Tele-ACP amidst COVID-19 pandemic and beyond

BackgroundWhen COVID-19 hit Singapore in 2020, the public was advised to avoid visiting the hospitals unless for essential services. Advance Care Planning (ACP) services in hospital and community had to be stopped to reduce exposure for the public. However, it was not feasible for ACP services to stop with no foresight of when it could resume. Ironically, ACP should all the more be advocated amidst the pandemic.Henceforth, the team planned and implemented a tele-ACP workflow in February 2020 to ensure accessibility in continuity of care and reduce waiting time for ACP appointments.MethodsTele-ACP is conducted only via Zoom, given its security and encryption features. Criteria of patients include ability to read basic English, having electronic device with internet access, and having no severe hearing or speech impairment.Pre-ACP appointment: Zoom details including a guide were sent to patients and/or NHS.On appointment day: Before session starts, ACP Facilitator will ensure that patient and/or NHS are at a space where there is privacy. Internet stability will also be checked.Post-ACP appointment: Signatures will be obtained electronically or via post, while ensuring personal data is well-protected.ResultsFrom February 2020 to November 2022, 105 tele-ACPs (14 General ACPs and 91 Preferred Plan of Care) were completed. 45 were completed in 2020 and 2021 each, while 15 were done in 2022 (as of November). The average duration for tele vs in-person ACPs is both about 90 minutes, indicating that the effort and time spent are not any less despite ACP discussions being done virtually.ConclusionsLooking at the number of tele-ACPs completed and how it is still actively carried out despite COVID-19 situation being stable and restrictions lifted, tele-ACP is clearly in healthy demand. This shows that tele-ACP is here to stay, being both sustainable and transferable to multiple settings.

Medical Dental Integration in Wisconsin: Integrating dental hygienists into pediatric well child visits and prenatal care

Disparities exist in access to early oral health care, disproportionately impacting minority ethnic groups and populations with low socioeconomic status. Medical dental integration provides an opportunity to create a new dental access point for early prevention and intervention as well as care coordination. The Wisconsin Medical Dental Integration (WI-MDI) model expanded early access to preventive oral health services by integrating dental hygienists (DHs) into pediatric primary care and prenatal care teams to address oral health inequities with the goal of reducing dental disease. This case study will describe how DHs were incorporated into the medical care teams in Wisconsin and how legislation expanding scope of practice made this possible. Since 2019, five federally qualified health systems, one non-profit clinic, and two large health systems have enrolled in the WI-MDI project. Thirteen DHs have worked across nine clinics in the WI-MDI project and over 15,000 patient visits to a medical provider included oral health services provided by DHs from 2019 to 2023. Dental hygienists working in alternative practice models such as those demonstrated in the innovative WI-MDI approach are positioned to reduce oral health disparities through the provision of early and frequent dental prevention, intervention, and care coordination.

Management of the covid crisis on board a marchant navy vessel

The merchant navy vesselAtalante was on a scientific mission in March, April 2020 as the Covid pandemic spread across the planet. The maritime crew were faced with a double risk, the interruption of routine medical care and the appearance of a cluster on board. These two risks were avoided by adapting quickly and effectively to this exceptional situation. A replacement for the usual medical treatment has been put in place and health measures have been rigorously applied. This answer is interesting to consider in the event of SSE (exceptional health situations) involving medicine in a situation of isolation.Copyright © 2023 Elsevier Masson SAS

The Consequences of Discontinuing a Home Care Service for Patients with Severe Mental Illness After the COVID-19 Pandemic.

Continuity of care has been considered, as a key component of the treatment process, especially after discharge from the hospital. Establishing treatment continuity is critical to achieving successful treatment outcomes. Roozbeh Home Care Program was developed to ensure the continuity of care in patients with severe mental illness. This study aims to investigate the consequences of discontinuing a home care service including; relapse, readmission, service satisfaction, severity and disability, in patients with severe mental illness in Iran. Forty-three patients who received home care service for more than 6 months were included. They were assessed 3 and 6 months after receiving the service; and 12 months after the program discontinuation. There was a significant difference between the hospitalization rate during (0.42 ± 0.64) and 1 year after the program's discontinuation (0.65 ± 1.46). The majority of the caregivers (70%) were highly satisfied with the home care services. Among the patients who received the homecare services, 40.4% were highly satisfied; and 21.2% were moderately satisfied. There was no significant difference between disability (as measured by World Health Organization Disability Assessment Schedule), clinical improvement (as measured by Clinical Global Impression-Improvement Scale), or severity of illness (as measured by Clinical Global Impression Severity of the Illness Scale) during and 1 year after program's discontinuation. During the time of receiving the service, hospitalization rate was reduced. Patients and caregivers were satisfied with the service. Providing psychiatric services at home should be considered as a solution to maintain the continuity of care.

