Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care.

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

The Investigational Clinical Center: a clinical-supportive and patient-centered trial unit model. Ten years of experience through normal and pandemic times of a large pediatric trial center in Italy.

Evidence-based medicine relies on appropriately designed, conducted and reported clinical trials (CTs) to provide the best proofs of efficacy and safety for pharmacological and non-pharmacological treatments. Modern clinical research features high complexity and requires a high workload for the management of trials-related activities, often hampering physicians' participation to clinical trials. Dealing with children in clinical research adds complexity: rare diseases, parents or legal guardian reluctance to engage and recruitment difficulties are major reasons of pediatric trials failure.However, because in pediatrics many treatments are prescribed off-label or are lacking, well-designed clinical trials are particularly needed. Clinical Trial Units (CTUs) are indeed an important asset in the implementation of clinical trials, but their support to investigators is limited to administrative and non-clinical tasks. In this paper we present the model of the Investigational Clinical Center (ICC) of the Bambino Gesù Children's Hospital in Rome. The ICC includes clinicians supporting the Principal Investigators for clinical management of enrolled patients in compliance of Good Clinical Practice, the legal framework of Clinical Trials. Furthermore, we present 10 years' experience in pediatric clinical trials and how it has been affected in 2020 by the COVID-19 pandemic. The activity of the ICC has been evaluated according to specific metrics of performance. The ICC model offers a complete support, helping investigators, patients and their families to overcome majority of barriers linked to clinical research, even in time of pandemic. We propose this organization as an innovative model for total-supportive and patient-centered clinical trial implementation.

Systemness Taps the Power of Interdependence in Healthcare.

SUMMARY: While the term systemness has been used in the healthcare sector for decades, its definition varies from organization to organization. Still, the goals are consistent: to improve patient experience, lower costs, reduce risk, and provide insights into a wide range of care and management issues. Most health systems face similar challenges, such as margin enhancement, quality improvement, increased access, and fending off disruptive competition. Systemness is a way to address these challenges while improving the overall interdependence of the organization. Although embraced by and advantageous to healthcare organizations, systemness efforts often fail. The obstacles are surmountable when organizations thoroughly analyze the achievable scale of systemness, community resources, and current mindset regarding the good of the whole. Leaders must play a vital role in promoting systemness by providing education and a routine review of day-to-day organizational activities. Sometimes, systemness requires a change in leadership or an updating of leadership skills.Organizations must recognize and assess their culture as it relates to principles of independence versus interdependence, and refocus clinical standardization through best-practice protocols and policies as COVID-19 affects the already-fractured healthcare sector. Fortunately, current and developing artificial intelligence, wearables, at-home testing, and improved technologies promise to provide a needed break for a contracting physician field and fatigued front line, and they present an opportunity for those organizations poised to meet the systemness challenge.

Shifting to whole-person care while fighting a pandemic: a Q&A with Mandy K. Cohen, MD, MPH.

To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a health care thought leader. The August issue features a conversation with Mandy K. Cohen, MD, MPH, secretary of the North Carolina Department of Health and Human Services.

Covid-19: A critical time for cross-sector social work care management.

Covid-19 has profoundly impacted social work and has exposed the existing inequities in the health care system in the United States. Social workers play a critical role in the pandemic response for historically marginalized communities and for those who find themselves needing support for the first time. Innovative approaches to care management, including the Center for Health and Social Care Integration (CHaSCI) Bridge Model of transitional care provides a foundation from which social workers can rise to meet these new challenges.

Person-Centered Communication Between Health Care Professionals and COVID-19-Infected Older Adults in Acute Care Settings: Findings From Wuhan, China.

OBJECTIVES: The current study aims to explore person-centered communication between health care professionals and COVID-19-infected older patients in acute care settings. METHODS: The current qualitative study explored the communication between professionals and COVID-19-infected older adults in the acute care setting through 2 rounds of interviews with physicians and nurses who provided direct care and treatment for COVID-19-infected older patients in Wuhan, China. We explored the possibilities and significance of facilitating effective communication despite multiple challenges in the pandemic. Conventional content analysis was adopted to analyze the rich data collected from our participants. RESULTS: It is possible and necessary to initiate and sustain person-centered communication despite multiple challenges brought by the pandemic. The achievement of person-centered communication can play significant roles in addressing challenges, building mutual trust, improving quality of care and relationships, and promoting treatment adherence and patients' psychological well-being. DISCUSSION: It is challenging for health care professionals to provide care for COVID-19-infected older adults, especially for those with cognitive and sensory impairment, in acute care settings. Facilitating person-centered communication is a significant strategy in responding to the pandemic crisis and a core element of person-centered care.

