Bringing cancer care to the patient's home through telemedicine and remote care services, including remote patient monitoring, cancer treatment at home, and hospital-at-home programs, has become an increasingly appealing opportunity to optimize patient experience, access, and value. Although these forms of remote care services came to the fore during the Covid-19 pandemic as a result of operational disruptions, their current use, future directions, and successes and barriers are largely unknown. The authors partnered with the Alliance of Dedicated Cancer Centers to conduct a landscape analysis through structured interviews with clinical leaders who have knowledge of these technologies across the United States. The interview was divided into five main sections, with questions focused on (1) telemedicine; (2) remote patient monitoring, including laboratory testing at home and the use of electronic patient-reported outcomes and biometric devices; (3) cancer treatment at home; (4) hospital-at-home programs; and (5) the use of AI to facilitate remote care. The authors interviewed 17 clinical leaders across 15 institutions. Several pertinent themes emerged during the interviews. The authors discovered that telemedicine visits are available to oncology patients across the country but vary in scope and capacity on an institutional level. Institutions share common barriers, including technical infrastructure, state licensure requirements, concerns about reimbursement parity, and institutional culture. A few institutions have prioritized telemedicine visits based on clinical operational strategy, made institutional investments to support it, and were able to surpass some of these barriers, serving as case studies for potential solutions. Other remote care services were rarely implemented in the institutions interviewed. A few institutions have received the necessary support, funding, and infrastructure to successfully implement programs and practices related to the five care delivery interventions and have demonstrated positive outcomes. Key aspects of their success include research efforts to provide an evidence base to support the transition of these interventions to standard of care, high-level (C-suite) institutional support, and the use of third-party vendors. Although telemedicine and remote care services are recognized as appealing options to improve patient care and experience, based on input and insights from the interviewees, the optimal implementation of such care delivery solutions in the home setting will require ongoing research investment, collaborative efforts, reimbursement security, changes in the regulatory and legislative environment, and advocacy.
Cystic fibrosis (CF) affects more than 160,000 individuals globally and has seen improved survival rates due to multidisciplinary care models and pharmacotherapy innovations. However, the associated costs remain substantial, prompting the authors to study and evaluate the expense of CF ambulatory care to understand how care structure influences costs. People with CF (PwCF) at large pediatric CF centers in both the United States and Ireland were recruited for parallel observational, prospective studies. Based upon the process of care, the lead clinicians at both sites identified and agreed on three strata of patients (0-11 months, 1-5 years, and 6-17 years of age). Process maps were developed for each of the age cohorts at each site, and the costs of ambulatory care - with emphasis on routine CF clinic visits - were measured utilizing time-driven activity-based costing (TDABC). A dollar-per-minute capacity cost rate (CCR) was calculated for all resources used in the care cycle. The total direct cost was obtained by multiplying the CCR for each resource by the time the resource was used during the patient's care cycle. The cost was summed across all resource types to obtain the cost over the entire care cycle for each site. Service operations were benchmarked to one site and variance analysis was performed. In total, 58 PwCF were included in the analysis (49 in the United States and 9 in Ireland); 4 were 0-11 months, 17 were 1-5 years, and 37 were 6-17 years of age. Physicians (United States) and respiratory consultants (Ireland) had the highest CCRs. Physicians and registered dietitians spent the most time with patients in the United States, compared with the clinical nurse specialists and dietitians in Ireland. The total variance in cost for clinical visits was largest in the 6- to 17-year-old group (28% variance, with 100% in the United States vs. 128% in Ireland). In the 6- to 17-year-old group, the largest drivers in total variance were quantity variance (variance in duration of time spent with patients), which was 108% greater in Ireland); the skill mix variance (variance in clinician type performing service for a given time), which was 49% greater in the United States; and the rate variance (variance in compensation levels across sites), which was 31% greater in the United States. The authors' use of TDABC to characterize the cost of multidisciplinary care during ambulatory clinic visits for PwCF, in combination with variance analysis (the quantitative investigation of the difference between actual and expected costs), provides new and innovative ways to compare costs across similar health care service delivery sites, providing insights into the distinctive features of each. A granular understanding of cost and comparison of resource utilization between centers provides valuable, organizationally relevant insights.