Gestion de la crise covid à bord d'un navire de marine marchande : Atalante

Résumé Le navire Atalante de la marine marchande effectuait une mission scientifique en mars, avril 2020 alors que la pandémie de Covid se répandait sur la planète. Le personnel de bord a été confronté à un double risque, la rupture de soins médicaux courants et l'apparition d'un cluster à bord. Ces deux risques ont été évités en s'adaptant rapidement et efficacement à cette situation exceptionnelle. Une suppléance à la médicalisation habituelle a été mise en place et les mesures sanitaires ont été appliquées avec rigueur. Cette réponse est intéressante à considérer en cas de SSE (Situations sanitaires exceptionnelles) impliquant la médecine en situation d'isolement. Summary The merchant navy vesselAtalante was on a scientific mission in March, April 2020 as the Covid pandemic spread across the planet. The maritime crew were faced with a double risk, the interruption of routine medical care and the appearance of a cluster on board. These two risks were avoided by adapting quickly and effectively to this exceptional situation. A replacement for the usual medical treatment has been put in place and health measures have been rigorously applied. This answer is interesting to consider in the event of SSE (exceptional health situations) involving medicine in a situation of isolation.

The impact of remote care approaches on continuity in primary care: a mixed-studies systematic review.

BACKGROUND: The value of continuity in primary care has been demonstrated for multiple positive outcomes. However, little is known about how the expansion of remote and digital care models in primary care have impacted continuity. AIM: To explore the impact of the expansion of remote and digital care models on continuity in primary care. DESIGN AND SETTING: A systematic review of continuity in primary care. METHOD: A keyword search of Embase, MEDLINE, and CINAHL databases was used along with snowball sampling to identify relevant English-language qualitative and quantitative studies from any country between 2000 and 2022, which explored remote or digital approaches in primary care and continuity. Relevant data were extracted, analysed using GRADE-CERQual, and narratively synthesised. RESULTS: Fifteen studies were included in the review. The specific impact of remote approaches on continuity was rarely overtly addressed. Some patients expressed a preference for relational continuity depending on circumstance, problem, and context; others prioritised access. Clinicians valued continuity, with some viewing remote consultations more suitable where there was high episodic or relational continuity. With lower continuity, patients and clinicians considered remote consultations harder, higher risk, and poorer quality. Some evidence suggested that remote approaches and/or their implementation risked worsening inequalities and causing harm by reducing continuity where it was valuable. However, if deployed strategically and flexibly, remote approaches could improve continuity. CONCLUSION: While the value of continuity in primary care has previously been well demonstrated, the dearth of evidence around continuity in a remote and digital context is troubling. Further research is, therefore, needed to explore the links between the shift to remote care, continuity and equity, using real-world evaluation frameworks to ascertain when and for whom continuity adds most value, and how this can be enabled or maintained.

Working together to contain and manage COVID-19: CMAJ

Canada's federal and provincial governments have taken unprecedented measures to promote social distancing in the wake of the World Health Organization's categorization of the coronavirus disease 2019 (COVID-19) outbreak as a global pandemic. Closing schools, banning large public gatherings and team events, and advising against travel are all intended to help Canada "flatten the curve" of the outbreak. Here, Laupacis asserts that we must work hard to ensure good communication and continuity of care. Furthermore, certain groups of patients who do not have COVID-19 will also need continuing care, although their regular clinics may be working below usual capacity. Clinicians will need to conduct more virtual consultations than before while uncertain about how to do so effectively;others may have to provide care that is outside their usual practice.