What is operational research and how can national tuberculosis programmes in low- and middle-income countries use it to end TB?

Despite considerable progress over the years, tuberculosis (TB) still remains the top cause of death among the infectious diseases and has devastating socio-economic consequences for people in low- and middle-income countries. To add to this, the emergence of the COVID-19 pandemic has worsened delivery of TB care across the globe. As a global community, we have committed to end the TB epidemic by 2030. The World Health Organization has framed a strategy to achieve this goal which consists of three pillars namely i) integrated patient-centred care and prevention, ii) bold policies and systems and iii) intensified research and innovation. An analysis of the performance of national tuberculosis programmes (NTPs) across the globe against the ten priority indicators recommended for monitoring the end TB strategy show that there are huge gaps at every step in the cascade of care of TB patients. In our view, these gaps reflect suboptimal implementation of existing strategies known to be efficacious and operational research (OR) is one of the best available tools to plug the gaps. In this paper, we define what operational research is and how it differs from other kinds of research. We also share our views and experiences about how operational research can be used by NTPs to identify implementation gaps and their reasons, and develop and test possible solutions - which are then integrated to make changes to policy and practice and eventually improve programme outcomes. OR can be defined as research into interventions, strategies and tools which produces practical useable knowledge that can be used to enhance the quality, coverage, effectiveness and efficiency of disease control programmes, health services or health systems in which the research is conducted. The key steps in integrating operational research in the NTPs include: i) securing political commitment reflected by inclusion of OR in the national strategic plans of NTPs and earmarked funding, ii) having a critical mass of dedicated and trained human resources in OR within the NTP, iii) setting research priorities and steering the direction of research in the country, iv) using output-oriented models of capacity building such as the Structured Operational Research Training Initiative (SORT IT) model and building communities of practice, v) harnessing existing capacity in the country by forging partnerships with academia, vi) NTP-led nationwide, multicentre OR studies, vii) providing access to anonymized patient and programme surveillance data, vii) creating a forum for evidence dissemination and fostering policy change and ix) monitoring and accountability. In conclusion, ending the TB epidemic will not be possible without new tools (diagnostics, drugs, vaccines) and a multi-sectoral response involving stakeholders beyond the health ministry, including private providers, patients and communities. However, timely conduct of operational research to fine-tune programme implementation and ensuring proper deployment of new tools will be equally crucial to maximize the effectiveness and efficiency of interventions and ultimately contribute towards ending TB.

Being present: Examining the efficacy of an Internet Mantram Program on RN-delivered patient-centered care.

BACKGROUND: The COVID-19 pandemic highlighted nurses' compassionate presence during stressful conditions. Strategies to reduce workplace stress are needed. PURPOSE: The purpose of this study was to evaluate a stress reduction strategy, an Internet-based Mantram Repetition Program (MRP), for nurses caring for hospitalized Veterans. METHODS: A one group pre-/post-test design was used to assess change in nurses' perceived outcomes after participating in the MRP. A post-test-only design was used to assess hospitalized Veterans' perceptions of nursing presence and satisfaction with care. Qualitative interviews were used to supplement quantitative data. FINDINGS: Patients perceived high levels of presence and satisfaction with care. Post MRP, nurses perceived increased mindfulness, compassion satisfaction, spiritual well-being, and nursing presence. Increased mindfulness was associated with greater compassion satisfaction and less burnout. DISCUSSION: For nurses working on the front lines of patient care, the potential for experiencing stress and burnout is a reality. Participating in a MRP could lessen these effects and facilitate nursing presence.

Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19.

