Storylines of family medicine XII: family medicine and the healthcare system.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XII: Family medicine and the future of the healthcare system', authors address the following themes: 'Leadership in family medicine', 'Becoming an academic family physician', 'Advocare-our call to act', 'The paradox of primary care and three simple rules', 'The quadruple aim-melding the patient and the health system', 'Fit-for-purpose medical workforce', 'Universal healthcare-coverage for all', 'The futures of family medicine' and 'The 100th essay.' May readers of these essays feel empowered to be part of family medicine's exciting future.

Value-Based Proposition of an Adapted Integrated Care Telehealth Service for Accountable Care Organization Members.

The authors describe a real-world application of virtually integrated primary and behavioral health care implemented within an accountable care organization (ACO) system. Cost-of-care data from before and after a 6-month intervention were analyzed for 121 Medicaid and Child Health Plan Plus ACO members. The intervention was associated with a significant shift in the distribution of health care costs, from inpatient and emergency care to outpatient and preventive care. The program demonstrates a flexible and replicable approach to integration that can help expand effective primary care.

Using Principles of Digital Development for a Smartphone App to Support Data Collection in Patients With Acute Myocardial Infarction and Physical Activity Intolerance: Case Study.

BACKGROUND: Advances in health have highlighted the need to implement technologies as a fundamental part of the diagnosis, treatment, and recovery of patients at risk of or with health alterations. For this purpose, digital platforms have demonstrated their applicability in the identification of care needs. Nursing is a fundamental component in the care of patients with cardiovascular disorders and plays a crucial role in diagnosing human responses to these health conditions. Consequently, the validation of nursing diagnoses through ongoing research processes has become a necessity that can significantly impact both patients and health care professionals. OBJECTIVE: We aimed to describe the process of developing a mobile app to validate the nursing diagnosis "intolerance to physical activity" in patients with acute myocardial infarction. METHODS: We describe the development and pilot-testing of a mobile system to support data collection for validating the nursing diagnosis of activity intolerance. This was a descriptive study conducted with 11 adults (aged ≥18 years) who attended a health institution for highly complex needs with a suspected diagnosis of coronary syndrome between August and September 2019 in Floridablanca, Colombia. An app for the clinical validation of activity intolerance (North American Nursing Diagnosis Association [NANDA] code 00092) in patients with acute coronary syndrome was developed in two steps: (1) operationalization of the nursing diagnosis and (2) the app development process, which included an evaluation of the initial requirements, development and digitization of the forms, and a pilot test. The agreement level between the 2 evaluating nurses was evaluated with the κ index. RESULTS: We developed a form that included sociodemographic data, hospital admission data, medical history, current pharmacological treatment, and thrombolysis in myocardial infarction risk score (TIMI-RS) and GRACE (Global Registry of Acute Coronary Events) scores. To identify the defining characteristics, we included official guidelines, physiological measurements, and scales such as the Piper fatigue scale and Borg scale. Participants in the pilot test (n=11) had an average age of 63.2 (SD 4.0) years and were 82% (9/11) men; 18% (2/11) had incomplete primary schooling. The agreement between the evaluators was approximately 80% for most of the defining characteristics. The most prevalent characteristics were exercise discomfort (10/11, 91%), weakness (7/11, 64%), dyspnea (3/11, 27%), abnormal heart rate in response to exercise (2/10, 20%), electrocardiogram abnormalities (1/10, 9%), and abnormal blood pressure in response to activity (1/10, 10%). CONCLUSIONS: We developed a mobile app for validating the diagnosis of "activity intolerance." Its use will guarantee not only optimal data collection, minimizing errors to perform validation, but will also allow the identification of individual care needs.

Patients' Reasons for Using Out-of-Network Mental and General Medical Health Providers.

