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Pediatric emergency department to primary care transfer protocol: Transforming access for patients’ needs 儿科急诊科到初级保健的转诊方案:改变病人需要的途径
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-09-01 DOI: 10.1016/j.hjdsi.2022.100643
S. Barron Frazier, James C. Gay, Shari Barkin, Michelle Graham, Michele Walsh, Kathryn Carlson

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.

背景以前的干预措施,以减少急诊室(ED)的过度使用从非紧急访问显示很少成功。在我们医院,我们创建了一个急诊室到初级保健诊所(PCC)的转移方案,用于非紧急急诊科就诊的既定患者。我们的研究分析了该方案对患者接触的影响。方法对2017年1月9日至2018年8月31日从急诊科转至PCC的回顾性队列进行回顾性分析。主要结果包括住院时间(LOS)、费用和返回急诊科的需要。通过比较急诊科相同的初次诊断与内部技术和专业财务数据的接触,计算节省的费用。次要结局是最终诊断和提供的初级保健服务。结果374例患者从急诊科转至急诊科。最常见的5种诊断为病毒性上呼吸道感染(n=80, 21.4%)、皮肤病诊断(n=37, 9.9%)、急性中耳炎(n=35, 9.4%)、咽炎(n=34, 9.1%)和流感(n=34, 9.1%)。总的来说,节省的总费用约为10万美元。对于前10名的诊断,每100美元的ED费用从29美元减少到46美元,平均每次就诊时间减少49分钟。对于这10种情况中的9种,两种情况下的费用都超过了报销;然而,与ED相比,PCC的评估减少了10-68%的收入损失。64例(17.1%)获得了额外的初级保健服务。没有安全事件或不适当的转移。结论:该方案为患者提供了一种安全、有效的方法,可在其医疗家中对患者进行评估,同时减少ed的非紧急急诊就诊。
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引用次数: 3
Implementation and evaluation of IGNITE (Improving GME Nursing Interprofessional Team Experiences) to improve care in an academic health system 实施和评估IGNITE(改善GME护理跨专业团队经验)以改善学术卫生系统的护理
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-09-01 DOI: 10.1016/j.hjdsi.2022.100642
Vineet M. Arora , Aviva Klein , Alesia Coe , Ajanta Patel , Debra Albert , Anita Blanchard , For the IGNITE/PEI Steering Committee

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.

在跨专业绩效改进团队中,让住院医生与护士一起参与可以改善学习和护理。芝加哥大学医学院的住院医师由护士确定,并得到项目主管的认可,与护士一起在改善GME护理跨专业团队体验(IGNITE)团队中服务。团队每月与改进教练会面,以实施与机构一致的改进计划。机构数据被用来监测进展情况。跨专业协作能力获得调查(ICCAS)评估了跨专业协作能力。Press Ganey临床医生参与(PGCE)数据检查了每年与团队合作相关的项目比较IGNITE单位和非IGNITE单位的差异。停留时间(LOS)的差异也被检查。从2015年到2019年,IGNITE扩展到9条服务线路,涉及100多名住院医生和护士。以单位为基础的小组侧重于增加护士参加查房,实施护士-住院医师会议,以及改进多学科查房。ICCAS评分显著提高。PGCE数据显示,IGNITE单元的综合团队合作和沟通得分逐年提高。所有成人住院IGNITE单位的平均LOS减少从- 0.15天到- 1.16天不等,相当于每个季度估计节省近300万美元的成本。经验教训包括:1)医院领导参与的重要性;2)需要将协作实践与机构目标保持一致;3)教练的关键作用;4)实践,以确保承诺,一致的参与者。
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引用次数: 1
COBALT: Supporting the mental well-being of the health care workforce with technology-facilitated care during Covid-19 and beyond 钴:在2019冠状病毒病期间及以后,通过技术便利的护理支持卫生保健人员的心理健康
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-09-01 DOI: 10.1016/j.hjdsi.2022.100640
Cecilia Livesey, Kelley Kugler, Jack J. Huang, Eleanor Burton, Avanti Rangnekar, Grace Vojta, Maria A. Oquendo, Lisa Bellini, David A. Asch

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.

