Integrated Care Models for Long Coronavirus Disease.

Professional or governmental agencies and organizations have developed guidelines to define the problem and evaluate and manage patients with Post-Acute Sequelae of SARS CoV-2 (PASC). Multidisciplinary models largely exist in academic centers and larger cities; however, most care for PASC patients is provided by the primary care providers. The American Academy of Physical Medicine and Rehabilitation has been in the forefront in releasing consensus statements as a part of the long COVID collaborative.

Pandemic Telemedicine Adoption Trends in a Predominantly Rural Integrated Health System.

Between March 2020 and February 2022, use of telemedicine services in the U.S. shifted dramatically in response to the evolving SARS-CoV2 pandemic. The initial wave caused many non-emergent clinical services to be postponed, including specialty care clinic visits, which were rapidly converted to telemedicine encounters. Telemedicine use ebbed and flowed with subsequent pandemic waves. This paper describes trends in telemedicine use from March 2020-February 2022 at Geisinger, a predominantly rural integrated health system. It highlights characteristics of 5,390 virtual vs. 15,740 in-person clinic visits to neurosurgery and gastroenterology specialists in December 2021 and January 2022. Differences in ordering of diagnostic testing and prescription medications, as well as post-clinic-visit utilization, varied by specialty. Virtual visits in these specialties saved patients from traveling over 174,700 miles/month to attend appointments. Analyzing telemedicine use patterns can inform future resource allocation and determine when virtual encounters can complement or replace in-person specialty care visits.

Emergency use authorization medication distribution, utilization, and monitoring in a national integrated healthcare system.

PURPOSE: The purpose of this project was to develop and optimize a dashboard and registry to manage the distribution, utilization, and monitoring of coronavirus disease 2019 (COVID-19) emergency use-authorized medications (CEUAMs). SUMMARY: CEUAMs have specific requirements that must be met for prescribing, monitoring, and compliance. When remdesivir, the first COVID-19 medication with emergency use authorization (EUA), was approved, it immediately became necessary for the Veterans Health Administration, a national integrated health system, to describe the requirements for EUA, to distribute the medication in a fair and equitable manner, and to ensure compliance with all EUA requirements. A dashboard was developed and iteratively updated as additional CEUAMs were approved. The dashboard tracked CEUAM distribution and monitoring at the national, regional, facility, and patient level. Par stock levels were initially determined at the national level. Facilities were also able to request an additional allotment of medication based on demand and allocated supplies from the Department of Health and Human Services. Providers completed a questionnaire for the CEUAM for each patient to ensure all requirements for the medication were met. If there were data integrity concerns, the entry was flagged for review at the facility level and, upon evaluation, corrections were made. CONCLUSION: Development of the dashboard was resource intensive but provided an excellent mechanism to share information among facilities and national offices. Other healthcare systems can develop similar dashboards to ensure appropriate use of CEUAMs for their patients while meeting all CEUAM requirements.

The effect of a non-congregate, integrated care shelter on health: A qualitative study.

OBJECTIVE: To describe the experiences of unstably housed, medically vulnerable residents living at the Haven, a novel, non-congregate integrated care shelter operating in a historic hotel during the COVID-19 pandemic. DESIGN: A qualitative descriptive design. SAMPLE/MEASUREMENT: Semi-structured qualitative interviews were conducted in February and March 2022 with a purposive sample of 20 residents living in the integrated care shelter. Data were analyzed in May and June 2022 using the thematic analysis methods described by Braun and Clarke. RESULTS: Six women and 14 men, ages 23-71 (M = 50, SD = 14), were interviewed. Lengths of stay at the time of the interview ranged from 74 to 536 days (M = 311 days). Medical co-morbidities and substance use details were collected at baseline. Three themes were identified: (1) Autonomy, (2) supportive environments, and (3) stability and the need for permanent housing. Participants characterized the integrated care, non-congregate model as having multiple advantages over traditional shelter systems. Participants emphasized the role of nurses and case managers in providing a respectful, caring environment in the integrated shelter model. CONCLUSION: Participants described acute physical and mental health needs which were largely met by the innovative integrated shelter care model. The effect of homelessness and housing insecurity on health is well documented, but few solutions exist that promote autonomy. Participants in this qualitative study emphasized the benefits of living in a non-congregate integrated care shelter and the services which promoted their self-management of chronic diseases. PATIENT OR PUBLIC CONTRIBUTION: Patients were the participants in the study, but were not involved in the design, analysis of interpretation of the data, or preparation of the manuscript. Due to this project's small scope, we could not involve patients or the public after the study concluded data collection.

