Showing papers on "Integrated care published in 2021"

Internet of Things for In-Home Health Monitoring Systems: Current Advances, Challenges and Future Directions

Abstract: Internet of Things has been one of the catalysts in revolutionizing conventional healthcare services. With the growing society, traditional healthcare systems reach their capacity in providing sufficient and high-quality services. The world is facing the aging population and the inherent need for assisted-living environments for senior citizens. There is also a commitment by national healthcare organizations to increase support for personalized, integrated care to prevent and manage chronic conditions. Many applications related to In-Home Health Monitoring have been introduced over the last few decades, thanks to the advances in mobile and Internet of Things technologies and services. Such advances include improvements in optimized network architecture, indoor networks coverage, increased device reliability and performance, ultra-low device cost, low device power consumption, and improved device and network security and privacy. Current studies of in-home health monitoring systems presented many benefits including improved safety, quality of life and reduction in hospitalization and cost. However, many challenges of such a paradigm shift still exist, that need to be addressed to support scale-up and wide uptake of such systems, including technology acceptance and adoption by patients, healthcare providers and policymakers. The aim of this paper is three folds: First, review of key factors that drove the adoption and growth of the IoT-based in-home remote monitoring; Second, present the latest advances of IoT based in-home remote monitoring system architecture and key building blocks; Third, discuss future outlook and our recommendations of the in-home remote monitoring applications going forward.

Impact of multimorbidity on healthcare costs and utilisation: a systematic review of the UK literature

Abstract: Background Managing multimorbidity is complex for both patients and healthcare systems. Patients with multimorbidity often use a variety of primary and secondary care services. Country-specific research exploring the healthcare utilisation and cost consequences of multimorbidity may inform future interventions and payment schemes in the UK. Aim To assess the relationship between multimorbidity, healthcare costs, and healthcare utilisation; and to determine how this relationship varies by disease combinations and healthcare components. Design and setting A systematic review. Method This systematic review followed the bidirectional citation searching to completion method. MEDLINE and grey literature were searched for UK studies since 2004. An iterative review of references and citations was completed. Authors from all articles selected were contacted and asked to check for completeness of UK evidence. The National Institutes of Health National Heart, Lung, and Blood Institute quality assessment tool was used to assess risk of bias. Data were extracted, findings synthesised, and study heterogeneity assessed; meta-analysis was conducted when possible. Results Seventeen studies were identified: seven predicting healthcare costs and 10 healthcare utilisation. Multimorbidity was found to be associated with increased total costs, hospital costs, care transition costs, primary care use, dental care use, emergency department use, and hospitalisations. Several studies demonstrated the high cost of depression and of hospitalisation associated with multimorbidity. Conclusion In the UK, multimorbidity increases healthcare utilisation and costs of primary, secondary, and dental care. Future research is needed to examine whether integrated care schemes offer efficiencies in healthcare provision for multimorbidity.

Recommendations for the recognition, diagnosis, and management of long COVID: a Delphi study.

Abstract: Background In the absence of research into therapies and care pathways for long COVID, guidance based on ‘emerging experience’ is needed. Aim To provide a rapid expert guide for GPs and long COVID clinical services. Design and setting A Delphi study was conducted with a panel of primary and secondary care doctors. Method Recommendations were generated relating to the investigation and management of long COVID. These were distributed online to a panel of UK doctors (any specialty) with an interest in, lived experience of, and/or experience treating long COVID. Over two rounds of Delphi testing, panellists indicated their agreement with each recommendation (using a five-point Likert scale) and provided comments. Recommendations eliciting a response of ‘strongly agree’, ‘agree’, or ‘neither agree nor disagree’ from 90% or more of responders were taken as showing consensus. Results Thirty-three clinicians representing 14 specialties reached consensus on 35 recommendations. Chiefly, GPs should consider long COVID in the presence of a wide range of presenting features (not limited to fatigue and breathlessness) and exclude differential diagnoses where appropriate. Detailed history and examination with baseline investigations should be conducted in primary care. Indications for further investigation and specific therapies (for myocarditis, postural tachycardia syndrome, mast cell disorder) include hypoxia/desaturation, chest pain, palpitations, and histamine-related symptoms. Rehabilitation should be individualised, with careful activity pacing (to avoid relapse) and multidisciplinary support. Conclusion Long COVID clinics should operate as part of an integrated care system, with GPs playing a key role in the multidisciplinary team. Holistic care pathways, investigation of specific complications, management of potential symptom clusters, and tailored rehabilitation are needed.