OBJECTIVE: The authors sought to assess why patients use out-of-network health care providers and whether patients' reasons differ for mental and general medical health providers. METHODS: In a national Internet survey of commercial plan enrollees (N=713) who used an out-of-network provider, participants indicated whether 12 reasons were "important" (vs. "not applicable" or "not important") in their decision to see an out-of-network provider. RESULTS: Reasons for using out-of-network care were multifactorial. Six reasons were similarly important, including the three most-cited reasons: convenient location (66% vs. 69% for mental vs. general medical health, respectively), higher quality (65% vs. 69%), and affordability (70% vs. 71%). Reasons more commonly cited for using out-of-network mental health care were that in-network providers were not taking new patients (34% vs. 24%), confidentiality (33% vs. 19%), cultural competence (33% vs. 23%), and inaccurate in-network provider directories (30% vs. 22%). CONCLUSIONS: The most common reasons for using out-of-network care were cited with similar frequency for both mental health and general medical health providers.

Impacts of Norway's extended free choice reform on waiting times and hospital visits.

Norway's extended free choice (EFC) reform extends the patient's choice of publicly funded hospitals for treatment to authorized private institutions (EFC providers). We study the effects of the reform on waiting times, number of visits, and patients' Charlson Comorbidity Index scores in public hospitals. We use a difference-in-differences model to compare changes over time for public hospitals with and without EFC providers in the catchment area. Focusing on five prevalent somatic services, we find that the EFC reform did not exert pressure on public hospitals to stimulate shorter waiting times and more visits. Moreover, we do not find that the sum of public and private visits increased. When we compare patient comorbidity between public hospitals and EFC providers, we find that for non-invasive diagnostic services, patient comorbidity is lower in EFC providers. For surgical services, we detect no difference in patient comorbidities between public and EFC providers.

Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: a realist evaluation.

BACKGROUND: Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Maori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. METHODS: This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. RESULTS: The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances. DISCUSSION: Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives. CONCLUSIONS: Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish. OTHER: This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).

Palliative Care in Saudi Arabia: An Updated Assessment Following the National Vision 2030 Reforms.

Background: Palliative care (PC) plays a crucial role in improving the quality of life for terminally ill patients and their families. In Saudi Arabia, the Reform of Healthcare Vision 2030 has recognized the importance of PC and aimed to enhance its availability and quality. Objectives: This study evaluates the current state of PC in Saudi Arabia post-Vision 2030 reforms. Design: A cross-sectional survey-based research was conducted at a ministry of health health care facility to assess the accessibility and quality of PC services. Setting/Subjects: The survey collected quantitative and qualitative data from PC managers in Saudi Arabia. Retrospective analysis of annual death records determined the demand for PC. Results: The results indicate notable progress in developing PC services in Saudi Arabia, including increased number of PC units, community home care services, outpatient services, and consultations. However, challenges persist in terms of geographical distribution, resource allocation, and availability of pain medications, particularly opioids. The study highlights the substantial need for PC for both cancer and noncancer patients, emphasizing the importance of expanding these services. Conclusions: To further improve PC, policymakers and stakeholders should prioritize resource allocation, health care workforce, and access to pain medications. These efforts will address the growing demand for PC and benefit terminally ill patients and their families in Saudi Arabia.

Public Reporting and Consumer Demand in the Home Health Sector.

Health care report cards improve information and are a crucial part of health care reform of the federal government of the United States. I exploit a natural experiment in the home health sector to assess whether a higher rating under the star ratings program affects patient choice. Higher rated agencies increased their market share by 1.4% or 0.25 (95% confidence interval: [-0.63, 1.12]) percentage points, a practically and statistically insignificant amount. I find no evidence of heterogeneous effects across the rating distribution or over time. I also find precise null effects among consumers expected to be more responsive, including community-entry patients and patients in competitive markets with more options and star types. Agencies may have modestly impeded consumer choice by engaging in some patient selection behaviors, although the evidence is only weakly suggestive. The star ratings are unlikely to improve home health quality despite continued policymaker interest.

Post-Acute Care in China: Development, Challenges, and Path Forward.

