Healthcare-The Journal of Delivery Science and Innovation最新文献

Background

Previous interventions to reduce emergency department (ED) overutilization from non-urgent visits have shown little success. At our hospital, we created an ED to primary care clinic (PCC) transfer protocol for non-urgent ED visits of established patients. Our study analyzed the impact of this protocol on patient encounters.

Methods

Chart reviews were conducted for a retrospective cohort of transfers from the ED to PCC from 9/01/17–8/31/18. Primary outcomes included length of stay (LOS), cost, and need for return to the ED. Cost savings were calculated by comparing encounters with identical primary diagnoses in the ED with internal technical and professional financial data. Secondary outcomes were final diagnoses and primary care services provided.

Results

374 patient encounters were transferred from ED to PCC. The five most common diagnoses were viral upper respiratory infection (n=80, 21.4%), dermatologic diagnoses (n=37, 9.9%), acute otitis media (n=35, 9.4%), pharyngitis (n=34, 9.1%), and influenza (n=34, 9.1%). Overall, total cost savings equaled approximately $100,000. For the top 10 diagnoses, costs were reduced from $29-$46 per $100 of ED costs and LOS was reduced by a mean of 49 min/encounter. For 9 of these 10 conditions, costs exceeded reimbursement in both settings; however, evaluation in PCC versus ED reduced the loss of revenue by 10–68%. Sixty-four encounters (17.1%) received additional primary care services. There were no safety events or inappropriate transfers.

Conclusions

This protocol provided a safe, efficient method for patients to be evaluated in their medical home while reducing non-urgent emergency visits in the ED.

Level of evidence

VI.

Engaging residents with nurses in interprofessional performance improvement teams can improve learning and care. Residents at the University of Chicago Medicine were identified by nurses, and endorsed by program directors, to serve alongside nurses in Improving GME Nursing Interprofessional Team Experiences (IGNITE) teams. Teams met monthly with improvement coaches to implement institutionally aligned improvement plans. Institutional data was used to monitor progress. The Interprofessional Collaborative Competencies Attainment Survey (ICCAS) assessed interprofessional collaboration competency. Press Ganey Clinician Engagement (PGCE) data examined year over year differences in items related to teamwork comparing IGNITE units and non-IGNITE units. Length of stay (LOS) differences were also examined. From 2015 to 2019, IGNITE spread to 9 service lines engaging over 100 residents and nurses. Unit-based teams focused on adding nurses to attending rounds, implementing nurses-resident huddles, and improving multidisciplinary rounds. ICCAS scores significantly improved. PGCE data showed year over year improvements in composite teamwork and communication scores in IGNITE units. All adult inpatient IGNITE units saw a mean LOS reduction ranging from −0.15 days to −1.16 days, equating to an estimated cost savings of nearly 3 million dollars per quarter. Lessons learned include: 1) the importance of engaging hospital leadership; 2) the need to align collaborative practices with institutional goals; 3) the critical role of coaching; and 4) practices to ensure committed, consistent participants.

Two-thirds of health professionals facing the clinical demands of responding to the Covid-19 pandemic experience psychiatric symptoms, including post-traumatic stress, anxiety, substance use, depression, insomnia, and suicide.^1,2 Compounding matters, access to mental health services is poor, quality is variable, and stigma is prevalent. COBALT, a digital mental health and wellness platform developed at Penn Medicine, was designed to support health care workers, offering a combination of self-directed resources, virtual group sessions, and individual appointments with a stepped care model of providers, including peers, resilience coaches, psychotherapists, and psychiatrists. In COBALT's first 11 months, the platform saw approximately 10,000 users, 200,000 page views, 1,400 one-on-one appointment bookings, over 1,000 group appointment reservations, and 158 interceptions of employees contemplating self-harm. COBALT reveals the unmet demand for mental health support among health professionals and provides a model for both expanding the supply of and streamlining access to services.

Background

Intensive primary care programs have had variable impacts on clinical outcomes, possibly due to a lack of consensus on appropriate patient-selection. The US Veterans Health Administration (VHA) piloted an intensive primary care program, known as Patient Aligned Care Team Intensive Management (PIM), in five medical centers. We sought to describe the PIM patient selection process used by PIM teams and to explore perspectives of PIM team members regarding how patient selection processes functioned in context.

Methods

This study employs an exploratory sequential mixed-methods design. We analyzed qualitative interviews with 21 PIM team and facility leaders and electronic health record (EHR) data from 2,061 patients screened between July 2014 and September 2017 for PIM enrollment. Qualitative data were analyzed using a hybrid inductive/deductive approach. Quantitative data were analyzed using descriptive statistics.

Results

Of 1,887 patients identified for PIM services using standardized criteria, over half were deemed inappropriate for PIM services, either because of not having an ambulatory care sensitive condition, living situation, or were already receiving recommended care. Qualitative analysis found that team members considered standardized criteria to be a useful starting point but too broad to be relied on exclusively. Additional data collection through chart review and communication with the current primary care team was needed to adequately assess patient complexity. Qualitative analysis further found that differences in conceptualizing program goals led to conflicting opinions of which patients should be enrolled in PIM.

Conclusions

A combined approach that includes clinical judgment, case review, standardized criteria, and targeted program goals are all needed to support appropriate patient selection processes.

Background

Judicious opioid prescribing and patient counseling, including in the postoperative context, are important efforts to address the U.S. opioid crisis. In discussions with patients and loved ones, there is commonly an emphasis on addiction risk. From a behavioral science standpoint, presenting addiction risk information represents a fear appeal. Clinicians may also seek to build trust and confidence by presenting balanced views of benefits and risks. However, little is known about if and how addiction risk information evokes negative emotions, affects perceptions of quality, and influences perspectives on judicious opioid prescribing.

Methods

We conducted a four-arm, randomized survey of U.S. adults involving a vignette about post-appendectomy pain management for a friend, including the quantity of opioids commonly prescribed. Participants were given either no additional information (control), addiction risk information, addiction plus health risk information, or addiction plus death risk information. We compared evoked affect, agreement with a reduced opioid prescription compared to common practice, and perceptions of quality.

Results

Among 1,546 participants (56% men, mean age 39), 78% agreed with reducing the quantity of opioids prescribed, relative to common practices. Compared to the control, providing addiction risk information did not impact the degree of evoked negative emotions or the likelihood of agreement with reduced opioid prescriptions. Providing opioid risk information increased the likelihood of high surgeon quality ratings.

Conclusions

Among a sample of U.S. adults, presenting addiction risk did not effectively appeal to fear, nor increase agreement with judicious opioid prescribing. Alternative communication strategies may be needed for those purposes.

In this article, we describe how innovation contests—a vehicle to crowdsource ideas and problem-solving efforts—propelled frontline employees to exert discretionary efforts in organizational problem-solving at Massachusetts General Hospital. As designers and administrators of four innovation contests in three disease centers, we share firsthand knowledge of how the contests enabled clinicians and administrative staff, whose primary job is delivering high-quality patient care, to become involved in ideation, selection, and implementation of their own ideas. We describe the processes that we designed and implemented, ideas that these processes generated, and findings from interviewing employees about their experiences afterwards. Our findings suggest that the benefits of implementing innovation contests were multifaceted. To employees, the contests provided a platform to voice suggestions and participate in any aspect of the innovation process that they found interesting. To managers, the contests revealed real, empirical issues affecting operation and patient care based on frontline employees’ knowledge. To the organization as a whole, the contests promoted collaborative problem-solving among likeminded, innovative employees.