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence.

Abstract: Background Coercive treatment comprises a broad range of practices, ranging from implicit or explicit pressure to accept certain treatment to the use of forced practices such as involuntary admission, seclusion and restraint. Coercion is common in mental health services. Aims To evaluate the strength and credibility of evidence on the efficacy of interventions to reduce coercive treatment in mental health services. Protocol registration: https://doi.org/10.17605/OSF.IO/S76T3. Method Systematic literature searches were conducted in MEDLINE, Cochrane Central, PsycINFO, CINAHL, Campbell Collaboration, and Epistemonikos from January 2010 to January 2020 for meta-analyses of randomised studies. Summary effects were recalculated using a common metric and random-effects models. We assessed between-study heterogeneity, predictive intervals, publication bias, small-study effects and whether the results of the observed positive studies were more than expected by chance. On the basis of these calculations, strength of associations was classified using quantitative umbrella review criteria, and credibility of evidence was assessed using the GRADE approach. Results A total of 23 primary studies (19 conducted in European countries and 4 in the USA) enrolling 8554 participants were included. The evidence on the efficacy of staff training to reduce use of restraint was supported by the most robust evidence (relative risk RR = 0.74, 95% CI 0.62–0.87; suggestive association, GRADE: moderate), followed by evidence on the efficacy of shared decision-making interventions to reduce involuntary admissions of adults with severe mental illness (RR = 0.75, 95% CI 0.60–0.92; weak association, GRADE: moderate) and by the evidence on integrated care interventions (RR = 0.66, 95% CI 0.46–0.95; weak association, GRADE: low). By contrast, community treatment orders and adherence therapy had no effect on involuntary admission rates. Conclusions Different levels of evidence indicate the benefit of staff training, shared decision-making interventions and integrated care interventions to reduce coercive treatment in mental health services. These different levels of evidence should be considered in the development of policy, clinical and implementation initiatives to reduce coercive practices in mental healthcare, and should lead to further studies in both high- and low-income countries to improve the strength and credibility of the evidence base.

Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF.

Abstract: During the coronavirus 2019 (COVID-19) pandemic, outpatient visits in the atrial fibrillation (AF) clinic of the Maastricht University Medical Centre (MUMC+) were transferred into teleconsultations. The aim was to develop anon-demand app-based heart rate and rhythm monitoring infrastructure to allow appropriatmanagement of AF through teleconsultation. In line with the fundamental aspects of integrated care, including actively involving patients in the care process and providing comprehensive care by a multidisciplinary team, we implemented a mobile health (mHealth) intervention to support teleconsultations with AF patients: TeleCheck-AF. The TeleCheck-AF approach guarantees the continuity of comprehensive AF management and supports integrated care through teleconsultation during COVID-19. It incorporates three important components: (i) a structured teleconsultation ('Tele'), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure ('Check'), and (iii) comprehensive AF management ('AF'). In this article, we describe the components and implementation of the TeleCheck-AF approach in an integrated and specialized AF-clinic through teleconsultation. The TeleCheck-AF approach is currently implemented in numerous European centres during COVID-19.

