Barriers, facilitators, and opportunities for Doctor of Nursing Practice engagement in translational research.

BACKGROUND: Little is known about how Doctor of Nursing Practice (DNP) graduates apply translational research competencies in the practice setting. PURPOSE: This qualitative descriptive study aimed to explore the barriers, facilitators, and opportunities for engaging in translational research among DNPs in practice. METHODS: We conducted semi-structured interviews with 11 DNPs working within an 8-hospital health system from November 2020 through July 2021. DISCUSSION: We identified four themes related to barriers (invisibility of the DNP degree and skillset; lack of role clarity and organizational structure for DNPs; lack of time for engagement in translational research; lack of support for engagement in translational research), one theme related to facilitators (encouragement from colleagues and supervisors), and two themes related to opportunities (DNP education promotes recognition of nurse role in translational research; DNPs are interested in role expansion to include translational research). CONCLUSION: DNPs have the interest and training to engage in translational research but face structural barriers to doing so.

Implementing a Machine Learning Screening Tool for Malnutrition: Insights From Qualitative Research Applicable to Other Machine Learning-Based Clinical Decision Support Systems.

BACKGROUND: Machine learning (ML)-based clinical decision support systems (CDSS) are popular in clinical practice settings but are often criticized for being limited in usability, interpretability, and effectiveness. Evaluating the implementation of ML-based CDSS is critical to ensure CDSS is acceptable and useful to clinicians and helps them deliver high-quality health care. Malnutrition is a common and underdiagnosed condition among hospital patients, which can have serious adverse impacts. Early identification and treatment of malnutrition are important. OBJECTIVE: This study aims to evaluate the implementation of an ML tool, Malnutrition Universal Screening Tool (MUST)-Plus, that predicts hospital patients at high risk for malnutrition and identify best implementation practices applicable to this and other ML-based CDSS. METHODS: We conducted a qualitative postimplementation evaluation using in-depth interviews with registered dietitians (RDs) who use MUST-Plus output in their everyday work. After coding the data, we mapped emergent themes onto select domains of the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework. RESULTS: We interviewed 17 of the 24 RDs approached (71%), representing 37% of those who use MUST-Plus output. Several themes emerged: (1) enhancements to the tool were made to improve accuracy and usability; (2) MUST-Plus helped identify patients that would not otherwise be seen; perceived usefulness was highest in the original site; (3) perceived accuracy varied by respondent and site; (4) RDs valued autonomy in prioritizing patients; (5) depth of tool understanding varied by hospital and level; (6) MUST-Plus was integrated into workflows and electronic health records; and (7) RDs expressed a desire to eventually have 1 automated screener. CONCLUSIONS: Our findings suggest that continuous involvement of stakeholders at new sites given staff turnover is vital to ensure buy-in. Qualitative research can help identify the potential bias of ML tools and should be widely used to ensure health equity. Ongoing collaboration among CDSS developers, data scientists, and clinical providers may help refine CDSS for optimal use and improve the acceptability of CDSS in the clinical context.

Benefits of an Early Mobility Program for Hospitalized Patients With Cancer.

PURPOSE: Patients with cancer are often hospitalized with complications from cancer and cancer treatment. Many experience a decline in physical functioning, including loss of mobility, which likely contributes to increased length of stay (LOS) and increased readmissions. We aimed to determine whether a mobility program would improve quality of care and decrease health care utilization. METHODS: We implemented a mobility aide program on an oncology unit in a large academic medical center for all patients without bedrest orders between October 1, 2018, and February 28, 2021. The program consisted of nursing evaluation using the Activity Measure for Post-Acute Care (AMPAC), an ordinal scale ranging from bed rest to ambulating ≥ 250 feet, to quantify mobility. Plan of care was determined in a multidisciplinary manner with physical therapy (PT), nursing, and a mobility aide, who is a medical assistant with enhanced rehabilitation training. Patients were then mobilized two times per day 7 days a week. Using descriptive statistics and mixed effects logistic regression, we evaluated the programs impact on LOS, readmissions, and changes in mobility during this time period compared with the 6-month interval before implementation. RESULTS: A total of 1,496 hospitalized patients were identified. The odds of hospital readmission within 30 days of discharge was significantly less for those who received the intervention (OR, 0.53; 95% CI, 0.37 to 0.78; P = .001). The odds ratio (OR) of having a final AMPAC score at or above the median was significantly higher for those who received the intervention (OR, 1.60; 95% CI, 1.04 to 2.45; P < .05). There was no significant difference in LOS. CONCLUSION: Use of this mobility program resulted in a significant decrease in readmissions and maintained or improved patients' mobility. This demonstrates that non-PT professionals can effectively mobilize hospitalized patients with cancer, thereby decreasing the burden on PT and nursing resources. Future work will evaluate the sustainability of the program and evaluate association with health care costs.