The Covid-19 pandemic challenged health care delivery systems worldwide. Many acute care hospitals in communities that experienced surges in cases and hospitalizations had to make decisions such as rationing scarce resources. Hospitals serving low-income communities, communities of color, and those in other historically marginalized or vulnerable groups reported the greatest operational impacts of surges. However, cross-institutional collaborations within jurisdictions offer unique opportunities to prevent or mitigate health disparities in resource utilization and access to care. In January 2020, in response to the emerging coronavirus epidemic, the San Francisco Department of Public Health (SFDPH) and local hospital and health systems partners convened to align and coordinate medical surge planning and response. Adopting a governance structure of mutual accountability and transparency, the San Francisco Health Systems Collaborative guided local medical and public health response in the areas of medical surge, vaccination administration, testing, and therapeutics. Four principles guided the collaborative response: (1) shared priorities, (2) clear governance and accountability, (3) data transparency, and (4) operational coordination. High-level priorities established included protecting vulnerable people, protecting health care workers, and maintaining health system capacity. The governance structure consisted of three layers: local hospital and health systems' CEOs coordinating with SFDPH executives; hospital chief medical and nursing officers coordinating high-level surge capacity assessments and mitigation plans; and local clinical operational managers working with public health response operational leaders to coordinate scarce resource utilization. Fluctuating with the tempo of the disease indicators and medical surge, governance and coordination were maintained through a tiered meeting and reporting system. Data visibility and transparency were key principles facilitating operational decision-making and executive-level coordination of resources, including identifying additional surge bed capacity for use systemwide, as well as ensuring efficient and equitable vaccine distribution through implementation of five mass-vaccination sites with prioritized access for vulnerable communities. Applying these four principles of shared priorities, accountability, transparency, and operational coordination and pragmatism helped the public health and individual hospital systems make contributions to the overall response that were aligned with their unique strengths and resources. Publication here represents the first official public use of the name San Francisco Health Systems Collaborative (which had served as the term used internally to refer to the group) and the first time codifying this structure. Through this coordination, San Francisco achieved one of the lowest Covid-19 death rates and had one of the highest vaccination and booster rates, compared with rates across California or the United States. Similar principles and implementation methods can be adopted by other health jurisdictions for future emergency outbreak response.
Patients with cancer spend considerable time commuting to, waiting for, and receiving health care. Patient-reported outcomes have been collected electronically to monitor patients for toxicity related to treatment, but, to the authors' knowledge, they have not been used as a strategy to minimize patients' time spent on cancer care by streamlining care delivery. Researchers at Penn Medicine set an objective to assess the effectiveness and implementation of a text message-based symptom reporting electronic triage (e-triage) versus usual care to minimize the time toxicity associated with ambulatory cancer care. The methods employed included a hybrid type 1 effectiveness-implementation, unblinded, randomized controlled trial and sequential mixed-methods study, which was conducted between December 1, 2021, and December 31, 2022, with a follow-up period of 3 months or three visits (whichever came first, but all within the 2-year window). Adult patients with solid tumors receiving single-agent immune checkpoint inhibitors (ICIs) with access to a text-messaging device were enrolled, with a target sample size of 176. The intervention was a symptom-based e-triage via mobile text messaging combined with routine laboratory testing. Participants in the e-triage group with normal bloodwork and no symptoms of drug toxicity on e-triage were eligible to fast-track to ICI infusion, bypassing the pretreatment office visit. The primary end point was total time per ambulatory encounter; secondary end points included wait time, ED or hospital visits, health-related quality of life, patient satisfaction, and implementation (reach and fidelity). Implementation readiness (acceptability, appropriateness, and feasibility), barriers, and facilitators were evaluated in a mixed-methods analysis among treating oncologists, measured via surveys and focus groups. For the study, 40 patients were randomly assigned, of which 31 were evaluated for the primary end point; the median age among the 40 