Implementing a system-wide cancer prehabilitation programme: The journey of Greater Manchester's ‘Prehab4cancer’

Abstract: Patients undergoing major cancer interventions such as major surgical resection, chemotherapy, radiotherapy, and immunotherapy are prone to the adverse effects of their cancer, as well as to the side effects of the treatments designed to cure them. The Prehabilitation process supports cancer patients in preparing for the physiological challenges of their cancer treatments, whilst aiming to shorten recovery time, reduce peri-operative complications and improve compliance with non-surgical treatments. Prehabilitation will be most useful in older patients. Greater Manchester Integrated Care system is the first regional system in the UK to introduce delivery of system-wide, large scale physical activity supported multi-modal prehabilitation and recovery programme, Prehab4Cancer as a standard of care for cancer patients. It builds upon the successful implementation of Enhanced Recovery After Surgery + programme to improve surgical care in Greater Manchester. During this review we describe the journey to develop a system wide prehabilitation model for patients with cancer. Prehab4Cancer to date has focused on robust co-design, development, and implementation of an effective service model with attention paid to stakeholder engagement. This has led to receipt of high numbers of referrals from across Greater Manchester for the all the cancer groups involved. The successful implementation of the P4C pathway in GM presents a best practice model that might be adopted by other local and combined authority areas nationally.

A marketing mix typology for integrated care: the 10 Ps

Abstract: This paper aims to accentuate the role of marketing as an integrator in integrated care through a marketing mix typology. To do so, this paper adopts a conceptual and contextual route to investigat...

Supporting parents as essential care partners in neonatal units during the SARS-CoV-2 pandemic.

Abstract: AIM: To review the evidence on safety of maintaining family integrated care practices and the effects of restricting parental participation in neonatal care during the SARS-CoV-2 pandemic. METHODS: MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched from inception to the 14th of October 2020. Records were included if they reported scientific, empirical research (qualitative, quantitative or mixed methods) on the effects of restricting or promoting family integrated care practices for parents of hospitalised neonates during the SARS-CoV-2 pandemic. Two authors independently screened abstracts, appraised study quality and extracted study and outcome data. RESULTS: We retrieved 803 publications and assessed 75 full-text articles. Seven studies were included, reporting data on 854 healthcare professionals, 442 parents, 364 neonates and 26 other family members, within 286 neonatal units globally. The pandemic response resulted in significant changes in neonatal unit policies and restricting parents' access and participation in neonatal care. Breastfeeding, parental bonding, participation in caregiving, parental mental health and staff stress were negatively impacted. CONCLUSION: This review highlights that SARS-CoV-2 pandemic-related hospital restrictions had adverse effects on care delivery and outcomes for neonates, families and staff. Recommendations for restoring essential family integrated care practices are discussed.

Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement.

Abstract: Importance The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. Objective To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. Evidence Review A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the termsleadershipand variations ofemergency,crisis,disaster,pandemic,COVID-19, orpublic health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. Findings The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. Conclusions and Relevance Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

Towards integrated youth care : a systematic review of facilitators and barriers for professionals

Abstract: To overcome fragmentation in support for children and their families with multiple and enduring problems across life domains, professionals increasingly try to organize integrated care. However, it is unclear what facilitators and barriers professionals experience when providing this integrated care. Our systematic review, including 55 studies from a broad variety of settings in Youth Care, showed that integrated care on a professional level is a multi-component entity consisting of several facilitators and barriers. Findings were clustered in seven general themes: ‘Child’s environment’, ‘Preconditions’, ‘Care process’, ‘Expertise’, ‘Interprofessional collaboration’, ‘Information exchange’, and ‘Professional identity’. The identified facilitators and barriers were generally consistent across studies, indicating broad applicability across settings and professional disciplines. This review clearly shows that when Youth Care professionals address a broad spectrum of problems, a variety of facilitators and barriers should be considered. Registration PROSPERO, registration number CRD42018084527.

