Inquiry-The Journal of Health Care Organization Provision and Financing最新文献

The Age-Friendly Health Systems movement has demonstrated remarkable reach, with thousands of health systems now recognized as Age-Friendly. We have served as co-Editors of this Special Issue, which comes at a pivotal time in the Age-Friendly Health System movement. Published in this Special Issue are articles that meaningfully move the field forward by: (1) describing implementation and effects of Age-Friendly adoption across diverse settings of care; (2) contending with the challenge of consistent measurement of the 4Ms of Age-Friendly Care; (3) rigorously evaluating how best to implement and evaluate Age-Friendly care processes; and (4) exploring how policy levers align with Age-Friendly principles. These articles also reveal that while the Age-Friendly Movement has achieved tremendous breadth, the movement must pivot to achieve depth of clinical practice to ensure all older adults receive Age-Friendly care, and depth of research rigor to demonstrate impact and promote sustainability. To make this transition, novel tools are needed to make Age-Friendly care delivery integrated into workflows and the standard of care for older adults. In addition, alignment between payment and policy levers and Age-Friendly implementation must be expanded-including investing in higher levels of recognition that recognize depth of practice, and investment in Age-Friendly Learning Health Systems to encourage both depth of clinical practice and research rigor.

Bundled payment programs aim to align the incentives of acute and post-acute providers during an episode of care. Prior studies of the impact of bundled payments on hospital length of stay (LOS) were mixed, and none evaluated hospital exposure to bundled payments across all payers (public and commercial). In this study, we used the American Hospital Association survey data for 2016 to 2022 to compare the LOS of hospitals that participated in bundled payments to those that did not participate. We used regression analysis with interaction terms to compare the changes in LOS of hospitals that participated in bundled payments with concurrent changes in LOS of hospitals that did not participate in bundled payments. The models included hospital and year fixed effects. We also conducted subgroup analyses by payer type. All-payer LOS was not associated with participation in bundled payment (ATT 0.08 days; 95% CI -0.34, 0.17; P = .54). Participation in bundled payments was associated with slightly longer LOS for stays paid for by Medicare (ATT 0.13 days, 95% CI 0.02, 0.25; P = .03), but not for the other payer types. Bundled payment program participation had a negligible impact on hospital LOS, acknowledging the limitation that the impact might be diminished due to evaluating average LOS across all admissions rather than condition-specific bundled payment programs.

This convergent parallel mixed-methods study examined how a primary care value-based payment (VBP) model affected patient health care use and captured implementation experiences from select clinics. Focusing on outpatient care as a key step to improving outcomes, we used a difference-in-differences model to compare outpatient utilization between PCPM (the VBP model) and non-PCPM clinics, and semi-structured interviews with a subset of participating clinics to explore implementation efforts on the ground. We identified our quantitative study population (cases N = 68 807; control N = 71 695) and outcomes from Oregon's All Payer All Claims (APAC) data system and, qualitatively, we conducted 12 interviews with operational/administrative staff at 7 PCPM clinics. Our findings indicated that PCPM patients experienced greater connection to primary and specialty care-both the proportion who used care and the average amount of care used per member-relative to the control group. Primary care use rose by 4.2 percentage points (95% CI: 3.3%, 5.1%; P < .001), and specialty care by 1.1 points (95% CI: 0.4%, 1.8%; P = .002). Among users, primary care visits increased by 136.9 per 1000 member months (95% CI: 107.2, 166.6; P < .001), and specialty care by 32.1 (95% CI: 10.5, 53.7; P = .004). Qualitative findings added further context: (1) staff communication about PCPM efforts connects directly to improvements in care delivery and patient outcomes; (2) success depends on care team staff being involved in the creation of new workflows and processes; and (3) access to program data helps to identify care gaps and improve patient care delivery. We concluded that care team staff engagement in VBP models is strengthened by making the connection between VBP and direct improvements to patient care. Models that motivate staff can lead to increased connection to primary and specialty care among the clinic's patient population.