Access to Hepatitis C Treatment during and after Incarceration in New Jersey, United States: A Qualitative Study.

Despite effective antiviral therapy for hepatitis C virus (HCV), people who are incarcerated and those returning to the community face challenges in obtaining HCV treatment. We aimed to explore facilitators and barriers to HCV treatment during and after incarceration. From July-November 2020 and June-July 2021, we conducted 27 semi-structured interviews with residents who were formerly incarcerated in jail or prison. The interviews were audio-recorded and professionally transcribed. We used descriptive statistics to characterize the study sample and analyzed qualitative data thematically using an iterative process. Participants included five women and 22 men who self-identified as White (n = 14), Latinx (n = 8), and Black (n = 5). During incarceration, a key facilitator was having sufficient time to complete HCV treatment, and the corresponding barrier was delaying treatment initiation. After incarceration, a key facilitator was connecting with reentry programs (e.g., halfway house or rehabilitation program) that coordinated the treatment logistics and provided support with culturally sensitive staff. Barriers included a lack of insurance coverage and higher-ranking priorities (e.g., managing more immediate reentry challenges such as other comorbidities, employment, housing, and legal issues), low perceived risk of harm related to HCV, and active substance use. Incarceration and reentry pose distinct facilitators and challenges to accessing HCV treatment. These findings signal the need for interventions to improve engagement in HCV care both during and after incarceration to assist in closing the gap of untreated people living with HCV.

A changing supply chain for a changing health care system: Barriers and facilitators of implementing enterprise resource planning.

BACKGROUND: No studies have examined how health care mergers and acquisitions affected the hospital supply chain and its employees since the passing of the Patient Protection and Affordable Care Act. OBJECTIVE: To describe the barriers and facilitators of digital transformation in a hospital supply chain from the employee perspective. METHODS: We conducted two rounds of interviews, one year apart, with supply chain employees at an urban academic health system preparing to adopt an enterprise resource planning (ERP) software (N = 11 in Round I and N = 8 in Round II). Two researchers coded transcripts for themes using NVivo 11. RESULTS: We identified the following barriers to technology integration: silos between supply chain groups (e.g. Purchasing, Information Management, Strategic Sourcing), between employees and management, and resulting from prior mergers; focus on short-term problems and fear of change; and lack of transparent communication about upcoming changes. Facilitators of technology integration included motivation to work in supply chain; long-term vision that allowed tolerance of change and positive outlook; and transparent communication. CONCLUSION: Desire for shared leadership among employees emerged as a major theme, indicating the need for active involvement of employees during transition to new integrative technology.

A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.

Feasibility of the Transport PLUS intervention to improve the transitions of care for patients transported home by ambulance: a non-randomized pilot study.

BACKGROUND: The growing population of patients over the age of 65 faces particular vulnerability following discharge after hospitalization or an emergency room visit. Specific areas of concern include a high risk for falls and poor comprehension of discharge instructions. Emergency medical technicians (EMTs), who frequently transport these patients home from the hospital, are uniquely positioned to aid in mitigating transition of care risks and are both trained and utilized to do so using the Transport PLUS intervention. METHODS: Existing literature and focus groups of various stakeholders were utilized to develop two checklists: the fall safety assessment (FSA) and the discharge comprehension assessment (DCA). EMTs were trained to administer the intervention to eligible patients in the geriatric population. Using data from the checklists, follow-up phone calls, and electronic health records, we measured the presence of hazards, removal of hazards, the presence of discharge comprehension issues, and correction or reinforcement of comprehension. These results were validated during home visits by community health workers (CHWs). Feasibility outcomes included patient acceptance of the Transport PLUS intervention and accuracy of the EMT assessment. Qualitative feedback via focus groups was also obtained. Clinical outcomes measured included 3-day and 30-day readmission or ED revisit. RESULTS: One-hundred three EMTs were trained to administer the intervention and participated in 439 patient encounters. The intervention was determined to be feasible, and patients were highly amenable to the intervention, as evidenced by a 92% and 74% acceptance rate of the DCA and FSA, respectively. The majority of patients also reported that they found the intervention helpful (90%) and self-reported removing 40% of fall hazards; 85% of such changes were validated by CHWs. Readmission/revisit rates are also reported. CONCLUSIONS: The Transport PLUS intervention is a feasible, easily implemented tool in preventative community paramedicine with high levels of patient acceptance. Further study is merited to determine the effectiveness of the intervention in reducing rates of readmission or revisit. A randomized control trial has since begun utilizing the knowledge gained within this study.