Healthcare Quality Management and Integrated Care Pathways (ICPs).

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is one of the largest causes of morbidity and chronic mortality and a public health problem of high importance. In Italy, COPD afflicts 5.6% of adult (3.5 million people) and is responsible for 55% of all deaths related to respiratory diseases. Smokers have a higher risk, in fact up to 40% develop the disease. From the Covid-19 pandemic, the most affected population is the elderly (mean age 80 years old), with previous chronic diseases, in 18% with chronic respiratory. The aim of the present work was to validate and measure the outcomes produced by the recruitment and care of COPD patients enrolled by an Healthcare Local Authority in the corresponding Integrated Care Pathways (ICPs) in order to measure how a multidisciplinary, systemic and e-health monitored care impacts upon mortality and morbidity. MATERIALS AND METHODS: Enrolled patients were stratified through the GOLD guidelines classification, a unified method to discriminate the various degrees of severity of COPD, using specific spirometric cut-points and providing homogeneous classes of patients. Monitoring examinations include simple spirometry, global spirometry, diffusing capacity measurement, pulse oximetry, EGA, 6-minute walk test. Chest Rx, chest CT, ECG may also be required. The severity of COPD identifies the timing of monitoring, which involves a fixed annual re-assessment for mild offset clinical forms, biannually in case of exacerbation, a quarterly cadence in moderate forms that becomes bimonthly in severe forms. RESULTS: In 2344 enrolled patients (46% women and 54% men, mean age 78 yo) 18% had GOLD severity 1, 35% GOLD 2, 27% GOLD 3 and 20% GOLD 4. In addition, 73% of patients had at least one other chronic comorbidity, mainly diabetes or hypertension, and in 48% both. The data analysis showed that the population followed in e-health presented a 49% reduction in improper hospital admissions and a 68% reduction in clinical exacerbations compared to the population enrolled in the ICPs but not followed also in e-health. Smoking habits present at the time of patient enrollment in the ICPs remained in 49% of the total population enrolled and in 37% of the population enrolled in e-health. The patients enrolled in GOLD 1 and 2 obtained the same benefits both if treated in e- health and if treated in the clinic. However, GOLD 3 and 4 patients instead presented better compliance if treated in e-health and continuous monitoring allowed punctual and early interventions such as to reduce complications and hospitalization. CONCLUSION: The e-health approach made possible to ensure proximity medicine and personalization of care. Indeed, the implemented diagnostic treatment protocols, if properly followed and monitored, are able to control complications and impact the mortality and disability of chronic disease. The advent of e-health and ICT tools are demonstrating a great support capacity for care taking that also allows greater adherence to patient care pathways, even more than the protocols up to now identified, characterized by a monitoring programmed over time, enhancing a patients and their families quality of life improvement.

Stakeholders' experiences and perception on transitional care initiatives within an integrated care project in Belgium: a qualitative interview study.

