"Building a Presence": Strategies Used to Implement and Expand Palliative Care Services Across Six Diverse Health Systems (Sci205)

1. Label the strategies used in implementing palliative care programs and demonstrate how the various strategies impacted acceptability and adoption. 2. Connect implementation strategies with teaming concepts, both within palliative care teams and between teams (ie, palliative care with oncology, primary care, or other specialty care teams). Implementation strategies are methods or techniques used to improve the adoption of new practices. Team-based health care, or teaming—which is when at least two providers work collaboratively within and across settings to achieve high-quality coordinated patient care—is necessary for successful palliative care. Understanding which strategies are related to teaming and their importance in different settings is essential for achieving desired outcomes in palliative care. Identify and compare implementation strategies related to teaming used by six diverse health systems in expanding palliative care services Sixty-five longitudinal interviews conducted over 2 years with implementers representing academic, large nonprofit, public, and community hospitals. Content analysis using the Expert Recommendations for Implementing Change (ERIC) strategies and strategy domains for categorizing implementation strategies. More than 35 of the 73 ERIC strategies were identified;strategies related to teaming fell primarily into three domains: 1) support clinicians, 2) train and educate stakeholders, and 3) develop stakeholder interrelationships. Creating new clinical teams (support clinicians) where there were previously none was an essential strategy;those unable to fully staff their teams experienced program establishment delays. Ongoing training, specifically in-person group trainings, and educational meetings (train and educate stakeholders) by the palliative care team to promote awareness and competencies within and across teams, were hindered by the COVID-19 pandemic, limiting initial adoption. Developing stakeholder interrelationships, particularly involving executive boards/leadership, was perceived as a necessary ongoing strategy for program establishment, adoption, and sustainability. Strategies related to teaming include creating palliative care teams, training and educating the interdisciplinary team and referring providers, and establishing relationships with providers and leadership, which impact the acceptability and adoption of palliative care services. Strategies promoting within and cross team relationships, education, and clinician support are necessary when expanding palliative care services and should be continuous. [ FROM AUTHOR] Copyright of Journal of Pain & Symptom Management is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

"Never waste a good crisis": A qualitative study of the impact of COVID-19 on palliative care in seven hospitals using the Dynamic Sustainability Framework.

BACKGROUND: The COVID-19 pandemic led to rapid adaptations among palliative care services, but it is unclear how these adaptations vary in relation to their unique organizational contexts. AIM: Understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the Dynamic Sustainability Framework. DESIGN: Twelve in-depth interviews with 15 key informants representing palliative care programs from seven hospital systems between April and June 2020. SETTING: Public, not-for-profit private, community, and academic teaching hospitals in the San Francisco Bay Area with existing palliative care programs that were expanding services to new clinical areas (e.g. new outpatient clinic or community-based care). RESULTS: Six themes characterized how palliative care programs were impacted and adapted during the early stages of the COVID-19 pandemic: palliative care involvement in preparing for surge, increased emphasis on advance care planning, advocating for visitors for dying patients, providing emotional support to clinicians, adopting virtual approaches to care, and gaps in chaplaincy support. There was variation in how new and existing programs were able to adapt to early pandemic stresses; systems with new outpatient programs struggled to utilize their programs effectively during the crisis onset. CONCLUSIONS: The fit between palliative care programs and practice setting was critical to program resiliency during the early stages of the pandemic. Reconceptualizing the Dynamic Sustainability Framework to reflect a bidirectional relationship between ecological system, practice setting, and intervention levels might better guide implementers and researchers in understanding how ecological/macro changes can influence interventions on the ground.

Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine.

Introduction: Many healthcare delivery systems have developed clinician-led quality improvement (QI) initiatives but fewer have also developed in-house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician-led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences. Aim: To describe the ICDP-ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021. Methods: Department-level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high-level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in-depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals. Results: Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID-19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system-wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi-year support to enable nimble response to dynamic health system needs and timely data access. Conclusion: Presence of embedded evaluation partners in the enterprise-wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross-cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

Teledermatology to Facilitate Patient Care Transitions From Inpatient to Outpatient Dermatology: Mixed Methods Evaluation.