Innovating in a crisis: a qualitative evaluation of a hospital and Google partnership to implement a COVID-19 inpatient video monitoring program.

OBJECTIVE: To describe adaptations necessary for effective use of direct-to-consumer (DTC) cameras in an inpatient setting, from the perspective of health care workers. METHODS: Our qualitative study included semi-structured interviews and focus groups with clinicians, information technology (IT) personnel, and health system leaders affiliated with the Mount Sinai Health System. All participants either worked in a coronavirus disease 2019 (COVID-19) unit with DTC cameras or participated in the camera implementation. Three researchers coded the transcripts independently and met weekly to discuss and resolve discrepancies. Abiding by inductive thematic analysis, coders revised the codebook until they reached saturation. All transcripts were coded in Dedoose using the final codebook. RESULTS: Frontline clinical staff, IT personnel, and health system leaders (N = 39) participated in individual interviews and focus groups in November 2020-April 2021. Our analysis identified 5 areas for effective DTC camera use: technology, patient monitoring, workflows, interpersonal relationships, and infrastructure. Participants described adaptations created to optimize camera use and opportunities for improvement necessary for sustained use. Non-COVID-19 patients tended to decline participation. DISCUSSION: Deploying DTC cameras on inpatient units required adaptations in many routine processes. Addressing consent, 2-way communication issues, patient privacy, and messaging about video monitoring could help facilitate a nimble rollout. Implementation and dissemination of inpatient video monitoring using DTC cameras requires input from patients and frontline staff. CONCLUSIONS: Given the resources and time it takes to implement a usable camera solution, other health systems might benefit from creating task forces to investigate their use before the next crisis.

A Mixed-methods Assessment of the Impact of Insurance Issues on the Emotional and Physical Health of Patients With Inflammatory Bowel Disease.

BACKGROUND: In patients with inflammatory bowel disease (IBD), failure to adhere to treatment regimens due to insurance issues can lead to disease complications. Our aim was to examine patients' perceptions of the impact of insurance issues on their health. METHODS: Twenty-nine patients with IBD at a large US academic center and an insurance issue participated in a mixed-methods study. Retrospective chart review and an online questionnaire were completed to collect demographic information, IBD characteristics, and validated resilience scores. Semistructured interviews were completed for insurance experiences, which were coded independently by 2 coders for themes. RESULTS: Twenty-nine patients completed the interview, and 24 completed the online survey. Sixteen had Crohn's disease, 13 had ulcerative colitis, and 66% were female. The most common insurance issue was lapsed insurance. Many experienced physical consequences, with 58% having flares, 14% undergoing surgery, and 14% developing antibodies. All emotional responses were negative, with the majority feeling stressed (38%). Providers were uninformed of insurance issues in 28% of cases. When asked about perceived resilience, 41% felt incapable of managing the situation, and 45% gave up trying to solve the problem. When asked how to improve going forward, 38% requested an easily accessible advocate to guide them. CONCLUSIONS: A large proportion of our cohort chose not to inform their provider, felt incapable of managing on their own, and gave up on resolving their insurance issue. This highlights the need to consider restructuring the insurance system, to identify those at risk for insurance issues, and to make advocates available to avoid devastating consequences.

Few studies have qualitatively examined the impact of insurance issues on the health of patients with IBD. We highlight the need to identify patients at risk of insurance issues and when they occur so as to make advocates available to avoid disease complications.

Improving Postpartum Care: Identifying Opportunities to Reduce Postpartum Emergency Room Visits Among Publicly-Insured Women of Color.