BACKGROUND: In 2015, a plan for integrated care was launched by the Belgium government that resulted in the implementation of 12 integrated care pilot project across Belgium. The pilot project Zorgzaam Leuven consists of a multidisciplinary local consortium aiming to bring lasting change towards integrated care for the region of Leuven. This study aims to explore experiences and perceptions of stakeholders involved in four transitional care actions that are part of Zorgzaam Leuven. METHODS: This qualitative case study is part of the European TRANS-SENIOR project. Four actions with a focus on improving transitional care were selected and stakeholders involved in those actions were identified using the snow-ball method. Fourteen semi-structured interviews were conducted and inductive thematic analysis was performed. RESULTS: Professionals appreciated to be involved in the decision making early onwards either by proposing own initiatives or by providing their input in shaping actions. Improved team spirit and community feeling with other health care professionals (HCPs) was reported to reduce communication barriers and was perceived to benefit both patients and professionals. The actions provided supportive tools and various learning opportunities that participants acknowledged. Technical shortcomings (e.g. lack of integrated patient records) and financial and political support were identified as key challenges impeding the sustainable implementation of the transitional care actions. CONCLUSION: The pilot project Zorgzaam Leuven created conditions that triggered work motivation for HCPs. It supported the development of multidisciplinary care partnerships at the local level that allowed early involvement and increased collaboration, which is crucial to successfully improve transitional care for vulnerable patients.

How to not revert to type: Complexity-informed learnings from the pandemic response for health system reform and universal access to integrated care.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Background: COVID-19 has highlighted existing health inequalities and health system deficiencies both in Ireland and internationally; however, understanding of the critical opportunities for health system change that have arisen during the pandemic is still emerging and largely descriptive. This research is situated in the Irish health reform context of Sláintecare, the reform programme which aims to deliver universal healthcare by strengthening public health, primary and community healthcare functions as well as tackling system and societal health inequities. Aims and objectives: This study set out to advance understanding of how and to what extent COVID-19 has highlighted opportunities for change that enabled better access to universal, integrated care in Ireland, with a view to informing universal health system reform and implementation. Methods: The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with sixteen health system professionals (including managers and frontline workers) from a range of responses to explore their experiences and interpretations of social processes of change that enabled (or hindered) better access to universal integrated care during the pandemic. A complexity-informed approach was mobilized to theorize the processes that impacted on access to universal, integrated care in Ireland in the COVID-19 context. Findings: A range of circumstances, strategies and mechanisms that created favorable system conditions in which new integrated care trajectories emerged during the crisis. Three key learnings from the pandemic response are presented: (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a social, human-centered health system. Policy and practice implications for health reform are discussed.

Hypertension care during the COVID-19 pandemic in an integrated health care system.

Retention in hypertension care, medication adherence, and blood pressure (BP) may have been affected by the COVID-19 pandemic. In a retrospective cohort study of 64 766 individuals with treated hypertension from an integrated health care system, we compared hypertension care during the year pre-COVID-19 (March 2019-February 2020) and the first year of COVID-19 (March 2020-February 2021). Retention in hypertension care was defined as receiving clinical BP measurements during COVID-19. Medication adherence was measured using prescription refills. Clinical care was assessed by in-person and virtual visits and changes in systolic and diastolic BP. The cohort had a mean age of 67.8 (12.2) years, 51.2% were women, and 73.5% were White. In 60 757 individuals with BP measurements pre-COVID-19, 16618 (27.4%) had no BP measurements during COVID-19. Medication adherence declined from 86.0% to 80.8% (p < .001). In-person primary care visits decreased from 2.7 (2.7) to 1.4 (1.9) per year, while virtual contacts increased from 9.5 (12.2) to 11.2 (14.2) per year (both p < .001). Among individuals with BP measurements, mean (SD) systolic BP was 126.5 mm Hg (11.8) pre-COVID-19 and 127.3 mm Hg (12.6) during COVID-19 (p = .14). Mean diastolic BP was 73.5 mm Hg (8.5) pre-COVID-19 and 73.5 mm Hg (8.7) during COVID-19 (p = .77). Even in this integrated health care system, many individuals did not receive clinical BP monitoring during COVID-19. Most individuals who remained in care maintained pre-COVID BP. Targeted outreach may be necessary to restore care continuity and hypertension control at the population level.

Barriers and solutions for the integrated care of diabetic patients from the point of view of general practitioners in Latvia.