BACKGROUND: Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination-dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap. OBJECTIVE: Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care. METHODS: Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients. RESULTS: More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic's capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19-related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient's own. CONCLUSIONS: Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers' preferences.

A 360 degree mixed-methods evaluation of a specialized COVID-19 outpatient clinic and remote patient monitoring program.

BACKGROUND: Our goals are to quantify the impact on acute care utilization of a specialized COVID-19 clinic with an integrated remote patient monitoring program in an academic medical center and further examine these data with stakeholder perceptions of clinic effectiveness and acceptability. METHODS: A retrospective cohort was drawn from enrolled and unenrolled ambulatory patients who tested positive in May through September 2020 matched on age, presence of comorbidities and other factors. Qualitative semi-structured interviews with patients, frontline clinician, and administrators were analyzed in an inductive-deductive approach to identify key themes. RESULTS: Enrolled patients were more likely to be hospitalized than unenrolled patients (N = 11/137 in enrolled vs 2/126 unenrolled, p = .02), reflecting a higher admittance rate following emergency department (ED) events among the enrolled vs unenrolled, though this was not a significant difference (46% vs 25%, respectively, p = .32). Thirty-eight qualitative interviews conducted June to October 2020 revealed broad stakeholder belief in the clinic's support of appropriate care escalation. Contrary to beliefs the clinic reduced inappropriate care utilization, no difference was seen between enrolled and unenrolled patients who presented to the ED and were not admitted (N = 10/137 in enrolled vs 8/126 unenrolled, p = .76). Administrators and providers described the clinic's integral role in allowing health services to resume in other areas of the health system following an initial lockdown. CONCLUSIONS: Acute care utilization and multi-stakeholder interviews suggest heightened outpatient observation through a specialized COVID-19 clinic and remote patient monitoring program may have contributed to an increase in appropriate acute care utilization. The clinic's role securing safe reopening of health services systemwide was endorsed as a primary, if unmeasured, benefit.

Patient and Health Professional Perceptions of Telemonitoring for Hypertension Management: Qualitative Study.

BACKGROUND: Hypertension is the most prevalent and important risk factor for cardiovascular disease, affecting nearly 50% of the US adult population; however, only 30% of these patients achieve controlled blood pressure (BP). Incorporating strategies into primary care that take into consideration individual patient needs, such as remote BP monitoring, may improve hypertension management. OBJECTIVE: From March 2018 to December 2018, Stanford implemented a precision health pilot called Humanwide, which aimed to leverage high-technology and high-touch medicine to tailor individualized care for conditions such as hypertension. We examined multi-stakeholder perceptions of hypertension management in Humanwide to evaluate the program's acceptability, appropriateness, feasibility, and sustainability. METHODS: We conducted semistructured interviews with 16 patients and 15 health professionals to assess their experiences with hypertension management in Humanwide. We transcribed and analyzed the interviews using a hybrid approach of inductive and deductive analysis to identify common themes around hypertension management and consensus methods to ensure reliability and validity. RESULTS: A total of 63% (10/16) of the patients and 40% (6/15) of the health professionals mentioned hypertension in the context of Humanwide. These participants reported that remote BP monitoring improved motivation, BP control, and overall clinic efficiency. The health professionals discussed feasibility challenges, including the time needed to analyze BP data and provide individualized feedback, integration of BP data, technological difficulties with the BP cuff, and decreased patient use of remote BP monitoring over time. CONCLUSIONS: Remote BP monitoring for hypertension management in Humanwide was acceptable to patients and health professionals and appropriate for care. Important challenges need to be addressed to improve the feasibility and sustainability of this approach by leveraging team-based care, engaging patients to sustain remote BP monitoring, standardizing electronic medical record integration of BP measurements, and finding more user-friendly BP cuffs.

Gearing Up for a Vaccine Requirement: A Mixed Methods Study of COVID-19 Vaccine Confidence Among Workers at an Academic Medical Center.