BACKGROUND/OBJECTIVES: The purpose of this study was to explore the postpartum experiences of publicly-insured women of color, and identify how postpartum care can be improved to reduce hospital emergency department usage after delivery. METHODS: We conducted four focus groups with 18 publicly-insured women who primarily self-identified as Black and/or Latina and gave birth between June 1, 2019 and May 1, 2020. We used inductive qualitative analysis to identify prominent themes from focus group discussions. RESULTS: We identified four domains: (1) lack of access to and communication with a medical team; (2) lack of preparation; (3) value of social support; and (4) participant-identified opportunities for improvement. CONCLUSIONS FOR PRACTICE: This study describes the postpartum experiences of publicly-insured women of color with the objective of identifying areas for intervention to reduce postpartum emergency department usage. Our findings suggest that focused efforts on enhancing continuity of care to increase healthcare access, strengthening patient-provider communication by training providers to recognize unconscious bias, increasing postpartum preparation by adapting teaching materials to an online format, and engaging women's caregivers throughout the pregnancy course to bolster social support, may be beneficial.

Photovoice as a tool to improve patient-Provider communication in inflammatory bowel disease clinic: A feasibility study.

BACKGROUND: The emotional health of patients with inflammatory bowel disease (IBD) is critical to self-management, but has been difficult to elucidate in routine care. Patients are often unsure how to communicate their preferences and concerns to their providers in ways that could directly inform shared decision making. Photovoice is an established research methodology used to give vulnerable patients a voice through photographic expression, but has not been previously used in gastroenterology or in IBD. OBJECTIVE: To determine the acceptability and feasibility of using Photovoice in an IBD clinic. PATIENT INVOLVEMENT: Patients with IBD took photos in response to open-ended prompts, participated in a focus group, and brainstormed ways to share their experience with clinicians. METHODS: Enrolled IBD patients received a digital camera, training on basic usage and 10 open-ended prompts related to management of their IBD. Participants completed one-hour in-depth interviews about their photos, which were audio-recorded and professionally transcribed. Three analysts coded transcripts for themes using qualitative analysis software QSR NVivo 11. A subset of patients participated in a focus group about their Photovoice experience. Gastroenterologists were interviewed, using patient photos as prompts, to evaluate feasibility of using Photovoice in the clinic. RESULTS: Eleven patients completed the interviews, with five participating in the focus group. Patients shared and discussed a total of 118 photographs. We identified two major themes: disease burden and patient - provider communication. Five IBD physicians reviewed select patient photos and suggested ways to incorporate Photovoice into clinical practice. DISCUSSION: Photovoice may be a feasible methodology for patients with IBD and acceptable for providers to use in a clinical setting. PRACTICAL VALUE: Photovoice may help providers identify patient concerns and make their communication more patient-centred.

Resilience-based Integrated IBD Care Is Associated With Reductions in Health Care Use and Opioids.

BACKGROUND & AIMS: Integrated inflammatory bowel disease (IBD) care is effective but not routinely implemented. Validated methods that simultaneously address mind and body targets such as resilience may improve access and outcomes. We describe the development and implementation of the GRITT method and its impact on resilience, health care utilization (HCU), and opioid use in IBD. METHODS: Consecutive patients from an academic IBD center were evaluated for low resilience on the basis of provider referral. Low resilience patients were invited to participate in the GRITT program. Primary outcome was % reduction in HCU. Secondary outcomes were change in resilience and corticosteroid and opioid use. Patients were allocated into 2 groups for analysis: GRITT participants (GP) and non-participants (NP). Clinical data and HCU in the year before enrollment were collected at baseline and 12 months. One-way repeated measures multivariate analysis of covariance evaluated group × time interactions for the primary outcome. Effect size was calculated for changes in resilience over time. RESULTS: Of 456 screened IBD patients 394 were eligible, 184 GP and 210 NP. GP had greater reduction in HCU than NP: 71% reduction in emergency department visits, 94% reduction in unplanned hospitalizations. There was 49% reduction in opioid use and 73% reduction in corticosteroid use in GP. Resilience increased by 27.3 points (59%), yielding a large effect size (d = 2.4). CONCLUSIONS: Mind-body care that focuses on building resilience in the context of IBD care may be a novel approach to reduce unplanned HCU and opioid use, but large, multicenter, randomized controlled trials are needed.

"There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19.

The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York.

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey.