INTRODUCTION: Ambulatory care sensitive indicators for chronic care patients, such as avoidable hospitalizations and preventable mortality, show worse results in Latvia in comparison with the EU average. Previous studies reveal the situation is not far behind in terms of the quantity of diagnostics and consultations, but it is possible to prevent at least 14% of hospitalizations in the chronic patient group. The aim of this study is to find out the opinions of GPs on the barriers and solutions for better care results for diabetic patients in the context of applying an integrated care approach. METHODS: A qualitative study was conducted in the form of semi-strucured in-depth interviews (5 themes, 18 questions), and analyzed using an inductive thematic analysis. The online interviews were conducted in May and April 2021. The respondents were GPs representing different rural regions (n=26). RESULTS: The results of the study reveal that the main barriers to integrated care are: the workload of GPs, especially in COVID conditions; the limited visit time; the lack of focused informational handouts; long queues for secondary care; and the lack of electronic patient health records (EHRs). GPs point to the need to set up patient EHRs, to develop diabetes training rooms in regional hospitals, and to expand GP practice with a third nurse. DISCUSSION: Special attention should be paid to developing integrated care tools at the healthcare system level and patient data digitization and care of socially isolated and sedentary patients by developing home care services, communication tools and integrating primary, secondary and social care at the regional level.

STIMULATE-ICP: A pragmatic, multi-centre, cluster randomised trial of an integrated care pathway with a nested, Phase III, open label, adaptive platform randomised drug trial in individuals with Long COVID: A structured protocol.

INTRODUCTION: Long COVID (LC), the persistent symptoms ≥12 weeks following acute COVID-19, presents major threats to individual and public health across countries, affecting over 1.5 million people in the UK alone. Evidence-based interventions are urgently required and an integrated care pathway approach in pragmatic trials, which include investigations, treatments and rehabilitation for LC, could provide scalable and generalisable solutions at pace. METHODS AND ANALYSIS: This is a pragmatic, multi-centre, cluster-randomised clinical trial of two components of an integrated care pathway (Coverscan™, a multi-organ MRI, and Living with COVID Recovery™, a digitally enabled rehabilitation platform) with a nested, Phase III, open label, platform randomised drug trial in individuals with LC. Cluster randomisation is at level of primary care networks so that integrated care pathway interventions are delivered as "standard of care" in that area. The drug trial randomisation is at individual level and initial arms are rivaroxaban, colchicine, famotidine/loratadine, compared with no drugs, with potential to add in further drug arms. The trial is being carried out in 6-10 LC clinics in the UK and is evaluating the effectiveness of a pathway of care for adults with LC in reducing fatigue and other physical, psychological and functional outcomes at 3 months. The trial also includes an economic evaluation which will be described separately. ETHICS AND DISSEMINATION: The protocol was reviewed by South Central-Berkshire Research Ethics Committee (reference: 21/SC/0416). All participating sites obtained local approvals prior to recruitment. Coverscan™ has UK certification (UKCA 752965). All participants will provide written consent to take part in the trial. The first participant was recruited in July 2022 and interim/final results will be disseminated in 2023, in a plan co-developed with public and patient representatives. The results will be presented at national and international conferences, published in peer reviewed medical journals, and shared via media (mainstream and social) and patient support organisations. TRIAL REGISTRATION NUMBER: ISRCTN10665760.

Perception of Healthcare Providers during the COVID-19 Pandemic: A Mixed Method Survey in an Integrated Healthcare Delivery System in Saudi Arabia.