participants was 67.5 years of age (interquartile range 59.5-71.5 years of age), 80.0% were male, and 84.6% were white. Those randomly assigned to the e-triage group of the pilot randomized controlled trial (n=19, n=16 evaluable) had an average of 66.0 minutes less total time (95% confidence interval [CI], -123.7 to -8.08 minutes; P=0.03) and 30.1 minutes less wait time (95% CI, -60.9 to 1.1 minutes; P=0.08) per encounter, than those in usual care (n=21 randomly assigned, n=15 evaluable). ED or hospital visits, health-related quality of life, and patient satisfaction scores were similar. In the mixed-methods study, oncologists (n=31, 17 completed the survey) found the e-triage acceptable (mean 3.8, standard error [SE] 0.1), appropriate (mean 3.8, SE 0.1), and feasible (mean 3.9, SE 0.1) on a 5-point Likert scale of agreeability. Perceived barriers to uptake included challenges in patient identification, potential for drug toxicity underreporting, and reimbursement concerns. The authors conclude that the results of this pilot randomized controlled trial of a text message-based e-triage supports further investigation into the use of text message-based symptom reporting by patients as a strategy to safely assess readiness for treatment and thus reduce the time toxicity associated with cancer care.
Preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention is a highly effective tool, but it is underutilized, and significant inequities exist regarding which populations are able to access PrEP. Although most PrEP care occurs in specialty settings, such as sexual health and HIV clinics, most individuals eligible for PrEP are seen in primary care; this imbalance represents an opportunity to expand PrEP access. New York City Health and Hospitals (NYC H+H) is a municipal health care system that provides primary and specialty care across the five boroughs of New York City. To address the gap in PrEP access within primary care, a multidisciplinary working group within NYC H+H was convened in June 2023, and it included primary care providers, nursing staff, and administrative stakeholders within primary care, virology, quality, and data and analytics. The working group interfaced with facilities directly to listen to and engage with the care teams and patients to identify barriers and develop supports to facilitate implementing PrEP services within primary care. In response to care team and patient needs, electronic medical record tools were developed, and customized training and patient-facing educational materials were created to address identified gaps in care team knowledge regarding PrEP care services. Training and electronic medical record tool dissemination occurred, initially, as a proof of concept at one pilot site in East New York, Brooklyn, from June to December 2023, and resulted in a threefold increase in PrEP uptake among patients who had a documented PrEP discussion with their care team, at 20% (15/76), as compared with the NYC H+H system for PrEP uptake, at 6.8% (1207/17,724) (P<0.000). Moreover, the increase in PrEP uptake was seen across populations that traditionally face barriers to accessing PrEP. Through this patient- and care team-centered approach, PrEP care services were able to be implemented in an equitable way within a primary care clinic setting.
Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.
More than 5 million patients are admitted to ICUs each year in the United States alone. ICUs are stressful environments given the patients' medical severity, family emotional experience, and staff burnout. However, psychosocial services are rarely offered and sustained in these settings. Multidisciplinary partnerships and innovative frameworks and services are needed to successfully integrate psychosocial care into these complex settings. To address this need, Massachusetts General Hospital developed the Recovering Together (RT) Initiative (2015-present) in its Neurosciences ICUs (Neuro-ICU). The hospital's aims were threefold: (1) to build a multidisciplinary collaboration to develop and sustain integrative care; (2) to implement a clinical, research, and training (CRT) framework to support patients, families, and staff; and (3) to develop an innovative, tailored evidence-based intervention for patient-caregiver dyads in the Neuro-ICU. The authors detail the process of developing the RT Initiative for the Neuro-ICU, including initial collaborations, psychosocial care implementation, and intervention development. This real-world approach to integrating psychosocial care in this setting was successful because of a strong multidisciplinary partnership, a feasible CRT framework, and funding to support the research and infrastructure. Physical proximity, consistent interactions and communication, mutual trust, and shared leadership priorities helped facilitate this integrated care approach. The findings provide practical guidance on how to integrate psychosocial care into medical settings. The authors hope that this approach is of value to clinicians, researchers, and health care systems working to develop and sustain integrated care models across complex medical settings.