OBJECTIVES: Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. DESIGN: Mixed-methods national survey. SETTING AND PARTICIPANTS: HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. METHODS: Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. RESULTS: Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). CONCLUSIONS AND IMPLICATIONS: HBPC practices experienced a wide array of COVID-19-related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.

Empowered transitions: Understanding the experience of transitioning from pediatric to adult care among adolescents with inflammatory bowel disease and their parents using photovoice.

OBJECTIVE: To identify barriers and facilitators of pediatric to adult transitions among adolescents with IBD and their parents. METHODS: This cross-sectional study used photovoice to explore adolescent and parent perspectives on transitions in IBD care. Adolescents with IBD aged 14-23 and their parents were recruited from an urban IBD center during clinic visits. Participants completed a survey, took photos, participated in a semi-structured interview, and optionally participated in a focus group. Interviews were recorded and transcribed. Two analysts coded interview data for themes using MAXQDA software. RESULTS: Thirteen adolescents and eleven parents submitted photos and participated in an interview. The mean patient age was 19.0 ± 3.0. The mean parent age was 51.5 ± 5.4. Eleven (84.6%) adolescents were Caucasian; 12 (92.3%) privately insured; 4 (30.8%) in high school, 5 (38.4%) in college, and 4 (30.8%) in the workforce. Adolescent transition-readiness, resilience, and IBD-related self-efficacy scores were relatively high, with high agreement between patient self-report and parent-reported children's resilience; parents over-estimated their children's IBD-related self-efficacy. Participants discussed barriers to transitions including psychological distress, disease uncertainty, gut-brain axis-related issues, a lack of understanding by people unaffected by IBD, and frequent life disruptions. Facilitators of transitions included having a disease narrative, deliberately shifting responsibility for disease management tasks, positivity/optimism, social support, engagement with the IBD community, and mental health support. CONCLUSION: Attention to psychosocial issues is warranted during the transition process from pediatric to adult IBD care, specifically related to understanding the gut-brain axis and accessing resources to optimize mental health and well-being among transition-aged adolescents and their caregivers.

"At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19.

BACKGROUND/OBJECTIVES: COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide. DESIGN: Cross-sectional qualitative design using semi-structured interviews. SETTING: HBPC practices in the NYC metro area during spring 2020. PARTICIPANTS: HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices. MEASUREMENTS: Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. RESULTS: Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients. CONCLUSION: NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.

Developing an Institute for Health Care Delivery Science: successes, challenges, and solutions in the first five years.

Medical knowledge is increasing at an exponential rate. At the same time, unexplained variations in practice and patient outcomes and unacceptable rates of medical errors and inefficiencies in health care delivery have emerged. Our Institute for Health Care Delivery Science (I-HDS) began in 2014 as a novel platform to conduct multidisciplinary healthcare delivery research. We followed ten strategies to develop a successful institute with excellence in methodology and strong understanding of the value of team science. Our work was organized around five hubs: 1) Quality/Process Improvement and Systematic Review, 2) Comparative Effectiveness Research, Pragmatic Clinical Trials, and Predictive Analytics, 3) Health Economics and Decision Modeling, 4) Qualitative, Survey, and Mixed Methods, and 5) Training and Mentoring. In the first 5 years of the I-HDS, we have identified opportunities for change in clinical practice through research using our health system's electronic health record (EHR) data, and designed programs to educate clinicians in the value of research to improve patient care and recognize efficiencies in processes. Testing the value of several model interventions has guided prioritization of evidence-based quality improvements. Some of the changes in practice have already been embedded in the EHR workflow successfully. Development and sustainability of the I-HDS has been fostered by a mix of internal and external funding, including philanthropic foundations. Challenges remain due to the highly competitive funding environment and changes needed to adapt the EHR to healthcare delivery research. Further stakeholder engagement and culture change working with hospital leadership and I-HDS core and affiliate members continues.

Can multidisciplinary team meetings reduce burnout?

Burnout is an epidemic affecting between a third and two-thirds of health care providers in the US. The prevalence and impact of burnout in the health care workforce is increasing, and most interventions thus far have shown limited efficacy. In an ongoing mixed-methods study of establishing a specialty medical home, providers reported gaining interprofessional learning and collegiate support through a patient-centered weekly team meeting that they believed was protective of burnout. Further research is needed into whether medical home models can improve not only patient, but also provider wellbeing.