OBJECTIVES: To evaluate the evolution and challenges of China's post-acute care (PAC) system over the past 20 years and suggest actionable policy recommendations for its improvement. DESIGN: A retrospective review of policies and initiatives aimed at PAC system development, analyzed alongside unsolved challenges in light of global PAC practices, informed by literature reviews and collaborative discussion. SETTING AND PARTICIPANTS: PAC in China involves diverse settings such as general hospitals, inpatient rehabilitation centers, skilled nursing facilities, community health centers, and homes. The patients are mainly those discharged from acute hospitals with functional impairment and in need of continuous care. METHOD: An extensive search of government policy documents, statistical sources, peer-reviewed studies, and the gray literature. The research team conducted literature reviews and discussions regularly to shape the findings. RESULTS: China has strengthened its PAC system through improved rehabilitation and nursing infrastructure, establishment of tiered rehabilitation networks, and adoption of innovative payment methods. However, challenges persist, including a lack of clinical consensus, resource constraints in PAC facilities and among professionals, the need for integrated care coordination, and the unification of PAC assessment tools and payment mechanisms. CONCLUSIONS AND IMPLICATIONS: Although China has made substantial progress in its PAC system over 2 decades, continued efforts are needed to address its lingering challenges. Elevating awareness of PAC's significance and instituting policy adjustments targeting these challenges are essential for the system's optimization.

Equity Implications of the Affordable Care Act Among People With Past-Year Criminal Legal Interactions.

OBJECTIVE: This study examined whether expansions of Affordable Care Act (ACA) coverage led to changes in insurance coverage and behavioral health treatment use among adults with past-year criminal legal interactions. METHODS: National Survey on Drug Use and Health data and a difference-in-differences design were used to compare changes in insurance coverage and behavioral health treatment use among respondents with a mental or substance use disorder, by past-year criminal legal involvement (N=103,818). RESULTS: Prior to ACA expansions, respondents with past-year criminal legal involvement (vs. without) were less likely to have insurance (61.5% vs. 79.3%) or to receive mental health treatment (34.7% vs. 36.3%). The ACA coverage expansions reduced insurance disparities for people with criminal legal involvement by almost 5 percentage points. No changes in behavioral health treatment use were found. CONCLUSIONS: Future policies that help people with criminal legal involvement get connected to coverage and treatment are warranted to address persistent disparities in coverage and treatment receipt.

'Having the dog as part of our family gives us hope': Experiences of the impact of assistance dogs on the occupational engagement of children with autism and their families.

BACKGROUND: Autism is a developmental disorder characterised by changes in social, communication, and behavioural performance. Assistance dogs can support children with autism to engage in everyday occupations. Despite more children being partnered with assistance dogs, there is limited research regarding the impact of assistance dogs on the occupational engagement of children with autism and their families, and further research is needed to fully understand the impact of this type of support within the Australian context. OBJECTIVES: To explore caregiver-reported experiences of an assistance dog on the occupational engagement of children with autism and their families. METHOD: Using a qualitative approach, semi-structured interviews were undertaken with six caregivers of seven children with autism, who each had an assistance dog. Interviews ranged from 45 to 60 minutes in duration. Data were transcribed verbatim and thematically analysed. Trustworthiness was maximised through independent recruitment, research team discussions, member checking, and a researcher reflective journal. FINDINGS: Three themes were identified: participation in everyday occupations prior to and after partnering with an assistance dog, increased engagement in everyday occupations, and impact of the assistance dog on the family unit. Assistance dogs were reported to progress children from community 'isolation' to 'freedom'. Participants reported the dog increased children's capacities through positively influencing completion of routines, increasing independence, and improving therapy engagement. Assistance dogs were viewed as supporting the whole family's occupational engagement. Some challenges were identified with the introduction of the assistance dog to the family unit, and with animal maintenance costs and time demands, public access rights, and limited government funding. CONCLUSION: This research identifies benefits and challenges for children who partner with autism assistance dogs. It provides insights to inform assistance animal referral, assessment, and support of assistance dogs in Australia for children with autism and occupational therapists working with them.

Association of Arizona's Implementation of a Behavioral Health Crisis Response System With Suicide Hospitalizations.