Continuity of care and medication adherence among youth with bipolar spectrum disorders enrolled in a large pragmatic study

This dissertation consists of two studies. Study one examined child-level predictors of mental health care service utilization among youth with bipolar spectrum disorders who were overweight/obese. Study two examined the differences in medication adherence and barriers to medication adherence among youth with bipolar spectrum disorders who were overweight/obese before and since the COVID-19 pandemic. Youth in this study were enrolled in Metformin for Overweight & OBese ChILdren and Adolescents with BIpolar Spectrum Disorders Treated with Second-Generation AntipsYchotics (MOBILITY), a prospective, large, pragmatic, randomized trial to study the impact of metformin and simple healthy lifestyle intervention (LIFE) vs. LIFE alone on patient-centered outcomes of body weight, second-generation antipsychotics (SGA) adherence, psychiatric symptom burden (e.g. mood/anxiety), and quality of life.Study One Introduction: The primary aim of this study was to examine variables, such as symptom severity and insurance status, related to continuity of care (follow-up visits, hospitalization) for youth with bipolar spectrum disorders who are overweight/obese. Methods: A secondary data analysis of data collected in MOBILITY was performed. All MOBILITY participants enrolled from November 5, 2015 through December 1, 2018 in the Midwest Region (N = 610) were included in analyses. Results: Participants enrolled from an inpatient hospital setting had fewer follow-up visits than those enrolled from an outpatient setting. Patients enrolled on an inpatient vs. outpatient setting were analyzed separately. Among patients enrolled from an outpatient setting, having public health insurance was associated with having higher numbers of psychiatric followup visits. Outpatients with lower CGI-S scores (less severe) at baseline had more follow-up visits. Higher CGI-S scores were associated with increased number of hospitalizations for those enrolled in outpatient settings. Outpatients with higher CGI-S scores and more follow-up visits had fewer hospitalizations than those with fewer follow-up visits. For participants enrolled on an inpatient setting, younger age was associated with higher number of hospitalizations. Conclusions: This study documented differences in continuity of care among the MOBILITY sample. Future studies are needed to determine if additional patient-level variables contribute to gaps in continuity of care so interventions can be targeted to those most vulnerable.Study Two The primary purpose of this study was to examine differences in SGA medication adherence among youth with bipolar spectrum disorders who were overweight/obese, before and iv since the COVID-19 pandemic. Methods: A secondary data analysis of data collected in MOBILITY was performed. All MOBILITY patient/caregiver dyads (N = 376) who completed tablet assessments for the Month 6 MOBILITY visit between March 1, 2019 and April 30, 2021 were included in analyses. Results: Before COVID-19, patients reported they missed 8.8% of prescribed doses/week, while caregivers reported patients missed 8.05% doses/week. Since COVID-19, patients reported missing 11.95% doses/week, and caregivers reported patients missed 4.63% doses/week. There were no significant differences in medication adherence rates before and since COVID-19 among patients or caregivers. The most frequently reported barrier to medication adherence among patients and caregivers in both time frames was forgetting to take medications. According to patients, caregiver assistance in taking medication may improve mediation adherence. Discussion: Patient and caregiver report of adherence rates since COVID19 differed, but reports of rates by both groups were similar before the pandemic. Future studies are needed to determine if adherence rates changed over time during the pandemic and to determine patient- and caregiver-acknowledged factors that facilitate adherence to medication regimens. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

REDESIGNING THE AMBULATORY ONCOLOGY SUPPORT TEAM

Oncology Nursing Practice The current supportive care team shortages have led to immeasurable negative impacts on the healthcare workforce, compounded by the existing workforce instability generated by the COVID-19 pandemic. To address increasing volume and complexity of patients coming to the ambulatory setting for oncology care amidst the current workforce challenges, it became imperative to re-design the roles and workflows for the ambulatory oncology support team. The Cancer Service Line (CSL) operations leadership team worked with Hospital, Ambulatory, and Laboratory leadership addressing workforce challenges to improve patient flow and satisfaction. The goals of this project were to improve integration, clinical oversight, and care coordination through a phased two-part initiative: 1) Transition Phlebotomists" working in the Cancer Center to align under CSL leadership, and 2) Increase resources and efficiency within Clinic and Lab by cross-training CSL Clinic CSAs and Lab Phlebotomy staff, creating a "one-stop shop" concept, where patients have pre-visit labs and vital signs captured in one location by one staff member. This project aims to improve both patient and provider experience through reduced delays, improved patient flow, and enhanced efficiency. CSL clinical support team expanded to include more role diversity to address the growing numbers of oncology patients amidst the current workforce shortages. Nurse Leaders assembled teams of Registered Nurses, Certified Medical Assistants, Certified Nursing Assistants, Phlebotomists, Licensed Practical Nurses, and Clinical Coordinators. All members of the clinical support team underwent extensive training to cross functional skillsets within the appropriate scope of practice. The cross-functional team received comprehensive didactic training, hands-on training, and competency validation. A new Cancer Center Intake workflow was created to improve patient flow and clinic efficiency. Patients now have their vital signs, intake questionnaires, and phlebotomy services in one location by one staff member, creating a "one-stop shop" for our patient's pre-visit intake needs. The care team redesign and new Intake workflow are being evaluated through the following metrics: patient satisfaction, improved patient flow, provider satisfaction with intake efficiency, increased "economies of scale" through better staffing coverage models, and staff satisfaction and retention through advancement and utilization of new skills. Early results indicate that the care team re-design and Intake workflow has consolidated pre-visit patient stops, streamlined patient flow, and increased efficiency. This low cost, high reward initiative may offer value in supporting oncology care team members through current and future workforce challenges.