The complexity of care for decompensated liver disease often necessitates the transfer of patients to tertiary care hospitals (TCHs) for management by advanced liver care teams. However, TCHs often have a wait list for transfers, which can lead to delays in timely care. These delays can increase the risk of medical errors, which can be compounded by the multiple handoffs and uncertainty during the transfer process. To address these limitations and reduce reliance on transfers, the Indiana University Health Hepatology team, based at the academic health center (AHC), implemented a remote inpatient telehepatology (INP-TH) consultation service for comanaging patients with advanced liver disease while they remain hospitalized at one of the integrated health care system's community hospitals. In this article, the authors describe the logistics, feasibility, and selected outcomes of the INP-TH service across three of the community hospitals. Multiple stakeholders at the community hospitals and from the health system leadership were engaged before establishing the service. The service was implemented at minimal additional cost, utilizing existing clinical staff and two patient-facing iPads at each community hospital. AHC-based dedicated inpatient hepatology physician assistants and hepatology attendings participated in the INP-TH consultations. Patients under evaluation in the ED or those receiving care in the ICU were not eligible for the INP-TH consultation request. The results presented are from the virtual consultations offered to 155 patients from July 1, 2022, to December 31, 2023. On establishing INP-TH, only 12 patients (8%) were transferred to the AHC at the discretion of the INP-TH team for reasons related to the severity of illness or specialized services only available at the AHC; the other 143 (92%) were comanaged locally. Of the 155 patients, 57% had an outpatient hepatology follow-up within 30 days, 28% were readmitted to a hospital within 30 days, and 8% died within 30 days, which included nine as inpatients and four as outpatients. Provider engagement and satisfaction surveys revealed strong support and high satisfaction levels from both hepatology providers and hospitalists, with no readily evident risk to the patients. The INP-TH initiative models an approach for locally comanaging patients with complex or advanced diseases by establishing the feasibility and efficacy of comanagement of patients with decompensated cirrhosis at community hospitals without the need for physical transfer. To enhance its scale and breadth, the adaptation and expansion of the service to other health care systems should be explored.
Remote patient monitoring (RPM) has been shown to support adults with treated but uncontrolled hypertension (HTN) outside the clinic setting, yielding significant benefits in the treatment and control of blood pressure (BP). Despite its proven efficacy and recommendation as guideline-concordant care, adoption of RPM is suboptimal, particularly among marginalized populations, who face structural barriers to HTN control. A barrier to equitable adoption among marginalized populations is the lack of digital inclusivity in the design and deployment of RPM. Digitally inclusive tools consider factors such as affordability, access, digital literacy, and skills. To address this challenge, the authors describe a digitally inclusive model of RPM for HTN management within the Family Health Centers (FHCs) at NYU Langone, a federally qualified health center (FQHC) that serves more than 110,000 patients each year. The model uses protocols from the Target: BP initiative in combination with team-based care and digitally inclusive strategies to improve HTN control. Specifically, care teams work collaboratively to identify patients with uncontrolled HTN and order RPM using electronic health record-embedded clinical decision support; provide patients with free home BP monitors and training in accurate BP measurement; deliver language-concordant health coaching and optimize the antihypertensive regimen via a virtual high-risk clinic (VHRC); and monitor patient progress through shared communications. Patients also receive support from community health workers (CHWs) to address digital barriers and unmet social needs. The authors present utilization and preliminary outcome data of their model, involving 429 patients who were enrolled in RPM and the VHRC across five FHC practices between January 1, 2022, and December 31, 2023. Enrolled patients attended a mean of 4.9 (standard deviation [SD]: 0.5) visits with a nurse practitioner for medication adjustments and counseling; 5.7 (SD: 0.5) health coaching visits with a nurse; and 1 visit (SD: 0.2) with a CHW for digital and social needs over a mean of 5.7 months (SD: 0.8). Enrolled patients sent a mean number of 65 BP readings (SD: 96.4) over their period of participation. On average, enrolled patients exhibited a -13.5/-8.0 mmHg reduction from their enrollment date to the date that they were discharged from the VHRC (approximately 5.7 months). This is in comparison to a -0.5/+0.6 mmHg change in mean BP exhibited by patients with uncontrolled HTN not enrolled in the Advancing Long-term Improvements in Hypertension Outcomes through a Team-based Care Approach (ALTA) program and receiving care at the practices during the same period (n=2,843). Across the practices, BP control had also increased from the pre-ALTA baseline period (January 1, 2021, to December 31, 2021) of 68.44%-82.99%, by the end of December 31, 2023, among all patients with uncontrolled HTN. While the implementation of this digitally inclusive RPM model has shown success in a large FQHC that cares for a diverse population of patients, there remain digital inequity barriers that must be addressed at the policy level to ensure this efficacious approach reaches all patients.
