Implementing patient-centred integrated care for multiple chronic conditions Evidence-informed framework

Fifteen years ago, the term multimorbidity rarely appeared in chronic disease health care policies. Today, research has revealed very high rates of multimorbidity, leading to it being labeled the number one challenge in developed countries. Paradoxically, chronic disease prevention and management (CDPM) programs of integrated care have popped up in all health care systems but they mainly follow a single-disease approach in their interventions. In this article, we define CDPM programs broadly as any interventions intended to improve care for patients with chronic diseases and risk factors; these are added to usual care and are typically delivered by a team.

The Growth of Integrated Care Models in Urology

With heightened awareness of health care outcomes and efficiencies and reimbursement-based metrics, it is ever more important that urologists consider the effects of integrated care models on physicians/staff/clinics fulfillment and patient outcomes, and whether and how to optimally implement these models within their unique practice settings. Despite growing evidence that integrating care improves outcomes, uncertainty persists regarding which approach is most efficient and achievable in terms of specialty considerations and financial resources. In this article, we discuss strategies for integrating urologic care and its impact on current and future health care delivery.

Behavioral interventions in acute COVID-19 recovery: A new opportunity for integrated care

New York City was the epicenter of the 2019 coronavirus disease (COVID-19) pandemic. Critically ill patients surviving prolonged ventilation, medical complications, and protracted delirium are profoundly debilitated. In response, our hospital temporarily created a novel, hybrid inpatient medicine-rehabilitation unit for COVID-19 survivors. Patients are medically monitored and work towards rehabilitation goals with daily physical and occupational therapy (PT/OT). To our knowledge, it is the only such unit in our region. Here, we describe how neuropsychology and consultation-liaison psychiatry have collaborated to implement interventions within this unit to facilitate patients' recovery.

The primary care behavioral health model (PCBH) and medication for opioid use disorder (MOUD): integrated models for primary care

Recent decades have witnessed increases in (a) integrated physical and behavioral health services and (b) the treatment of opioid use disorders (OUD) in primary care settings – also known as office-based opioid treatments (OBOT) – using a combination of medication and psychosocial support. Providing these services requires a workforce trained to address addiction’s psychosocial components and interventions addressing addiction’s biological and neurological mechanisms. This paper examines the implementation factors, clinic workflow and roles, and administrative considerations of two models of integrated care in order to identify ways of increasing treatment capacity and expanding OUD treatment uptake in integrated primary care ...

Transitional Care Experiences of Patients with Hip Fracture Across Different Health Care Settings

Transitions of care often result in fragmented care, leading to unmet patient needs and poor satisfaction with care, especially in patients with multiple chronic conditions.

This project aimed to understand how experiences of patients with hip fracture, caregivers, and healthcare providers differ across different points of transition.

The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care

Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot.

The association of vertically integrated care with health care use and outcomes

The objective of this article is to determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program

The purpose of this article was to develop and implement a new model of collaborative care that includes a triage and referral management system. The authors present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.  

The Affordable Care Act: policy predictors of integrated care between Hispanic-serving and mainstream mental health organizations

The Patient Protection and Affordable Care Act increased funding for integrated care to improve access to quality health care among underserved populations. There is evidence that integrated care decreases inequities in access and quality of mental health care among Hispanic clients. Increasing integrated care at Hispanic-Serving Organizations may help to eliminate mental health service disparities among Hispanic clients.

Impact of Proactive Integrated Care on Chronic Obstructive Pulmonary Disease

In the United States, chronic obstructive pulmonary disease (COPD) affects over 16 million people, costs $32 billion per year, and is the fourth leading cause of death.Exacerbations of COPD are among the most devastating complications of COPD, because they greatly increase the risk of death and account for 60% of COPD costs.Efforts have focused on standardizing recommendations for therapies that improve symptoms and limit exacerbations, identifying patients who might benefit from these treatments, and increasing compliance with recommended therapies.Surprisingly, only about 50% of COPD patients receive recommended therapies for COPD and COPD exacerbations, up to two-thirds of ...