Trends in the availability of community-based psychological counselling services for oldest-old in China, 2005 to 2018.

BACKGROUND: Community-based psychological counselling services (CPCS) is crucial for the oldest-old who often faces challenges or are reluctant to seek care at the healthcare settings. This study aims to examine trends in availability of CPCS over time and rural-urban disparities in service availability among nationwide oldest-old in China. METHODS: Multiple cross-sectional data were derived from the 2005-2018 Chinese Longitudinal Health Longevity Survey. Service availability was reported by each oldest-old participant or their next-of-kins as having CPCS in one's neighborhood. We used Cochran-Armitage tests to estimate service availability trends and applied sample-weighted logistic regression models to examine its rural-urban disparities. RESULTS: Of 38,032 oldest-old, CPCS availability decreased from 6.7 % in 2005 to 4.8 % in 2008/2009, followed by continual increases to 13.6 % in 2017/2018. In 2017/2018, rural oldest-old's neighborhoods had no greater service availability. Oldest-old residing in the Central (6.7 %), Western (13.4 %) and Northeast China (8.1 %) were less likely to report having services locally than their Eastern counterparts (17.8 %). Oldest-old having any disability or living in the nursing homes reported having greater service availability than those without disability or living at home. LIMITATION: Service availability might have been disrupted during the COVID-19 pandemic. CONCLUSIONS: Despite the increasing service availability, as of 2017/2018, only 13.6 % oldest-old in China had reported CPCS availability. It raises concerns on the disproportionate access to and continuity of mental health care, especially for those living the Central, Western China and those living at home. Policy efforts are needed to incentivize service expansion and eliminate disparities in the service availability.

Women's experience of continuity of midwifery care in North-Eastern Italy: A qualitative study.

INTRODUCTION: The establishment of a maternity path is often hampered by the fragmentation of care processes resulting in discontinuity of care. The interruption of continuity of care negatively affects the experience of maternity. The purpose of this research is to analyze the experience of women who get midwifery continuity of care from pregnancy till after childbirth. METHODS: A qualitative study using a phenomenological-grounded approach was undertaken. Audio-recorded semi-structured interviews were taken from 11 pregnant women who received midwifery care during maternity. This research was carried out between March 2020 and February 2021. RESULTS: Continuous and quality care is what allows women to develop new skills, increasing awareness and confidence in themselves and in their abilities both during pregnancy and after delivery. Assistance provided by competent professionals allows women to be taken in charge globally with greater personalization of care.Since the research was carried out during the first wave of the COVID-19 pandemic, some of the repercussions that the situation had on women during maternity were also experienced negatively, such as the interruption of continuity of care or the inability to choose whom to have next to. CONCLUSIONS: From the perspective of prevention and protection of maternal and child health, in the short- and long-term, it becomes essential to focus on developing maternal competencies. This may be possible by implementing midwifery continuity of care pathways with an appropriate and flexible organizational system capable of responding to women's needs throughout the maternity journey, even during periods of a health emergency.

Evaluation, Description and Magnitude of Readmission Phenomenon in Azienda Ospedaliero Universitaria Pisana (AOUP) for Chronic-Degenerative Diseases in the Period 2018-2021.