The Future of Telemedicine in the Management of Heart Failure Patients

Abstract: Telemedicine (TM) is potentially a way of escalating heart failure (HF) multidisciplinary integrated care. Despite the initial efforts to implement TM in HF management, we are still at an early stage of its implementation. The coronavirus disease 2019 pandemic led to an increased utilisation of TM. This tendency will probably remain after the resolution of this threat. Face-to-face medical interventions are gradually transitioning to the virtual setting by using TM. TM can improve healthcare accessibility and overcome geographic inequalities. It promotes healthcare system efficiency gains, and improves patient self-management and empowerment. In cooperation with human intervention, artificial intelligence can enhance TM by helping to deal with the complexities of multicomorbidity management in HF, and will play a relevant role towards a personalised HF patient approach. Artificial intelligence-powered/telemedical/heart team/multidisciplinary integrated care may be the next step of HF management. In this review, the authors analyse TM trends in the management of HF patients and foresee its future challenges within the scope of HF multidisciplinary integrated care.

Building health system resilience through policy development in response to COVID-19 in Ireland: From shock to reform.

Abstract: Health systems worldwide are experiencing profound shocks resulting from the COVID-19 pandemic, with increased attention to health system resilience and researching ways to endure shocks. Pre-COVID-19, Ireland had begun a ten-year programme of reform, Slaintecare, aiming to deliver universal, timely access to integrated care. This study examines whether and how the Irish government's pandemic response contributed to health system reform and increased resilience including delivering universal healthcare. Documentary analysis identified and critiqued relevant government, health system and budgetary documents, published March 2020 - May 2021. Thirteen national policy documents were found, showing increased policy rhetoric and intent to implement reform, demonstrated by increased policy alignment with and budgetary allocation to Slaintecare, alongside implementation of key innovations. Ireland's health system response to COVID-19 offers a unique opportunity to advance understanding of government efforts to reform amidst a global pandemic. It indicated policy intent and funding to manage the Irish COVID-19 crisis, but to also build health system resilience through implementing Slaintecare. This case study has international significance, enabling policy development with potential for long-term health system transformation.

Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review

Abstract: Introduction: Millions of people worldwide have complex health and social care needs. Care coordination for these patients is a core dimension of integrated care and a key responsibility for primary healthcare. Registered nurses play a substantial role in care coordination. This review draws on previous theoretical work and provides a synthesis of care coordination interventions as operationalized by nurses for complex patient populations in primary healthcare. Methodology: We followed Arksey and O’Malley’s methodological framework for scoping reviews. We carried out a systematic search across CINAHL, MEDLINE, Scopus and ProQuest. Only empirical studies were included. We performed a thematic analysis using deductive (the American Nurses Association Framework) and inductive approaches. Findings were discussed with a group of experts. Results: Thirty-four articles were included in the synthesis. Overall, nursing care coordination activities were synthesized into three categories: those targeting the patient, family and caregivers; those targeting health and social care teams; and those bringing together patients and professionals. Interpersonal communication and information transfer emerged as cross-cutting activities that support every other activity. Our results also brought to light the nurses’ contribution to care coordination efforts for patients with complex needs as well as critical components that should be present in every care coordination intervention for this clientele. These include an increased intensity and frequency of activities, relational continuity of care, and home visits. Conclusion: With the growing complexity of patient’s needs, efforts must be directed towards enabling the primary healthcare level to effectively play its substantial role in care coordination. This includes finding primary care employment models that would facilitate multidisciplinary teamwork and the delivery of integrated care, and guarantee the delivery of intensive yet efficient coordinated care.

Integrated Care Systems and the Aortovascular Hub.

Abstract: Aortovascular medicine and surgery in relation to vascular health of the population requires input from a broad range of specialists and institutions throughout a patient life as well as integration with allied health care providers. This paper presents the essence of the novel clinical concept of the ‘Aortovascular Hub’ .

The effectiveness and cost-effectiveness of integrating mental health services in primary care in low- and middle-income countries: systematic review.