During the COVID-19 pandemic, telemedicine was broadly adopted for patient care. Considering this experience, it is crucial to understand the perceptions of teleclinic healthcare professionals. In Saudi Arabia, telemedicine literature was restricted to physicians working in government and private hospitals. This study examined perceptions in relation to telemedicine among physicians and other healthcare professionals practicing in Saudi Arabian military hospitals in the Taif region. During COVID-19, telemedicine was implemented in military hospitals; consequently, this study assists in evaluating introduced practices and the perceptions of health professionals regarding these new practices. A quantitative, descriptive, correlational, and cross-sectional study was undertaken on healthcare professionals (N = 153). Twenty (20) items based on standardized measures were used to collect data using an online questionnaire. The measures contained three subscales: perceived usefulness, perceived ease, and behavioral intention. It was hypothesized that the perception of teleclinic usefulness and ease score by healthcare providers would be significantly correlated with behavioral intention. Descriptive statistics for mean, frequency, and standard deviation, as well as a Pearson correlation coefficient and regression analysis, were conducted to assess the relationship and predictive association between variables. In addition, a focus group discussion was organized to collect information directly from healthcare professionals. Most of the participants were approximately 40 years of age, Saudi Nationals (63%), medical specialists (62%), and were involved in teleclinic practices before the COVID-19 pandemic (60%). The reliability of all three scales was determined to be acceptable (α = 0.75-0.91). Perceived usefulness and perceived ease were shown to be significantly correlated with behavioral intention (r = 0.877, p = 0.05). In addition, the regression analysis indicated that perceived usefulness and perceived ease are predictors of the behavioral intention (R2 = 0.777, F (2,152) = 261.76, p = 0.001) of teleclinic practices among healthcare professionals. The positive perception of telemedicine integration in healthcare systems revealed by this study is a major catalyst for continuous adoption. On the other hand, certified telemedicine platforms, on-the-job training, Internet of things, and a flexible approach are required to find opportunities and enhancements in telemedicine interactions.

STIMULATE-ICP-Delphi (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways Delphi): Study protocol.

INTRODUCTION: As mortality rates from COVID-19 disease fall, the high prevalence of long-term sequelae (Long COVID) is becoming increasingly widespread, challenging healthcare systems globally. Traditional pathways of care for Long Term Conditions (LTCs) have tended to be managed by disease-specific specialties, an approach that has been ineffective in delivering care for patients with multi-morbidity. The multi-system nature of Long COVID and its impact on physical and psychological health demands a more effective model of holistic, integrated care. The evolution of integrated care systems (ICSs) in the UK presents an important opportunity to explore areas of mutual benefit to LTC, multi-morbidity and Long COVID care. There may be benefits in comparing and contrasting ICPs for Long COVID with ICPs for other LTCs. METHODS AND ANALYSIS: This study aims to evaluate health services requirements for ICPs for Long COVID and their applicability to other LTCs including multi-morbidity and the overlap with medically not yet explained symptoms (MNYES). The study will follow a Delphi design and involve an expert panel of stakeholders including people with lived experience, as well as clinicians with expertise in Long COVID and other LTCs. Study processes will include expert panel and moderator panel meetings, surveys, and interviews. The Delphi process is part of the overall STIMULATE-ICP programme, aimed at improving integrated care for people with Long COVID. ETHICS AND DISSEMINATION: Ethical approval for this Delphi study has been obtained (Research Governance Board of the University of York) as have approvals for the other STIMULATE-ICP studies. Study outcomes are likely to inform policy for ICPs across LTCs. Results will be disseminated through scientific publication, conference presentation and communications with patients and stakeholders involved in care of other LTCs and Long COVID. REGISTRATION: Researchregistry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/6246bfeeeaaed6001f08dadc/.

Trends in HPV vaccine administration and HPV vaccine coverage in children by race/ethnicity and socioeconomic status during the COVID-19 pandemic in an integrated health care system in California.

BACKGROUND: We sought to evaluate the trends of HPV vaccination between 03/2019-09/2021 and whether the impact of the COVID pandemic on HPV vaccination varied by race/ethnicity and neighborhood deprivation index (NDI). METHODS: Electronic medical records at Kaiser Permanente Southern California were used to assess monthly volume of HPV vaccine doses administered among children aged 9-12.9yrs, and up-to-date coverage (% vaccinated) by age 13 between 03/2019-09/2021. Modified Poisson models were used to evaluate the interactions between race/ethnicity, NDI and the pandemic periods on HPV vaccine coverage. RESULTS: HPV vaccine doses administered in 2020/2021 have returned to the 2019 level after the initial drop. The average up-to-date coverage in 05/2021-09/2021 (54.8%) remained lower than the pre-pandemic level (58.5%). The associations between race/ethnicity, NDI and HPV vaccine coverage did not vary due to the pandemic. CONCLUSION: HPV vaccine promotion efforts are needed to address COVID-19 pandemic's lasting impact on HPV vaccination coverage.