BACKGROUND: Readmissions are hospitalizations following a previous hospitalization (called index hospitalization) of the same patient that occurred in the same facility or nursing home. They may be a consequence of the progression of the natural history of a disease, but they may also reveal a previous suboptimal stay, or ineffective management of the underlying clinical condition. Preventing avoidable readmissions has the potential to improve both a patient's quality of life, by avoiding exposure to the risks of re-hospitalization, and the financial well-being of health care systems. METHODS: We investigated the magnitude of 30 day repeat hospitalizations for the same Major Diagnostic Category (MDC) in the Azienda Ospedaliero Universitaria Pisana (AOUP) over the period from 2018 to 2021. Records were divided into only admissions, index admissions and repeated admission. The length of the stay of all groups was compared using analysis of variance and subsequent multi-comparison tests. RESULTS: Results showed a reduction in readmissions over the period examined (from 5.36% in 2018 to 4.46% in 2021), likely due to reduced access to care during the COVID-19 pandemic. We also observed that readmissions predominantly affect the male sex, older age groups, and patients with medical Diagnosis Related Groups (DRGs). The length of stay of readmissions was longer than that of index hospitalization (difference of 1.57 days, 95% CI 1.36-1.78 days, p < 0.001). The length of stay of index hospitalization is longer than that of single hospitalization (difference of 0.62 days, 95% CI 0.52-0.72 days, p < 0.001). CONCLUSIONS: A patient who goes for readmission thus has an overall hospitalization duration of almost two and a half times the length of the stay of a patient with single hospitalization, considering both index hospitalization and readmission. This represents a heavy use of hospital resources, about 10,200 more inpatient days than single hospitalizations, corresponding to a 30-bed ward working with an occupancy rate of 95%. Knowledge of readmissions is an important piece of information in health planning and a useful tool for monitoring the quality of models of patient care.

Difference in general practice telehealth utilisation associated with birth country during COVID-19 from two Australian states.

Objective: Telehealth has been an integral part of ensuring continued general practice access during the COVID-19 pandemic. Whether telehealth was similarly adopted across different ethnic, cultural, and linguistic groups in Australia is unknown. In this study, we assessed how telehealth utilisation differed by birth country. Methods: In this retrospective observational study, electronic health record data from 799 general practices across Victoria and New South Wales, Australia between March 2020 to November 2021 were extracted (12,403,592 encounters from 1,307,192 patients). Multivariate generalised estimating equation models were used to assess the likelihood of a telehealth consultation (against face-to-face consultation) by birth country (relative to Australia or New Zealand born patients), education index, and native language (English versus others). Results: Patients born in Southeastern Asia (aOR: 0.54; 95% CI: 0.52-0.55), Eastern Asia (aOR: 0.63; 95% CI: 0.60-0.66), and India (aOR: 0.64; 95% CI: 0.63-0.66) had a lower likelihood of having a telehealth consultation compared to those born in Australia or New Zealand. Northern America, British Isles, and most European countries did not present with a statistically significant difference. Additionally, higher education levels (aOR: 1.34; 95% CI: 1.26-1.42) was associated with an increase in the likelihood of a telehealth consultation, while being from a non-English-speaking country was associated with a reduced likelihood (aOR: 0.83; 95% CI: 0.81-0.84). Conclusions: This study provides evidence showing differences in telehealth use associated with birth country. Strategies to ensure continued healthcare access for patients, whose native language is not English, such as providing interpreter services for telehealth consultations, would be beneficial. Perspectives: Understanding cultural and linguistic differences may reduce health disparities in telehealth access in Australia and could present an opportunity to promote healthcare access in diverse communities.

Efforts and Challenges to Ensure Continuity of Mental Healthcare Service Delivery in a Low Resource Settings During COVID-19 Pandemic-A Case of a Kenyan Referral Hospital.

The rising number of patients with Covid-19 as well as the infection control measures have affected healthcare service delivery, including mental healthcare. Mental healthcare delivery in low and middle income countries where resources were already limited are likely to be affected more during this pandemic. This paper describes the efforts of ensuring mental healthcare delivery is continued in a referral hospital in Kenya, Moi Teaching and Referral hospital, as well as the challenges faced. These efforts are guided by the interim guidelines developed by the Kenyan ministry of health. Some of the adjustments described includes reducing number of patients admitted, shortening the stay in the inpatient setting, using outdoors for therapy to promote physical distancing, utilization of electronic platforms for family therapy sessions, strengthening outpatient services, and supporting primary care workers to deliver mental health care services. Some of the challenges include limited ability to move about, declining ability for patients to pay out of pocket due to the economic challenges brought about by measures to control Covid-19, limited drug supplies in primary care facilities, inability to fully implement telehealth due to connectivity issues and stigma for mental health which results in poor social support for the mentally ill patients. It is clear that current pandemic has jeopardized the continuity of usual mental healthcare in many settings. This has brought to sharp focus the need to decentralize mental health care and promote community based services. Meanwhile, there is need to explore feasible alternatives to ensure continuity of care.