Abstract: Aims and method This systematic review examines the effectiveness and cost-effectiveness of behavioural health integration into primary healthcare in the management of depression and unhealthy alcohol use in low- and middle-income countries. Following PRISMA guidelines, this review included research that studied patients aged ≥18 years with unhealthy alcohol use and/or depression of any clinical severity. An exploration of the models of integration was used to characterise a typology of behavioural health integration specific for low- and middle-income countries. Results Fifty-eight articles met inclusion criteria. Studies evidenced increased effectiveness of integrated care over treatment as usual for both conditions. The economic evaluations found increased direct health costs but cost-effective estimates. The included studies used six distinct behavioural health integration models. Clinical implications Behavioural health integration may yield improved health outcomes, although it may require additional resources. The proposed typology can assist decision-makers to advance the implementation of integrated models.

Racism, Mental Health, Healthcare Provider Trust, and Medication Adherence Among Black Patients in Safety-Net Primary Care

Abstract: There has been a growing research focus on social determinants to health disparities in general and medication adherence more specifically in low-income Black populations. The purpose of this study was to examine whether prior experiences of racism among Black patients in safety-net primary care indirectly predicts poor medication adherence through increased mental health symptoms and low healthcare provider trust. Two competing models were run whereby mental health leads to provider trust or provider trust leads to mental health in this multiple mediational chain. A group of 134 Black patients (76 men, average age 45.39 years) in a safety-net primary care clinic completed measures of these constructs. Results revealed that in the first model, mental health mediated the relationship between racism and provider trust, and provider trust mediated the relationship between mental health and medication adherence. All paths within this model were statistically significant, except the path between provider trust and medication adherence which approached significance. In the second model, provider trust and mental health significantly mediated the relationship between racism and medication adherence, and all direct and indirect paths were statistically significant, though the path between provider trust and medication adherence was omitted. These results may serve as catalysts to assess and attempt to mitigate specific minority-based stressors and associated outcomes within safety-net primary care settings.

Integrated Care in England - what can we Learn from a Decade of National Pilot Programmes?

Abstract: Introduction: For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care. Description: The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration. The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots’ objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy. Discussion: There was little stable or shared understanding of what ‘integrated care’ meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. Conclusion: Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-Effectiveness Study

Abstract: Background: Integrated care can generate health and social care efficiencies through the defragmentation of care and adoption of patient-centered preventive models. eHealth can be a key enabling technology for integrated care. Objective: The aim of this study was to assess the effectiveness and cost-effectiveness of the implementation of a mobile health (mHealth)-enabled integrated care model for complex chronic patients. Methods: As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, two-arm, parallel implementation trial was held in a rural region of Catalonia, Spain. During 3 months, elderly patients with chronic obstructive pulmonary disease or heart failure and their carers experienced the combined benefits of the CONNECARE organizational integrated care model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care. We assessed changes in health status with the 12-Item Short-Form Survey (SF-12), unplanned visits and admissions during a 6-month follow up, and the incremental cost-effectiveness ratio (ICER). Results: A total of 48 patients were included in the integrated care arm and 28 patients receiving usual care were included in the control arm (mean age 82 years, SD 7 years; mean Charlson index 7, SD 2). Integrated care patients showed a significant increase in the SF-12 physical domain with a mean change of +3.7 (SD 8.4) (P=.004) and total SF-12 score with a mean change of +5.8 (SD 12.8) (P=.003); however, the differences in differences between groups were not statistically significant. Integrated care patients had 57% less unplanned visits (P=.004) and 50% less hospital admissions related to their main chronic diseases (P=.32). The integrated care program generated savings in different cost scenarios and the ICER demonstrated the cost-effectiveness of the program. Conclusions: The implementation of a patient-centered mHealth-enabled integrated care model empowering the patient, and connecting primary, hospital, and social care professionals reduced unplanned contacts with the health system and health costs, and was cost-effective. These findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement integrated care.