Over the past several years, accelerated by the Covid-19 pandemic, immersive technologies - including virtual reality (VR) and augmented or mixed reality, also known collectively as extended reality or XR - have shown mounting promise in their ability to enhance clinical care delivery and support clinical staff. These immersive systems alongside standard of care in several areas and are at minimum used as additional ways to augment evidence-based therapies. These non-invasive and easy-to-use tools have demonstrated ability to effectively channel patient experience into therapeutic activities, facilitate home-based care, provide valuable longitudinal patient data, and enhance treatment adherence. Given this promise, immersive health care applications have spread across the Veterans Health Administration (VA), building additional evidence for efficacy and laying implementation groundwork. To date, VA has documented more than 40 indications for immersive technology utilization within our organization, with more in the pipeline. Early exploration of immersive technology in VA began with 5 sites and 10 staff engaged in a Community of Practice and has now grown to 172 sites and more than 2,300 engaged VA staff. The most uptake and impact has been seen in pain management, physical rehabilitation, and mental health care, including anxiety, depression, and post-traumatic stress disorder (PTSD). Crucial to further scaling the use of immersive technology, VA has developed standardized resources such as knowledge networks, implementation guides, electronic health record templates, and standard operating procedures. VA continues to offer opportunities for more heads in headsets, as this is an effective way to demonstrate to Veterans and staff how immersive technology can enhance care. Key to future success in VA will entail increasing equitable access; growing the scope of content; standardizing training for staff and patients; and improving processes for synthesizing and analyzing relevant data to optimize these tools. Through these activities and continued planning, VA is poised to define the landscape of immersive technology in health care and inform adoption beyond VA.
The U.S. Supreme Court decision on Dobbs v. Jackson Women's Health has had a disruptive impact on not only the patients who seek reproductive health care, abortion care providers, and abortion care-adjacent organizations, but has also sparked a need for public health departments to take on new roles to support their communities. In the wake of that 2022 decision, the Philadelphia Department of Public Health launched an ongoing initiative to increase support for the provision of abortion and sexual and reproductive health care. The authors describe the effort, which started with a landscape analysis and qualitative interview analysis to understand the needs and concerns of those comprising the abortion care delivery system in Philadelphia. The authors found that the immediate, short-term needs to support the local abortion care delivery network included funding for patients seeking abortion care, plus communication and education to counter misinformation about the legality of abortion in Pennsylvania. Through the initiative's research efforts, the authors also found that long-term needs included care capacity-building and health systems-strengthening by removing non-evidence-based restrictions on abortion access and care. Another ongoing role for public health systems is to address and avert legislative or regulatory efforts to impose restrictions to Medicaid coverage for abortion services or other impediments that would disrupt the ability or capacity of health care providers to deliver comprehensive reproductive care. Today, public health departments are uniquely suited to address and mitigate the emerging post-Dobbs chilling effect on both patients and clinicians who may fear legal, professional, or personal consequences as they navigate options for appropriate, evidence-based reproductive health care, even in states where abortion remains legal.