Factors and Behaviors Related to Successful Transition of Care After Hospitalization for Ischemic Stroke.

BACKGROUND: Our objective is to describe adoption of the posthospitalization behaviors associated with successful transition of care and related baseline characteristics. METHODS: This study includes 550 participants in the Transition of Care Stroke Disparities Study, a prospective observational cohort derived from the Florida Stroke Registry. Participants had an ischemic stroke (2018-2021), discharged home or to rehabilitation, with modified Rankin Scale score=0-3 (44% women, 24% Black, 48% White, 26% Hispanic, 35% foreign-born). We collected baseline sociodemographic and clinical characteristics. A structured telephone interview at 30-day postdischarge evaluated outcomes including medication adherence, medical appointment attendance, outpatient therapy, exercise, diet modification, toxic habit cessation, and a calculated composite adequate transition of care measure. Multivariable analyses assessed the association of baseline characteristics with 30-day behaviors. RESULTS: At 30 days, medication adherence was achieved by 89%, medical appointments by 82%, outpatient therapy by 76%, exercise by 71%, diet modification by 68%, toxic habit cessation by 35%, and adequate transition of care measure by 67%. Successful adequate transition of care participants were more likely to be used full-time (42% versus 31%, P=0.02), live with a spouse (60% versus 47%, P=0.01), feel close to ≥3 individuals (84% versus 71%, P<0.01), have history of dyslipidemia (45 versus 34%, P=0.02), have thrombectomy (15% versus 8%, P=0.02), but less likely to have a history of smoking (17% versus 32%, P<0.001), coronary artery disease (14% versus 21%, P=0.04), and heart failure (3% versus 11%, P<0.01). Multivariable logistic regression analyses revealed that multiple socio-economic factors and prestroke comorbid diseases predicted fulfillment of transition of care measures. There was no difference in outcomes during the Covid-19 pandemic (2020-2021) compared with prepandemic years (2018-2019). CONCLUSIONS: One in 3 patients did not attain adequate 30-day transition of care behaviors. Their achievement varied substantially among different measures and was influenced by multiple socioeconomic and clinical factors. Interventions aimed at facilitating transition of care from hospital after stroke are needed. REGISTRATION: URL: https://clinicaltrials.gov/; Unique identifier: NCT03452813.

Ensuring continuity of care during the COVID-19 pandemic in Guinea: Process evaluation of a health indigent fund.

Background: The emergence of the COVID-19 has disrupted the health and socioeconomic sectors, particularly in resource-poor settings such as Guinea. Like many sub-Saharan countries, Guinea is facing shortcomings related to its fragile health system and is further affected by the passage of the Ebola virus disease. The pandemic has worsened the socio-economic situation of the poorest people, leading to their exclusion from health care. To promote access to care for the most vulnerable populations, a system was set up to provide care for these people who are victims of health marginalization to promote their access to care. This study aimed to analyze access to health services by vulnerable populations during the COVID-19 pandemic in Guinea through the establishment of a health indigent fund (HIF). Methods: This was a qualitative study to assess the project implementation process. A total of 73 in-depth individual interviews were conducted with beneficiaries, health workers, community health workers and members of the HIF management committee, and a few informal observations and conversions were also conducted in the project intervention areas. The data collected were transcribed and coded using the deductive and inductive approaches with the Nvivo software before applying the thematic analysis. Results: A total of 1,987 indigents were identified, of which 1,005 were cared for and 64 referred to all 38 intervention health facilities within the framework of the HIF. All participants appreciated the project's social action to promote access to equitable and quality health care for this population excluded from health care services. In addition, the project has generated waves of compassion and solidarity toward these "destitute" people whose main barrier to accessing health care remains extreme poverty. A state of poverty that leads some to sell their assets (food or animal reserves) or to go into debt to ensure access to care for their children, considered the most at risk. Conclusion: The HIF can be seen as an honest attempt to provide better access to health care for the most vulnerable groups. Some challenges need to be addressed including the current system of acquiring funds before the attempt can be considered scalable.