Comparison of Quality Performance Measures for Patients Receiving In-Person vs Telemedicine Primary Care in a Large Integrated Health System.

Importance: Despite its rapid adoption during the COVID-19 pandemic, it is unknown how telemedicine augmentation of in-person office visits has affected quality of patient care. Objective: To examine whether quality of care among patients exposed to telemedicine differs from patients with only in-person office-based care. Design, Setting, and Participants: In this retrospective cohort study, standardized quality measures were compared between patients with office-only (in-person) visits vs telemedicine visits from March 1, 2020, to November 30, 2021, across more than 200 outpatient care sites in Pennsylvania and Maryland. Exposures: Patients completing telemedicine (video) visits. Main Outcomes and Measures: χ2 tests determined statistically significant differences in Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between office-only and telemedicine-exposed groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities. Results: The study included 526 874 patients (409 732 office-only; 117 142 telemedicine exposed) with a comparable distribution of sex (196 285 [49.7%] and 74 878 [63.9%] women), predominance of non-Hispanic (348 127 [85.0%] and 105 408 [90.0%]) and White individuals (334 215 [81.6%] and 100 586 [85.9%]), aged 18 to 65 years (239 938 [58.6%] and 91 100 [77.8%]), with low overall health risk scores (373 176 [91.1%] and 100 076 [85.4%]) and commercial (227 259 [55.5%] and 81 552 [69.6%]) or Medicare or Medicaid (176 671 [43.1%] and 52 513 [44.8%]) insurance. For medication-based measures, patients with office-only visits had better performance, but only 3 of 5 measures had significant differences: patients with cardiovascular disease (CVD) receiving antiplatelets (absolute percentage difference [APD], 6.71%; 95% CI, 5.45%-7.98%; P < .001), patients with CVD receiving statins (APD, 1.79%; 95% CI, 0.88%-2.71%; P = .001), and avoiding antibiotics for patients with upper respiratory infections (APD, 2.05%; 95% CI, 1.17%-2.96%; P < .001); there were insignificant differences for patients with heart failure receiving ß-blockers and those with diabetes receiving statins. For all 4 testing-based measures, patients with telemedicine exposure had significantly better performance differences: patients with CVD with lipid panels (APD, 7.04%; 95% CI, 5.95%-8.10%; P < .001), patients with diabetes with hemoglobin A1c testing (APD, 5.14%; 95% CI, 4.25%-6.01%; P < .001), patients with diabetes with nephropathy testing (APD, 9.28%; 95% CI, 8.22%-10.32%; P < .001), and blood pressure control (APD, 3.55%; 95% CI, 3.25%-3.85%; P < .001); this was also true for all 7 counseling-based measures: cervical cancer screening (APD, 12.33%; 95% CI, 11.80%-12.85%; P < .001), breast cancer screening (APD, 16.90%; 95% CI, 16.07%-17.71%; P < .001), colon cancer screening (APD, 8.20%; 95% CI, 7.65%-8.75%; P < .001), tobacco counseling and intervention (APD, 12.67%; 95% CI, 11.84%-13.50%; P < .001), influenza vaccination (APD, 9.76%; 95% CI, 9.47%-10.05%; P < .001), pneumococcal vaccination (APD, 5.41%; 95% CI, 4.85%-6.00%; P < .001), and depression screening (APD, 4.85%; 95% CI, 4.66%-5.04%; P < .001). Conclusions and Relevance: In this cohort study of patients with telemedicine exposure, there was a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care. This study also identifies a need for understanding relationships between the optimal blend of telemedicine and in-office care.