Integrated Healthcare and the Dilemma of Public Health Emergencies

Abstract: Traditional healthcare services have demonstrated structural shortcomings in the delivery of patient care and enforced numerous elements of integration in the delivery of healthcare services. Integrated healthcare aims at providing all healthcare that makes humans healthy. However, with mainly chronically ill people and seniors, typically suffering from numerous comorbidities and diseases, being recruited for care, there is a need for a change in the healthcare service structure beyond direct-patient care to be compatible in peacetime and during public health emergencies. This article’s objective is to discuss the opportunities and obstacles for increasing the effectiveness of healthcare through improved integration. A rapid evidence review approach was used by performing a systematic followed by a non-systematic literature review and content analysis. The results confirmed that integrated healthcare systems play an increasingly important role in healthcare system reforms undertaken in European Union countries. The essence of these changes is the transition from the episodic treatment of acute diseases to the provision of coordinated medical services, focused on chronic cases, prevention, and ensuring patient continuity. However, integrated healthcare, at a level not yet fully defined, will be necessary if we are to both define and attain the integrated practice of both global health and global public health emergencies. This paper attains the necessary global challenges to integrate healthcare effectively at every level of society. There is a need for more knowledge to effectively develop, support, and disseminate initiatives related to coordinated healthcare in the individual healthcare systems.

Factors Influencing the Implementation of Patient Navigation Programs for Adults with Complex Needs: A Scoping Review of the Literature:

Abstract: Patient navigation is a model of care that aims to improve access to care by reducing the complexity of navigating health, education, and social services across the continuum of care and care settings. Little is known about the processes that facilitate or impede the implementation of patient navigation programs (PNPs). We conducted a scoping review to identify and summarize the current state of knowledge regarding the implementation and outcomes of existing implemented PNPs. We employed a 6-stage scoping review framework to identify and review eligible articles. Sixty-articles met the inclusion criteria (58 peer-reviewed and 2 grey literature). The Consolidated Framework for Implementation Research served as the theoretical framework during analysis to help extract factors relevant to implementation of navigator programs. Results of the scoping review are reported thematically. Influences on implementation were identified: (a) planning to ensure alignment with organizational need (b) funding (c) multidisciplinary engagement (d) establishing workflow (e) mechanisms for communication (f) stakeholders to encourage buy-in (g) appropriate caseload (h) in kind resources. PNPs improve the experiences of patients and families. The findings of this scoping review provides implementation considerations of PNPs across global care settings. Strategies for overcoming pragmatic and logistical issues must be developed for optimal implementation.

Clinical outcomes of the Centre for Eye Health: an intra-professional optometry-led collaborative eye care clinic in Australia

Abstract: Clinical relevance: This novel clinical model is the first of its kind in Australia and was designed to help reduce unnecessary referrals into overburdened public systems by utilising pre-existing community-based resources.Background: The Centre for Eye Health (CFEH) is an intra-professional optometry-led care clinic offering an alternative pathway to traditional ophthalmology-based pathways (public hospital clinics or private practices) for 'at-risk' patients requiring ocular imaging, diagnostic and management services. This study evaluates the CFEH integrated eye-care model in the identification of chronic eye diseases within the community.Methods: A retrospective random clinical audit of over 750 medical records of patients referred to the CFEH between July 2016 and June 2019 was conducted. Demographics of patients, referral type, final diagnosis and recommended management plans were extracted from this subset. Clinic key performance indicators (referral turnaround time, and net cost per patient appointment) were also extracted.Results: Of the 755 referrals associated with the audited records, 77.4% resulted in the identification of patients with or at-risk of developing eye diseases with 73.5% of this cohort requiring ongoing monitoring at CFEH or referral to ophthalmology. Although the CFEH model is not designed to diagnose or manage acute conditions, 1.5% of patients in this pathway required same day ophthalmological or medical intervention. The cost per patient was equivalent to hospital eye departments costs.Conclusion: This integrated care pathway has the potential to reduce unnecessary referrals from optometrists to hospital ophthalmological service by offering a safe and effective alternate pathway. The majority of patients seen within this pathway were able to be monitored within optometry-led services. This is a unique clinical model utilising inter-professional referrals within optometry which has the potential to reduce preventable blindness within the community through the early detection of eye diseases.