Changes in physiotherapy services and use of technology for people with multiple sclerosis during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has led to reorganization or reduction of neurorehabilitation services for people with multiple sclerosis (PwMS). The aim of this study was to explore the changes in the organizational framework and technology usage in physiotherapy services for PwMS during the COVID-19 pandemic. METHODS: This international cross-sectional survey study was designed, developed, and disseminated by RIMS European Network for Best Practice and Research in Multiple Sclerosis Rehabilitation. Physiotherapists from nine countries (Australia, Belgium, Czech Republic, Ireland, Israel, Italy, Norway, Spain, Turkey) who provided physiotherapy services to PwMS, were invited to complete an online survey to compare physiotherapy delivery to PwMS prior to and during the pandemic period. RESULTS: The survey was completed by 215 physiotherapists. Accessibility, the average number, length and perceived effectiveness of physiotherapy sessions provided to PwMS were significantly reduced during the COVID-19 pandemic (p=0.001). Physiotherapists increased the advice of mobile apps, recorded videos for rehabilitation and exercise websites during the pandemic (p<0.001) while the use of telerehabilitation and virtual reality technology did not change. CONCLUSION: There was of a reduction in the number, duration and perceived effectiveness of rehabilitation sessions for people with multiple sclerosis during the COVID-19 pandemic while use of remote technologies for physiotherapy did not change. To ensure the continuity of physiotherapy for PwMS with complex healthcare needs also during pandemics, the provision of guidelines and training in telehealth technologies in professional education becomes crucial.

Evaluation of primary care during the COVID-19 pandemic in a Peruvian región

Introducción: La atención primaria es el pilar fundamental de un sistema de salud efectivo;el incumplimiento de los atributos esenciales podría contribuir al colapso de los sistemas de salud en eventuales pandemias. Objetivo: Evaluar el cumplimiento de los atributos de la atención primaria y sus factores asociados, según perspectiva del usuario externo en el contexto de la pandemia por COVID-19, en una región del Perú. Método: Estudio transversal, que incluyó 1064 usuarios externos, seleccionados aleatoriamente. Utilizando la Encuesta se recogieron características sociodemográficas y de salud. El cumplimiento de los atributos de la atención primaria fue valorado con la versión modificada del instrumento PCAT-A10. Se realizó un análisis descriptivo y multivariado mediante modelos lineales generalizados de la familia Poisson para evaluar ciertos factores asociados al incumplimiento de los atributos de la atención primaria. Resultados: De los participantes, el 76,6% perciben que los atributos básicos esenciales se incumplen;asimismo, en el primer contacto (74,7%), continuidad (87,8%), coordinación (95,7%), globalidad (88,3%) y competencia cultural (75,9%). La condición de estudiante (p<0,001), autopercepción de salud regular (p=0,010), adulto de 30 a 59 años (p<0,001) y la condición de usuarios del centro de salud Subtanjalla (p=0,001), Parcona (p<0,001) y Guadalupe (p<0,001), se encuentran asociados a mayor percepción de incumplimiento de los atributos de la atención primaria. Conclusiones: Desde la perspectiva de los usuarios externos los atributos esenciales son incumplidos en los centros de atención primaria;existen factores asociados a mayor probabilidad de percibir que estos atribuidos son incumplidos.Alternate :Introduction: Primary care attention is the fundamental pillar of an effective health system;a failure to comply with its essential attributes could contribute to the collapse of the health systems in the event of pandemics. Objective: To evaluate the compliance of the primary attention's attributes and its associated factors, according to the external user's perspective in the context of the COVID-19 pandemic in a Peruvian region. Method: Cross-sectional study, which included 1064 randomly selected external users. Also, the sociodemographic and health characteristics were collected using the survey. And the compliance of the primary care attributes was valued using the modified version of the PCAT-A10 instrument. Finally, a descriptive and multivariate analysis was performed using generalized linear models of the Poisson family to evaluate certain factors associated with noncompliance with the attributes of primary care. Results: 76.6% of the participants perceive that the essential basic attributes are not met;likewise, in the first contact (74.7%), continuity (87.7%), coordination (95.7%), globality (88.3%) and cultural competence (75.9%). The student condition (p<0,001), self-perception of regular health (p=0.010), adult from 30 to 59 years old (p<0.001), and the condition of users of Subtanjalla (p=0.001), Parcona (p<0.001) and Guadalupe (p<0.001) health centers were associated with a greater perception of noncompliance with the attributes of primary health care. Conclusions: From the external user's perspective the essential attributes are met in primary care centers;there are factors associated with a greater probability of perceiving that these attributes are not met.