Informal caregivers provide essential support to cancer patients from diagnosis through treatment, palliative care, and end-of-life care. While their practical contributions are widely acknowledged, the emotional and psychological experiences of caregivers remain underexplored, particularly in home-based palliative care settings. Understanding these experiences is crucial to improving support and interventions for caregivers. This study explored the emotional and subjective experiences of informal caregivers providing home-based palliative care for family members with cancer, using retrospective data collected after the patient's death. A qualitative exploratory study was conducted using semi-structured interviews with 12 informal caregivers recruited from Primorsko-Goranska County, Croatia. Interviews were conducted face-to-face, audio-recorded, transcribed verbatim, and analyzed using thematic analysis to capture patterns and insights in caregivers' experiences. Analysis revealed one overarching theme, "Still Invisible but Essential," and 2 major themes: "Confronting the reality of an incurable cancer diagnosis" and "Facing the paradox - choosing between length and quality of life," encompassing 5 sub-themes. Caregivers described both rewarding and stressful aspects of care, including emotional challenges, communication difficulties, decision-making burdens, and unmet needs for professional support, alongside practical caregiving responsibilities. Informal caregivers are indispensable to home-based palliative care, yet their emotional and subjective experiences are often overlooked. Findings highlight the need for tailored interventions and support services addressing both practical and emotional aspects of caregiving, informing policy, clinical practice, and caregiver support in Croatia and similar contexts.

Telehealth has expanded access to psychotherapy for veterans, yet little is known about how art therapy is experienced in remote formats. In this paper, we describe a thematic analysis that involved male and female veterans with PTSD and TBI (aside from one participant without a TBI) in individual telehealth art therapy. This paper explores the similarities and differences in male and female veterans' engagement in art therapy. Nine veterans (6 male, 3 female) diagnosed with PTSD (with most also having TBI) participated in eight sessions of individual telehealth art therapy. Clinical notes, session summaries, and artwork were analyzed using thematic analysis to identify key patterns in veterans' therapeutic experiences. Three primary themes emerged from the data: a) Striving to manage self and emotions; b) Diverse relationships with artmaking and media; and c) Seeking to improve interpersonal connection. Telehealth art therapy supported emotional expression, trauma processing, and relational insight in veterans with PTSD and TBI. The findings underscore the value of flexible, personalized approaches in remote care and demonstrate how art therapy can be meaningfully adapted for telehealth delivery and meet the needs of diverse participants. Future research should explore hybrid models, individualized interventions, and the influence of identity and environment on therapeutic engagement and outcomes, as well as the possibly unique experiences of male and female veterans.

This paper aims to establish an intelligent delivery system integrated with track logistics and explores its impact on the clinical transportation of goods. The study analyzed hospital delivery items before and after the implementation of an intelligent delivery system combined with automated track logistics in 2023. Delivery conditions prior to the system's activation served as the control group, while those post-implementation formed the observation group. This research assesses the effects on transportation efficiency, resource allocation, transport safety, and satisfaction among medical staff. The average delivery time of goods significantly decreased following the adoption of the intelligent delivery system combined with automated track logistics (P < .01). The total number of adverse delivery-related events was reduced from 25 to 4 (P < .01). Departmental medical staff reported substantial increases in scores for delivery efficiency, error incidence, and overall satisfaction with the delivery process (P < .01). The integration of the intelligent delivery system with automated track logistics significantly enhances the efficiency of clinical goods transportation, optimizes resource allocation, ensures the safe transport of items, and improves the patient experience and clinical staff satisfaction with delivery operations. Regular system maintenance and adjustments, supported by professional technical personnel, are essential to fully leverage the system's advantages.

The 4Ms Framework is the foundation of the Age-Friendly Health System (AFHS) movement. While the framework is based on standalone evidence for each M, there is limited evidence about the impact on outcomes when practiced as a set. A composite measure capturing adherence to the many care processes that comprise the 4Ms is a necessary but complex component of closing the evidence gap. We offer a navigation guide that addresses key considerations for developing a hospital-based composite measure of 4Ms care. The Institute for Healthcare Improvement operationalizes the 4Ms Framework as a minimum set of Assessment and Act On care processes. In developing a composite measure of inpatient 4Ms adherence, we offer a 4 step framework with associated discussion of considerations related to composite measure type (eg, continuous, dichotomous), and synchrony within and across the Ms containing these care processes. Using real-world electronic health record data capturing care process adherence in the 4Ms implementation at a large academic hospital, we illustrate the considerations, and report the implications for sample size and composite measure scoring. We also present our selected composite measure-a dichotomous measure delineating 4Ms care when all encounter-level processes (those needing to be done only once during the hospital encounter) are followed and all day- and shift-level processes are followed for at least 50% of hospital days. While there is no single, standard approach to create a 4Ms composite at this early stage of the AFHS movement, as organizations develop their measure(s), our guide and the considerations we suggest should serve to inform this process and support progress toward meaningful measurement.