OBJECTIVE: In July 2022, the 988 Suicide and Crisis Lifeline went live. The Lifeline is part of larger federal and state efforts to build comprehensive behavioral health crisis response systems that include mobile crisis units and crisis diversion and stabilization centers. Comprehensive response systems are anticipated to reduce hospitalizations for suicide and other behavioral health crises; however, research testing this assumption has been limited. The authors used Arizona-a state known for its comprehensive crisis system-to determine the association between state implementation of a comprehensive behavioral health crisis response system and suicide-related hospitalizations. METHODS: A comparative interrupted time-series (CITS) design was used to compare changes in suicide-related hospitalizations after the 2015 implementation of Arizona's crisis response system (N=215,063). Data were from the 2010-2019 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Nevada (N=84,091 hospitalizations) was used as a comparison state because it is a western state that had not yet implemented a comprehensive crisis system and had available HCUP SID data. The CITS model included controls for time-varying differences in state demographic composition. RESULTS: From 2010 to 2014 to 2019, annual suicide-related hospitalizations in Arizona increased from 122.0 to 324.2 to 584.5, respectively, per 100,000 people, and in Nevada, hospitalizations increased from 94.7 to 263.2 to 595.5, respectively, per 100,000 people. Arizona's crisis response system was associated with a significant relative decrease in the quarterly trend of 2.57 suicide-related hospitalizations per 100,000 people (p=0.033). CONCLUSIONS: More research is needed to understand how the implementation of a comprehensive crisis response system may affect suicide-related hospitalizations.

Four System Enablers of Large-System Transformation in Health Care: A Mixed Methods Realist Evaluation.

Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. CONTEXT: Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems. METHODS: A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. FINDINGS: Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly. CONCLUSIONS: System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

Changes in State Laws Related to Coverage for Substance Use Disorder Treatment Across Insurance Sectors, 2006-2020.

OBJECTIVE: The authors assessed changes in state insurance laws related to coverage for substance use disorder treatment across public and private insurance sectors from 2006 through 2020 in all 50 U.S. states. METHODS: Structured policy surveillance methods, including a coding protocol with duplicate coding and quality controls, were used to track changes in state laws during the 2006-2020 period. The legal database Westlaw was used to identify relevant statutes within each state's commercial insurance (large group, small group, and individual), state employee health benefits, and Medicaid codes. The legal coding instrument included six questions across four themes: parity, mandated coverage, definition of substance use disorders, and enforcement and compliance. Scores were calculated to reflect the comprehensiveness of states' laws and to interpret changes in scores over time. RESULTS: Comprehensiveness scores across all sectors (on a 0-9 scale) increased, on average, from 1.47 in 2006 to 2.84 in 2020. In 2006, mean scores ranged from 0.47 (state employee sector) to 2.80 (large-group sector) and in 2020, from 1.22 (state employee) to 4.26 (large group). CONCLUSIONS: Comprehensiveness of state insurance laws in relation to substance use disorder treatment improved across all insurance sectors in 2006-2020. The State Substance Use Disorder Insurance Laws Database created in this study will aid future legal epidemiology studies in assessing the cumulative effects of parity-related insurance laws on outcomes of substance use disorder treatments.

Understanding Peerness in Recovery-Oriented Mental Health Care.

Emotional and interpersonal support systems are fundamental to recovery-oriented support programs. Peerness represents the quality of shared lived experience that enhances such support programs. Through peerness, providers of formal peer support (FPS) strategically disclose their lived experience to help service recipients reach their goals. FPS disclosure is limited compared with the kind of free sharing in mutual support programs, with FPS focusing on information that specifically helps service recipients on their recovery journey. Peerness has additional value for shared experiences relevant for diversity, equity, and inclusion efforts. This Open Forum also considers where peerness conceptually fits into research of recovery-based services.

The hopes and stakes of a public health reform. The example of New Caledonia / Espoirs et enjeux d'une réforme d'une santé publique : l'exemple de la Nouvelle-Calédonie

At a time when many of us desire fundamental reform of our health system, we return to the case of the New Caledonian Do-Kamo project. The proposed model provides interesting elements of reflection, due to it being person-centered and favoring a cultural approach to disease.

À l'heure où nous sommes nombreux à souhaiter une réforme de fond de notre système de santé, nous revenons sur l'exemple néo-calédonien en la matière avec le projet Do Kamo. Le modèle proposé peut être source d'éléments de réflexion intéressants ; en effet, il est centré sur la personne, dans une vision d'appropriation de l'approche culturelle des maladies.