GOAL: Assessing barriers to vaccination among healthcare workers may be particularly important given their roles in their respective communities. We conducted a mixed methods study to explore healthcare worker perspectives on receiving COVID-19 vaccines at a large multisite academic medical center. METHODS: A total of 5,917 employees completed the COVID-19 vaccine confidence survey (20% response rate). Most participants were vaccinated (93%). Compared to vaccinated participants, unvaccinated participants were younger (60% < 44 years), more likely to be from a non-Asian minority group (48%), and more likely to be nonclinical employees (57% vs. 46%). Among the unvaccinated respondents, 53% indicated they would be influenced by their healthcare provider, while 19% reported that nothing would influence them to get vaccinated. Key perceived barriers to vaccination from the qualitative analysis included the need for more long-term safety and efficacy data, a belief in the right to make an individual choice, mistrust, a desire for greater public health information, personal health concerns, circumstances such as prior COVID-19 infection, and access issues. PRINCIPAL FINDINGS: Strategies endorsed by some participants to address their concerns about safety and access included a communication campaign, personalized medicine approaches (e.g., individual appointments to discuss how the vaccine might interact with personal health conditions), and days off to recover. Mistrust and a belief in the right to make an individual choice may be harder barriers to overcome; further dialogue is needed. APPLICATIONS TO PRACTICE: These findings reflect potential strategies for vaccine requirements that healthcare organizations can implement to enhance vaccine confidence. In addition, organizations can ask respected health professionals to serve as spokespeople, which may help shift the perspectives of unvaccinated healthcare workers.

Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits.

BACKGROUND AND OBJECTIVES: To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties. METHODS: Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return). RESULTS: Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination. DISCUSSION: Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool.

BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility. METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits. RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics. CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

Relationship of socio-demographics, comorbidities, symptoms and healthcare access with early COVID-19 presentation and disease severity.

BACKGROUND: COVID-19 studies are primarily from the inpatient setting, skewing towards severe disease. Race and comorbidities predict hospitalization, however, ambulatory presentation of milder COVID-19 disease and characteristics associated with progression to severe disease is not well-understood. METHODS: We conducted a retrospective chart review including all COVID-19 positive cases from Stanford Health Care (SHC) in March 2020 to assess demographics, comorbidities and symptoms in relationship to: 1) their access point of testing (outpatient, inpatient, and emergency room (ER)) and 2) development of severe disease. RESULTS: Two hundred fifty-seven patients tested positive: 127 (49%), 96 (37%), and 34 (13%) at outpatient, ER and inpatient, respectively. Overall, 61% were age < 55; age > 75 was rarer in outpatient setting (11%) than ER (14%) or inpatient (24%). Most patients presented with cough (86%), fever/chills (76%), or fatigue (63%). 65% of inpatients reported shortness of breath compared to 30-32% of outpatients and ER patients. Ethnic/minority patients had a significantly higher risk of developing severe disease (Asian OR = 4.8 [1.6-14.2], Hispanic OR = 3.6 [1.1-11.9]). Medicare-insured patients were marginally more likely (OR = 4.0 [0.9-17.8]). Other factors associated with developing severe disease included kidney disease (OR = 6.1 [1.0-38.1]), cardiovascular disease (OR = 4.7 [1.0-22.1], shortness of breath (OR = 5.4 [2.3-12.6]) and GI symptoms (OR = 3.3 [1.4-7.7]; hypertension without concomitant CVD or kidney disease was marginally significant (OR = 2.3 [0.8-6.5]). CONCLUSIONS: Early widespread symptomatic testing for COVID-19 in Silicon Valley included many less severely ill patients. Thorough manual review of symptomatology reconfirms the heterogeneity of COVID-19 symptoms, and challenges in using clinical characteristics to predict decline. We re-demonstrate that socio-demographics are consistently associated with severity.

Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation.

BACKGROUND: Telemedicine has been used for decades. Despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. However, the COVID-19 pandemic prompted health care systems worldwide to reconsider traditional health care delivery. To safeguard health care workers and patients, many health care systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care. OBJECTIVE: To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess adoption, acceptability, appropriateness, and perceptions of potential sustainability. METHODS: Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semistructured interviews with providers (n=30) completed between March and May 2020. RESULTS: Video visits were adopted rapidly; overall, 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted their satisfaction. Video visits were reported to be more convenient for patients, families, and caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination. CONCLUSIONS: Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience.

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.