Health care systems are increasingly recognizing the environmental harms generated by medical care and are seeking to reduce their carbon footprints. They can accomplish measurable reductions in greenhouse gas emissions while maintaining high quality and even improving care by pursuing cobenefits - programs that simultaneously reduce environmental harm and benefit patients' health. The authors describe Advanced Comprehensive Diabetes Care (ACDC), an evidence-based telehealth program for diabetes patients in the U.S. Department of Veterans Affairs (VA) system that has concurrently improved patient care and reduced the VA's carbon footprint. Designed for patients with poor diabetes control, the program leverages existing clinical infrastructure to provide nurse-delivered telemonitoring, self-management support, and provider-aided medication management. ACDC has improved patient outcomes while reducing patient travel time, out-of-pocket costs, and greenhouse gas emissions. ACDC served 576 patients between 2017 and 2022. The authors estimate that the program has prevented over 200,000 miles of driving, saving around US$20,000 in gasoline costs for patients and 82 metric tons of carbon dioxide emission compared with equivalent in-person care. ACDC provides a template for improving health outcomes and patient as well as provider satisfaction while saving money and producing measurable reductions in carbon footprint.
Heart failure remains a leading cause of potentially avoidable hospital admissions throughout the United States and a significant driver of unnecessary, avoidable costs within value-based care programs. In a baseline population of 3233 hospital emergency department (ED) visits for heart failure, which occurred over 12 months ending in June 2023 across six WellSpan Health acute care hospitals, 2868 (88.7%) resulted in inpatient admissions. Among those admissions, 2535 (96.0%) were deemed potentially avoidable by the U.S. Centers for Medicare and Medicaid Services (CMS) Prevention Quality Indicator (PQI) 08 heart failure admission quality indicator. Collectively, these admissions totaled US$27,618,825 in potentially avoidable total costs of care. Through process improvements that modified triaging algorithms related to heart failure exacerbations where shortness of breath or lower extremity edema were present, 92.2% of triaged patients with heart failure were managed in an ambulatory setting, with 84.7% avoiding an ED visit within 24 hours. The 12% cost reduction goal was almost achieved just 1 year into the intervention, with an 11.2% reduction in potentially avoidable admissions (CMS PQI 08, a core quality measure) and a US$3,352,248 reduction in total costs of care. This novel intervention executed with Lean management principles was a pragmatic process improvement that can be readily replicated by other systems to reduce unnecessary, avoidable referrals of mild to moderate heart failure exacerbations to hospital EDs.
The NorthStar Trauma Network (NSTN) launched an initiative in 2018 to address systemic and local hospital challenges in the delivery of fracture care across a metropolitan area with a population of about 3 million. This regional fracture care model has expanded, serving seven hospitals in three health systems by 2023, including five participating community hospitals with level 2 or 3 trauma care centers and one level 1 pediatric hospital, all anchored by a level 1 university teaching trauma center. Recruitment and culture have been built around shared academic values, inclusive of investigation and education, promoting a surgeon retention rate of 100% for the first 6 years while sharing learned information and innovation that helps to drive impact in the local and larger community. Three aspects of the NSTN model, which is part of the HealthPartners system, differentiate it from other specialty or trauma care models; these are related to staffing, mission, and access. First, the NSTN model is designed to build trauma programs for hospitals rather than just providing call coverage; these programs are distinguished by their commitment of dedicated trauma-trained staff to network-member hospitals, which may be owned and operated by a variety of different - even competing - health systems. Second, the NSTN is anchored by one leadership team that promotes a collective academic mission among members; this is galvanized by the activities of the NorthStar Trauma Society, a related 501(c)(3) nonprofit organization focused on research, education, and innovation. Third, the NSTN model emphasizes subspecialist-level orthopedic trauma care (generally only seen at level 1 trauma centers) at level 2 and 3 trauma center hospitals, as well as level 1 pediatric hospitals, which expands access to care. This documentation of the evolution and methods of the NSTN may serve as a helpful example for other metropolitan communities with hospitals and health systems that seek to improve the quality of specialty-specific trauma care, the alignment of surgeons, and growth in surgical care.
