influenza vaccination, cholesterol screening, colorectal cancer screening, bone densitometry, and mammography; and whether care receipt was associated with physician mix visited. RESULTS: Survivors were consistently less likely to receive influenza vaccination, cholesterol screening, colorectal cancer screening, and bone densitometry but more likely to receive mammograms than controls (all p < 0.05). Over time, colorectal cancer screening and mammography decreased and influenza vaccination increased for both groups (all p < 0.0001). Trends over time in care receipt were similar for survivors and controls. In Year 1, survivors had more visits to PCPs but fewer visits to other physicians than controls (both p < 0.05). Over time, survivors' visits to PCPs and other physicians increased and to oncology specialists decreased (all p < 0.0001). Controls' visits to PCPs increased (p < 0.0001) faster than survivors' (p = 0.003). Controls' visits to other physicians increased (p < 0.0001) at a rate similar to survivors. Survivors who visited both a PCP and oncology specialist were most likely to receive each service. CONCLUSIONS: Better coordination between PCPs and oncology specialists may improve care for older breast cancer survivors.

Prevention, screening, and surveillance care for breast cancer survivors compared with controls: changes from 1998 to 2002.

PURPOSE: To examine how care for breast cancer survivors compares with controls. PATIENTS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare database, we examined five cohorts of stages 1 to 3 breast cancer survivors diagnosed from 1998 to 2002. For each survivor cohort (defined by diagnosis year), we calculated the number of visits to oncology specialists, primary care providers (PCPs), and other physicians and the percentage who received influenza vaccination, cholesterol screening, colorectal cancer screening, bone densitometry, and mammography during survivorship year 1 (days 366 to 730 postdiagnosis). We compared survivors' care to that of five cohorts of screening controls who were matched to survivors on age, ethnicity, sex, and region and who had a mammogram in the survivor's year of diagnosis and to that of five cohorts of comorbidity controls who were matched on age, ethnicity, sex, region, and comorbidity. We examined whether survivors' care was associated with the mix of physician specialties that were visited. RESULTS: A total of 23,731 survivors were matched with 23,731 screening controls and 23,396 comorbidity controls. There was no difference in trends over time in PCP visits between survivors and either control group. The survivors' rate of increase in other physician visits was greater than screening controls (P = .002) but was no different from comorbidity controls. Survivors were less likely to receive preventive care than screening controls but were more likely than comorbidity controls. Trends over time in survivors' care tended to be better than screening controls but were no different than comorbidity controls. Survivors who visited both a PCP and oncology specialist were most likely to receive recommended care. CONCLUSION: Involvement by both PCPs and oncology specialists can facilitate appropriate care for survivors.