The Tailored Activity Program (TAP), an intervention for people living with dementia (PLWD) and their caregivers, has been shown to reduce behavioral symptoms for PLWD and caregiver burden. While TAP is proven as an evidence-based practice (EBP), it has yet to be implemented at scale. The Department of Veterans Affairs (VA) has prioritized the Age-Friendly Health System (AFHS) initiative, providing an opportunity to test implementation of TAP in a complex healthcare system. We conducted semi-structured pre-implementation interviews with leaders and clinicians at 6 VA Medical Centers (VAMCs) to engage key implementation partners and understand their unique implementation contexts. We utilized team-based rapid qualitative analysis to identify themes related to implementation determinants. We interviewed 65 unique informants in 58 interviews (5 VAMC leaders, 36 department leaders, and 17 frontline clinical staff). Informants identified 4 key factors critical to consider prior to implementing TAP: (1) alignment with organizational priorities; (2) perceived value and fit with existing clinical workflows; (3) competition with existing organizational and clinical priorities; and (4) considerations about the effect of caregiver burden on participation. We identified key factors to consider for successful implementation of a multicomponent intervention for PLWD and their caregivers within a complex healthcare system. As the AFHS initiative expands, there is a growing need for EBPs focused on the care of PLWD and their caregivers. These factors can guide clinicians, leaders, and implementation scientists in planning for implementation and sustainment of EBPs to bolster AFHS initiatives.Trial RegistrationRegistered 05 May 2021, at ISRCTN #60,657,985.Reporting GuidelinesThe COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used to ensure proper standards for reporting qualitative studies (see attached).

We examined regression models predicting health services standardized costs (HSSC) during the years preceding death using varied temporal parameters related to the dependent and independent variables. The regression models sought to elucidate how costs before the final year of life, temporal factors, and demographics are associated with costs in the final year. Anonymized data were derived from the records of Israel's largest health maintenance organization for 71,855 people aged 65+ in 2006, who died between 2008 and 2011. In the regression models, the Independent Variables of age, sex, and comorbidity (as measured by the Charlson Comorbidity Index) were significant predictors of the dependent variable of HSSC during the final year of life. However, the strongest predictor (independent variable) of the dependent variable, HSSC in the final year of life was the independent variable, HSSC in the years preceding the final year of life. Prediction was more accurate when the predicting period was closer to the predicted period. Accuracy declined as the predicted period approached death. The results provide insights into methodological considerations in the process of prediction of end-of-life expenditures, which may assist in setting methodological standards that may facilitate arriving at consistent findings in this field. While end-of-life is associated with aberrant increases in costs, that is, increases that deviate from prior predictions, significant predictions can still be made.

Current fall prevention guidelines are largely reactive to a history of falls and are thus an ineffective approach to primary fall prevention. This work aims to identify objective measures that predict fall risk to facilitate broader implementation in primary care settings. Longitudinal data were available from 952 men (48%) and women aged 60 to 97 enrolled in the Baltimore Longitudinal Study of Aging who had an index and subsequent visit approximately 2.5 years apart. Participants received objective measures at index visit and answered "yes" or "no" to the question "Have you fallen in the past 12 months?" at both visits. Main predictors included muscle strength (hamstrings/quadriceps), narrow walk, progressive static balance (semi-tandem, full tandem, single leg stance) tests and performance on conditions I and II of the modified Clinical Test of Sensory Interaction in Balance (mCTSIB). Each test was parameterized using validated methods. Logistic regression models adjusted for age, sex, race, and BMI were used to predict fall risk. Persons who failed the semi-tandem, full tandem, single leg stance, narrow walk, and condition II had, respectively, 2.59 (95% CI 1.51, 4.46), 1.57 (95% CI 1.06, 2.33), 1.54 (95% CI 1.15, 2.06), 2.21 (95% CI 1.37, 3.58), and 3.56 (95% CI 1.01, 12.57) times the odds of a future fall than persons who did not fail these tests. Observation of standing balance by assessing sway with eyes closed (condition II), ability to hold progressively challenging standing positions, or inability to traverse a narrow walk are all prognostic of a future fall. As these tests require no special equipment and take only 30 s to administer, identifying older persons at elevated risk of falling is feasible. Whether identifying persons at risk of falling can proactively prevent a future fall remains to be demonstrated.