Decentralizing referral prioritization to general practitioners at the primary care level: A qualitative case study based on the Grounded Theory.

BACKGROUND: Patient referral prioritizations is an essential process in coordinating healthcare delivery, since it organizes the waiting lists according to priorities and availability of resources. OBJECTIVE: This study aims to highlight the consequences of decentralizing ambulatory patient referrals to general practitioners that work as family physicians in primary care clinics. METHODS: A qualitative case study was carried out in the municipality of Rio de Janeiro. The ten health regions of Rio de Janeiro were visited during fieldwork, totalizing 35 hours of semi-structured interviews and approximately 70 hours of analysis based on the Grounded Theory. RESULTS: The findings of this study show that the obstacles to adequate referrals are beyond the management of vacancies, ranging from the standardization of prioritization criteria to ensuring the proper employment of referral protocols in diverse locations assisted by overloaded health workers with different backgrounds and perceptions. Efforts in decentralizing patient referral to primary care still face the growing dilemmas and challenges of expanding the coverage of health services while putting pressure on risk assessment, as well as sustaining the autonomy of physicians' work while respecting the eligibility when ordering waiting lists. CONCLUSION: A major strength of this work is on the method to organize and aggregate qualitative data using visual representations. Limitations concerning the reach of fieldwork in vulnerable and hardly accessible areas were overcame using snowball sampling techniques, making more participants accessible.

Sustainable Development Goals and the role of and implications for primary care physicians.

The Declaration of Alma-Ata in 1978 and the subsequent Declaration of Astana in 2018 highlight the important role of primary health care in delivering 'health for all' and supporting progress towards universal health coverage. Alongside these key declarations, the United Nations' Sustainable Development Goals (SDGs) establish an ambitious framework aimed at promoting sustainable development worldwide by addressing poverty, inequality, climate change, health and other global challenges by 2030. There has been progress in respect of many SDGs since their launch in 2015. Nevertheless, many challenges remain, and there will need to be a significant increase in effort if the 2030 targets are to be met in full. Primary health care in Malaysia has evolved in line with broader, global developments. Nonetheless, there are opportunities for the country's primary care physicians to do more to support efforts to achieve the SDGs, including those that extend beyond the health sector as conventionally defined. This paper outlines a number of areas where primary care physicians, fulfilling roles as clinicians, community members, managers of their practices and influential members of society, can contribute to promoting sustainable development in line with the SDG agenda.

Job adjustment predictive factors of healthcare midwives in health system reform in Iran.

BACKGROUND: Possessing sensitive and multiple responsibilities in the country's health system, particularly after the implementation of the health reform in Iran, midwives must be able to optimally perform their duties in their new job as healthcare providers. This study aimed to identify the factors that predict job adjustment for Iranian midwives working in healthcare. METHODS: In this cross-sectional study, 310 midwives were recruited from 209 health centers in the Iranian province of West Azerbaijan using the census method and asked to complete research questionnaires. Data were collected using job adjustment, job satisfaction, and organizational commitment scales. SPSS version 25 was used to perform ANOVA and calculate multiple linear regression coefficients for data analysis. In addition, the AMOS software was employed for path analysis and the identification of predictive variables. RESULTS: The mean age of the participants was 37.67 ± 7.1 years. Most participants (35.5%) were interested in their occupation as a midwife, and 27.1% were very interest. They had a moderate to strong tendency (76.1%) to remain in their new profession. In addition, 58.1% of participants experienced moderate job adjustment. For healthcare midwives, "desire to remain in the midwifery profession" and "organizational commitment" were significant predictors of job adjustment. "Desire to remain in the midwifery profession" directly affected midwives' job adjustment, while "interest in the new profession" had an indirect effect. Furthermore, "adequacy of income to expenses," "job satisfaction," and "organizational commitment" through the mediating role of "desire to remain in the profession" can, directly and indirectly, influence their job adjustment. CONCLUSION: To better prepare midwives for their role as healthcare providers, organizational managers should focus their efforts and plan primarily on providing incentives to increase the longevity of staying in the profession of midwifery increase job adjustment, job satisfaction, and organizational commitment, thereby improving the quality-of-service delivery.