Health systems could play an important role in efforts to build vaccine confidence in communities that have been hardest hit by Covid-19. Boston Medical Center (BMC) health system, New England's largest safety-net hospital, along with its community partners, implemented a Covid Response Program aimed at building vaccine confidence. The program was supported by a multifaceted and multilingual communications campaign including: 1) traditional and social media channels with trusted messengers, 2) consistent and accessible core messaging, 3) transparent dialogue, and 4) partnership with state and local health government officials. Between December 2020 and June 2022, BMC disseminated 650 social media posts leading to 12 million impressions and more than 1.8 million post engagements. The campaign included a TikTok video later featured during the presidential inauguration, resulting in more than 3.7 million views. BMC's HealthCity digital publication released 20 articles gaining more than 73,000 views while the FAQ/vaccine scheduling site, translated into seven languages, reached 844,000 page visits. At six months into the vaccination program, 70% of BMC primary care patients 18 years or older had received at least one shot and 60% were fully vaccinated, having received either two mRNA doses or one adenovirus vaccine. The proportions rose to 82% with one dose and 75% fully vaccinated at 12 months. By 24 months into the program, 83% of BMC primary care patients had received at least one shot and 77% were fully vaccinated; however, notable differences existed by race/ethnicity. Seventy six percent of Black patients and 75% of Latino patients were fully vaccinated, compared with 85% of Asian and 81% White patients. Key lessons learned include the importance of a multilingual, multimedia campaign and the need for bidirectional communication that could quickly shift to address evolving issues.
Antiretroviral preexposure prophylaxis (PrEP) is nearly 100% effective at decreasing HIV acquisition but is underused in priority populations. Primary care clinicians need tools to help them identify persons likely to benefit from PrEP use and prescribe it when appropriate. The researchers developed and validated an automated decision support tool with interactive alerts in the electronic health record to increase PrEP discussions and prescribing in primary care. They piloted the tool at three federally qualified health centers and assessed feasibility, acceptance by clinicians, and preliminary impact on PrEP care. Of 33,803 patients who visited the pilot clinics from July 2022 through January 2023, providers received PrEP alerts at the point of care for 2.2% of patients, demonstrating feasibility. Although numbers of PrEP prescriptions remained low, the proportion of all patients with new PrEP prescriptions was 4.5 times higher at pilot clinics compared with matched control clinics (0.09% vs. 0.02%). Implementation of the decision support tool was associated with a statistically nonsignificant 5.5% increase in HIV tests per 100 patients. In qualitative interviews, providers said the tool facilitated PrEP discussions with patients, particularly for those patients who would not have initiated discussions because of stigma. The researchers found that acceptance, use, and impact of machine-learning models for PrEP depends on collaborating with and building trust among providers, including blending a data-driven approach to identifying patients at increased risk for HIV acquisition with providers' traditional decision-making framework. These approaches could be useful for health care organizations seeking to implement automated prediction models across all areas of medicine.
Hospital readmission remains a common and costly event. For patients, hospital readmission is often associated with adverse outcomes in the short and long term. Despite broad interest in reducing hospital readmissions and the implementation of a wide range of programs to combat unplanned preventable readmissions, progress has been challenging. Multipronged, complex interventions have demonstrated effectiveness in published studies, yet they typically target a particular patient population (e.g., older adults), condition (e.g., heart failure), or hospital unit and are seldom implemented at the whole-hospital level. There is a pressing need for implementation studies of hospital-wide, comprehensive discharge care interventions. This article describes the design and first 2 years of implementation of the Discharge Care Center (DCC), a hospital-wide intervention designed to reduce readmissions at Vanderbilt University Hospital. Structured around a nurse-led Triage Team and a multidisciplinary Care Coordination Team specialized in post-discharge response to patient needs, the DCC utilizes a combination of automated surveillance and risk-based support to provide comprehensive and personalized coverage to adult patients discharged from the hospital to home. In its first 2 years of implementation, the DCC has cared for patients after 80,247 hospital discharges, providing 57,352 clinically relevant interventions. Vanderbilt University Hospital has seen a highly promising impact on readmissions, from a baseline (July 2019-June 2021) monthly mean 30-day unplanned readmission rate of 10.6% to a new rate of 9.9%, sustained for 2 consecutive years (July 2021-October 2023). This article presents the key functions of the DCC, the forms of implementation adopted, and practical advice for other healthcare systems aiming to implement a successful discharge care intervention at scale.