Family integrated care: Supporting parents as primary caregivers in the neonatal intensive care unit

Abstract: Family integrated care (FICare) is a collaborative model of neonatal care which aims to address the negative impacts of the neonatal intensive care unit (NICU) environment by involving parents as equal partners, minimizing separation, and supporting parent-infant closeness. FICare incorporates psychological, educational, communication, and environmental strategies to support parents to cope with the NICU environment and to prepare them to be able to emotionally, cognitively, and physically care for their infant. FICare has been associated with improved infant feeding, growth, and parent wellbeing and self-efficacy; important mediators for long-term improved infant neurodevelopmental and behavioural outcomes. FICare implementation requires multi-disciplinary commitment, staff motivation, and sufficient time for preparation and readiness for change as professionals relinquish power and control to instead develop collaborative partnerships with parents. Successful FICare implementation and culture change have been applied by neonatal teams internationally, using practical approaches suited to their local environments. Strategies such as parent and staff meetings and relational communication help to break down barriers to change by providing space for the co-creation of knowledge, the negotiation of caregiving roles and the development of trusting relationships. The COVID-19 pandemic highlighted the vulnerability within programs supporting parental presence in neonatal units and the profound impacts of parent-infant separation. New technologies and digital innovations can help to mitigate these challenges, and support renewed efforts to embed FICare philosophy and practice in neonatal care during the COVID-19 recovery and beyond.

An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19.

Abstract: Background: UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals – one in the US, two in Mexico – as high volumes of severely ill patients overwhelmed hospitals. Objective: We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border. Methods: We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery. Findings: In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital. Conclusion: A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.

A Telehealth-supported, Integrated care with CHWs, and MEdication-access (TIME) Program for Diabetes Improves HbA1c: a Randomized Clinical Trial

Abstract: Many individuals with diabetes live in low- or middle-income settings. Glycemic control is challenging, particularly in resource-limited areas that face numerous healthcare barriers. To compare HbA1c outcomes for individuals randomized to TIME, a Telehealth-supported, Integrated care with CHWs (Community Health Workers), and MEdication-access program (intervention) versus usual care (wait-list control). Randomized clinical trial. Low-income Latino(a) adults with type 2 diabetes. TIME consisted of (1) CHW-participant telehealth communication via mobile health (mHealth) for 12 months, (2) CHW-led monthly group visits for 6 months, and (3) weekly CHW-physician diabetes training and support via telehealth (video conferencing). Investigators compared TIME versus control participant baseline to month 6 changes of HbA1c (primary outcome), blood pressure, body mass index (BMI), weight, and adherence to seven American Diabetes Association (ADA) standards of care. CHW assistance in identifying barriers to healthcare in the intervention group were measured at the end of mHealth communication (12 months). A total of 89 individuals participated. TIME individuals compared to control participants had significant HbA1c decreases (9.02 to 7.59% (− 1.43%) vs. 8.71 to 8.26% (− 0.45%), respectively, p = 0.002), blood pressure changes (systolic: − 6.89 mmHg vs. 0.03 mmHg, p = 0.023; diastolic: − 3.36 mmHg vs. 0.2 mmHg, respectively, p = 0.046), and ADA guideline adherence (p 0.50% HbA1c reductions (88.57% vs. 43.75%, p 1 barrier to care, of whom 91.7% had medication issues. CHWs identified the majority (87.5%) of barriers. TIME participants resulted in improved outcomes including HbA1c. CHWs are uniquely positioned to identify barriers to care particularly related to medications that may have gone unrecognized otherwise. Larger trials are needed to determine the scalability and sustainability of the intervention. NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456