mHealth App to Facilitate Remote Care for Patients With COVID-19: Rapid Development of the DrCovid+ App.

BACKGROUND: The 2019 novel COVID-19 has severely burdened the health care system through its rapid transmission. Mobile health (mHealth) is a viable solution to facilitate remote monitoring and continuity of care for patients with COVID-19 in a home environment. However, the conceptualization and development of mHealth apps are often time and labor-intensive and are laden with concerns relating to data security and privacy. Implementing mHealth apps is also a challenging feat as language-related barriers limit adoption, whereas its perceived lack of benefits affects sustained use. The rapid development of an mHealth app that is cost-effective, secure, and user-friendly will be a timely enabler. OBJECTIVE: This project aimed to develop an mHealth app, DrCovid+, to facilitate remote monitoring and continuity of care for patients with COVID-19 by using the rapid development approach. It also aimed to address the challenges of mHealth app adoption and sustained use. METHODS: The Rapid Application Development approach was adopted. Stakeholders including decision makers, physicians, nurses, health care administrators, and research engineers were engaged. The process began with requirements gathering to define and finalize the project scope, followed by an iterative process of developing a working prototype, conducting User Acceptance Tests, and improving the prototype before implementation. Co-designing principles were applied to ensure equal collaborative efforts and collective agreement among stakeholders. RESULTS: DrCovid+ was developed on Telegram Messenger and hosted on a cloud server. It features a secure patient enrollment and data interface, a multilingual communication channel, and both automatic and personalized push messaging. A back-end dashboard was also developed to collect patients' vital signs for remote monitoring and continuity of care. To date, 400 patients have been enrolled into the system, amounting to 2822 hospital bed-days saved. CONCLUSIONS: The rapid development and implementation of DrCovid+ allowed for timely clinical care management for patients with COVID-19. It facilitated early patient hospital discharge and continuity of care while addressing issues relating to data security and labor-, time-, and cost-effectiveness. The use case for DrCovid+ may be extended to other medical conditions to advance patient care and empowerment within the community, thereby meeting existing and rising population health challenges.

Managing the community caseload to deliver the best patient, family and clinician experience – an evolution from individual, to team, to locality caseloads

BackgroundAs referral numbers rise and hospice community teams face the challenges presented by the recent pandemic, with periods of unprecedented staff shortage, models of community working have required careful consideration.AimsThis service evaluation aims to track the evolution from individual, to team, to locality caseloads, whilst considering the advantages and disadvantages presented by these different approaches to caseload management.MethodThe hospice community manager, consultant team and clinical director reviewed the model of community working prompted by themes identified through mortality reviews, reflection following complaints and staff feedback. Team meetings were held using the Grow Model (Grant, 2011. The Coaching Psychologist. 7: 118) to identify current challenges and options for change putting the team at the centre of plans for transition. Individual caseload models of working were considered in keeping with the hospice’s previous approach and the current predominant model across hospice community teams.ResultsWhole team communication allowed a successful transition from the one team caseload to smaller locality caseloads of 4-5 practitioners, looking after approximately 100 patients. Each locality is led by a team leader who co-ordinates monthly caseload reviews, joined by a consultant. This has resulted in improved work satisfaction, continuity of care for patients and families, and a more manageable telephone follow-up list. Regular caseload review has prompted the identification of stable patients for discharge, as well as creating the opportunity to invite external community practitioners to join the team for collaborative learning.ConclusionConsidering different models of caseload management allows community teams to manage fluctuating referral numbers alongside unpredictable workforce numbers, whilst providing the best care possible for patients and families. During the height of the COVID-19 pandemic a one team caseload allowed the team to operate with restricted team numbers. Once the team had stabilised transition to a locality caseload has seen an improvement in continuity of care and staff satisfaction.