在面临应对Covid-19大流行临床需求的卫生专业人员中,有三分之二的人出现精神症状,包括创伤后应激障碍、焦虑、药物使用、抑郁、失眠和自杀。1,2更复杂的是,获得精神卫生服务的机会很少,质量参差不齐,而且普遍存在耻辱。宾夕法尼亚大学医学院(Penn Medicine)开发的数字心理健康和保健平台COBALT旨在为医护人员提供支持,提供自我指导资源、虚拟小组会议和个人预约的组合,并提供阶梯护理模式,包括同伴、弹性教练、心理治疗师和精神科医生。在COBALT的前11个月里,该平台获得了大约1万名用户,20万次页面浏览量,1400次一对一预约,1000多次团体预约,并拦截了158名想要自残的员工。《钴》揭示了保健专业人员对心理健康支助的需求未得到满足的情况,并为扩大服务供应和简化服务获取提供了一个模式。
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引用次数: 0
Putting the design in health system redesign: Accounting for anchoring effects 将设计纳入卫生系统重新设计:考虑锚定效应
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-09-01 DOI: 10.1016/j.hjdsi.2022.100644
Joseph H. Joo , Joshua M. Liao
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引用次数: 1
Patient selection strategies in an intensive primary care program 重症初级保健项目中的患者选择策略
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-06-01 DOI: 10.1016/j.hjdsi.2022.100627
Elizabeth Hulen , Avery Z. Laliberte , Marian L. Katz , Karleen F. Giannitrapani , Evelyn T. Chang , Susan E. Stockdale , Jessica A. Eng , Elvira Jimenez , Samuel T. Edwards

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.

背景:密集的初级保健计划对临床结果有不同的影响,可能是由于在适当的患者选择上缺乏共识。美国退伍军人健康管理局(VHA)在五个医疗中心试点了一项名为“患者联合护理团队强化管理”(PIM)的强化初级保健计划。我们试图描述PIM团队使用的PIM患者选择过程,并探索PIM团队成员关于患者选择过程如何在上下文中起作用的观点。方法本研究采用探索性顺序混合方法设计。我们分析了对21名PIM团队和设施负责人的定性访谈,以及2014年7月至2017年9月期间为PIM登记筛选的2061名患者的电子健康记录(EHR)数据。定性数据分析采用混合归纳/演绎方法。定量资料采用描述性统计进行分析。结果使用标准化标准确定的1887例PIM服务患者中,超过一半的患者被认为不适合PIM服务,要么是因为没有门诊护理敏感条件、生活状况,要么已经接受了推荐的护理。定性分析发现,团队成员认为标准化标准是一个有用的起点,但过于宽泛,不能完全依赖。需要通过图表审查和与当前初级保健团队的沟通来收集额外的数据,以充分评估患者的复杂性。定性分析进一步发现,对项目目标概念化的差异导致了对哪些患者应该参加PIM的意见冲突。结论临床判断、病例回顾、标准化标准和有针对性的项目目标都需要综合方法来支持适当的患者选择过程。
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引用次数: 2
Effects of opioid addiction risk information on Americans’ agreement with postoperative opioid minimization and perceptions of quality 阿片类药物成瘾风险信息对美国人术后阿片类药物最小化和质量感知的影响
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-06-01 DOI: 10.1016/j.hjdsi.2022.100629
Irene Y. Zhang , David R. Flum , Nidhi Agrawal , Joshua M. Liao

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.