Opioid treatment programs (OTPs) operate within a rigid set of clinical guidelines and regulations that specify the number of required OTP visits for supervised administration of methadone. To ensure physical distancing in light of COVID-19, the federal government loosened regulations to allow for additional flexibility. As OTP providers in the Bronx, NY, caring for more than 3600 patients in the epicenter of both the overdose and COVID-19 pandemics, we describe how our clinical practice changed with COVID-19. We halted toxicology testing, and to promote physical distancing and prevent interruptions in access to treatment for medications for opioid use disorder (MOUD), we drastically increased unsupervised take-home doses of MOUD. Within two weeks, we reduced the proportion of patients with 5-6 OTP visits per week from 47.2% to 9.4%. To guide treatment decision-making, we shifted focus from toxicology tests to other patient-centered measures, such as engagement in care and patient goals. In the initial three months, our patients experienced six nonfatal overdoses, no fatal overdoses, and 20 deaths attributable to COVID-19. This experience provides an opportunity to re-imagine care in OTPs going forward. We advocate that OTPs rely less on toxicology testing and more on the other patient-centered measures to guide decisions about distribution of take-home doses of MOUD. To minimize financial risk to OTPs and facilitate their transition to a more flexible model of care, we advocate for the reassessment of OTP reimbursement models.

Realizing the Promise of Learning Organizations to Transform Mental Health Care: Telepsychiatry Care As an Exemplar.

To address the global mental health crisis exacerbated by the COVID-19 pandemic, an urgent need has emerged to transform the accessibility, efficiency, and quality of mental health care. The next suite of efforts to transform mental health care must foster the implementation of "learning organizations," that is, organizations that continuously improve patient-centered care through ongoing data collection. The concept of learning organizations is highly regarded, but the key features of such organizations, particularly those providing mental health care, are less well defined. Using telepsychiatry care as an example, the authors of this Open Forum concretely describe the key building blocks for operationalizing a learning organization in mental health care to set a research agenda for services transformation.

Life in 90 words: opportunities for person-centred care amidst COVID-19.

OBJECTIVE: Coronavirus disease 2019 and the consequent public health and social distancing measures significantly impacted on service continuity for mental health patients. This article reports on contingency planning initiative in the Australian public sector. METHODS: Ninety-word care synopses were developed for each patient. These formed the basis for guided conversations between case managers and consultant psychiatrists to ensure safe service provision and retain a person-centred focus amidst the threat of major staffing shortfalls. RESULTS: This process identified vulnerable patient groups with specific communication needs and those most at risk through service contraction. The challenges and opportunities for promoting safety and self-management through proactive telehealth came up repeatedly. The guided conversations also raised awareness of the shared experience between patients and professionals of coronavirus disease 2019. CONCLUSION: There is a parallel pandemic of anxiety which creates a unique opportunity to connect at a human level.

Organizational Health Literacy: Opportunities for Patient-Centered Care in the Wake of COVID-19.

BACKGROUND AND OBJECTIVES: The coronavirus disease-2019 (COVID-19) pandemic is transforming the health care sector. As health care organizations move from crisis mobilization to a new landscape of health and social needs, organizational health literacy offers practical building blocks to provide high-quality, efficient, and meaningful care to patients and their families. Organizational health literacy is defined by the Institute of Medicine as "the degree to which an organization implements policies, practices, and systems that make it easier for people to navigate, understand, and use information and services to take care of their health." METHODS: This article synthesizes insights from organizational health literacy in the context of current major health care challenges and toward the goal of innovation in patient-centered care. We first provide a brief overview of the origins and outlines of organizational health literacy research and practice. Second, using an established patient-centered innovation framework, we show how the existing work on organizational health literacy can offer a menu of effective, patient-centered innovative options for care delivery systems to improve systems and outcomes. Finally, we consider the high value of management focusing on organizational health literacy efforts, specifically for patients in health care transitions and in the rapid transformation of care into myriad distance modalities. RESULTS: This article provides practical guidance for systems and informs decisions around resource allocation and organizational priorities to best meet the needs of patient populations even in the face of financial and workforce disruption. CONCLUSIONS: Organizational health literacy principles and guidelines provide a road map for promoting patient-centered care even in this time of crisis, change, and transformation. Health system leaders seeking innovative approaches can have access to well-established tool kits, guiding models, and materials toward many organizational health literacy goals across treatment, diagnosis, prevention, education, research, and outreach.