The health care field is at a critical moment. Progress on patient safety, outside some key quality measures, has stagnated, and health care professionals are seeing increased calls in the literature for balancing current approaches to safety with some more future-ready ones if they are to realize the level of improvement they seek. Yet, judging by the various action plans and structural measures put forth over the past few years or so, there is still a gap in realizing this new approach, even as an increasing number of organizations and agencies are open to the idea. In this article, the authors discuss complexity in health care and why a transformed approach to how health care professionals advance patient safety is being called for. The authors also describe the experiences of two health systems in manifesting a human-centered resilience engineering approach to driving performance in the complex, adaptive field of health care. The authors end by calling for renewed curiosity and courage from the health care safety community, and invite everyone to share and learn together as we progress toward a new approach to patient safety in health care.
To address the growing prevalence of food insecurity and its adverse effects on health, health care organizations are partnering with community organizations to develop nutrition programs aimed at both reducing hunger and improving diet-related health. Although there has been little effort to document improvements in mental health outcomes among nutrition program recipients who receive support through a community-health care partnership, this study suggests a beneficial relationship. The Greater Boston Food Bank, a 501(c)3 organization that supplies food pantries and tracks food insecurity throughout eastern Massachusetts, has developed a mobile market (MM) intervention in partnership with community health centers (CHCs) and other community-based locations to provide free produce, dairy, and high-protein food to low-income residents of eastern Massachusetts in a farmers' market-style environment, with the primary goal to reduce food insecurity. The data collected through the CHC partnership indicate that attendance at the MM was associated with improvement in depression score among CHC patients. All MM attendees experienced improvement in depression score with increased MM utilization, but the biggest effect was for patients with a diagnosis of depression at baseline. This partnership experience demonstrates that interventions developed by health care-community partnerships may have benefits for program participants beyond the primary goal of the program. During the study period of more than 3 years, for all patients in the study, each MM visit was associated with a 0.05-point decrease in the subsequent nine-item Patient Health Questionnaire (PHQ-9) score (95% confidence interval [CI], -0.08 to -0.02), which is a measure of depression on a scale of 0 to 27. Among those who had a diagnosis of moderate or severe depression before the MM intervention (PHQ-9 higher than 9), each MM visit was associated with a 0.27-point decrease in the subsequent PHQ-9 score (95% CI, -0.33 to -0.20). Mean attendance at the MM for patients with a diagnosis of depression was 6.7 visits, which translates to a predicted 1.8-point reduction in PHQ-9 score per patient during the study period.
This article examines the paradox of value-based drug pricing, wherein lifesaving pharmaceuticals are increasingly priced based on perceived therapeutic value without regard to the development or production costs, with results that most observers would not recognize as offering value. Although this approach appears to promise to reward innovation and align incentives, it often results in unsustainable costs for consumers, health systems, and the government - particularly in the United States, where drug prices are dramatically higher than in other wealthy nations. This article dissects different pricing rationales and illustrates how market failures and monopolies combine with inadequate government policy to distort value-based logic into an illogical outcome. The authors propose reforms that preserve incentives for innovation while promoting affordability, including competitive market mechanisms, regulatory oversight, and international market recognition. The goal is to align value, access, innovation, and sustainability in pharmaceutical pricing.