明智的阿片类药物处方和患者咨询,包括在术后背景下,是解决美国阿片类药物危机的重要努力。在与患者和亲人的讨论中,通常会强调成瘾风险。从行为科学的角度来看,呈现成瘾风险信息代表了一种恐惧诉求。临床医生也可以通过提出利益和风险的平衡观点来寻求建立信任和信心。然而,关于成瘾风险信息是否以及如何引起负面情绪,影响对质量的感知,以及影响对明智的阿片类药物处方的看法,人们知之甚少。方法:我们对美国成年人进行了一项四组随机调查,涉及一个朋友关于阑尾切除术后疼痛管理的小短文,包括常用阿片类药物的数量。参与者要么没有获得额外信息(对照组),要么获得成瘾风险信息,要么获得成瘾加健康风险信息,要么获得成瘾加死亡风险信息。我们比较了诱发的影响,与常规做法相比,减少阿片类药物处方的一致性,以及对质量的感知。结果在1546名参与者中(56%的男性,平均年龄39岁),78%的人同意减少处方阿片类药物的数量,相对于常规做法。与对照组相比,提供成瘾风险信息并不影响诱发负面情绪的程度或减少阿片类药物处方的可能性。提供阿片类药物风险信息增加了外科医生高质量评分的可能性。结论:在美国成年人的样本中,呈现成瘾风险并不能有效地引起恐惧,也不能增加对明智的阿片类药物处方的认同。为了达到这些目的,可能需要其他的沟通策略。
{"title":"Effects of opioid addiction risk information on Americans’ agreement with postoperative opioid minimization and perceptions of quality","authors":"Irene Y. Zhang ,&nbsp;David R. Flum ,&nbsp;Nidhi Agrawal ,&nbsp;Joshua M. Liao","doi":"10.1016/j.hjdsi.2022.100629","DOIUrl":"10.1016/j.hjdsi.2022.100629","url":null,"abstract":"<div><h3>Background</h3><p>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.</p></div><div><h3>Methods</h3><p>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.</p></div><div><h3>Results</h3><p>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.</p></div><div><h3>Conclusions</h3><p>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.</p></div>","PeriodicalId":29963,"journal":{"name":"Healthcare-The Journal of Delivery Science and Innovation","volume":"10 2","pages":"Article 100629"},"PeriodicalIF":2.5,"publicationDate":"2022-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44486094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Putting the design in health system redesign: Minimizing cognitive load 将设计纳入卫生系统的重新设计:最大限度地减少认知负荷。
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-06-01 DOI: 10.1016/j.hjdsi.2022.100625
Joshua M. Liao
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引用次数: 1
Increasing value and facilitating adoption of telehealth in the post-COVID era: An interview with chair of the American Telemedicine Association Joseph Kvedar 在后covid时代增加远程医疗的价值并促进采用:对美国远程医疗协会主席Joseph Kvedar的采访
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-06-01 DOI: 10.1016/j.hjdsi.2022.100624
Kaushik P. Venkatesh MBA, MPH, Nathan Mallipeddi BS
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引用次数: 2
International Medical Graduates and practice rates in underserved communities in Florida 佛罗里达服务不足社区的国际医学毕业生和执业率
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-06-01 DOI: 10.1016/j.hjdsi.2022.100628
Nishant Uppal , Elizabeth T. Chin , Caroline H. Lee , Parsa Erfani , Katherine R. Peeler
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引用次数: 0
Engaging frontline employees using innovation contests: Lessons from Massachusetts General Hospital 利用创新竞赛吸引一线员工:麻省总医院的经验教训
IF 2.5 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2022-06-01 DOI: 10.1016/j.hjdsi.2022.100615
Olivia S. Jung PhD , Julia Jackson MBA , Maulik Majmudar MD , Paula McCree MS , Eric M. Isselbacher MD, MSc

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.

在这篇文章中,我们描述了创新竞赛——一种众包想法和解决问题努力的工具——如何推动麻省总医院的一线员工在组织解决问题方面发挥自由裁量的努力。作为三个疾病中心四个创新竞赛的设计者和管理者,我们分享第一手的知识,这些竞赛如何使临床医生和行政人员,他们的主要工作是提供高质量的病人护理,参与到他们自己的想法的构思、选择和实施中。我们描述了我们设计和实施的流程,这些流程产生的想法,以及之后对员工的采访结果。我们的研究结果表明,实施创新竞赛的好处是多方面的。对员工来说,这些竞赛提供了一个平台,让他们提出建议,并参与到他们感兴趣的创新过程的任何方面。对管理人员来说,这些竞赛揭示了影响手术和病人护理的真实的、经验性的问题,这些问题基于一线员工的知识。对于整个组织来说,这些竞赛促进了志同道合、具有创新精神的员工之间的协作解决问题。
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引用次数: 7
期刊
Healthcare-The Journal of Delivery Science and Innovation
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