Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.

This protocol outlines the plan for the development, implementation, and ...

Enhanced Integrated Behavioral Health Model Improves Depressive Symptoms in a Low-Income, Uninsured, Primarily Hispanic Population Served by a Free and Charitable Clinic

Residents living in US-Mexico border communities have some of the worst health outcomes nationally. Rates of chronic disease such as obesity, diabetes, and related mortality in the Rio Grande Valley exceed those in most other regions of Texas and the nation. Poverty is pervasive, placing residents at high risk for poor health; they are more likely to be exposed to environmental hazards and have higher rates of chronic physical and mental health concerns.

At its foundation, integrated behavioral health care aims to address multiple health concerns, and related social determinants, by bringing behavioral health and primary care services together. No ...

Screening Isn’t Enough: A Call to Integrate Behavioral Health Providers in Women’s Health and Perinatal Care Settings

This paper aims to enhance the current understanding of integrated mental health services in the United States and how they can be better incorporated in perinatal and women’s health specialty care from the perspective of a behavioral health provider. 

The reimagination of sustainable integrated care in Ontario, Canada

To encourage clinical and financial efficiency, the Canadian province of Ontario initiated an integrated care program – Integrated Funding Models (IFMs) that required collaboration and coordination across acute and post-acute care sectors. This research shows how program implementers went beyond policy-makers’ original designs, to make integrated care sustainable for chronic diseases.

Telemedicine for housebound older persons during the Covid-19 pandemic

Hollander and Brendan highlighted the benefit to decision-making that may be drawn from the use of automated screening algorithms in prioritizing patient care to better allocate resources during the Coronavirus disease 2019 (Covid-19) pandemic.  A strategy to screen older community dwellers at risk for home confinement-related adverse consequences must, therefore, be adopted based on an efficient and effective forward triage framework. In older community dwellers, assessing frailty is a definite cornerstone of triage, as it provides insight into the degree of vulnerability in their health status and their risk for ...

Goal-Oriented Care: A Catalyst for Person-Centred System Integration

Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation.

Financing of integrated health service networks

The countries of Latin America and the Caribbean need to increase their public resources in health to expand equitable and efficient access to health. The increase should finance a specific model with proven effectiveness, such as integrated health service networks (IHSN) based on primary health care. The global literature has not paid sufficient attention to financing IHSN; rather, it has focused on isolated facilities and agents, as well as on specific mechanisms. However, in the Region of the Americas, their development has been a necessity for years. An IHSN is a group of health organizations that offers coordinated health interventions ...

Health Networks in Action: The experiences of Argentina, Brazil, Colombia and Mexico

Dioselina is a 54-year-old divorcée who has no children and lives alone in a large city. She has been unemployed for a year and just started receiving welfare six months ago. As for her health, she has long-term obesity, chronic obstructive pulmonary disease, and diabetes. In recent months, she began to develop foot ulcers because her blood sugar was not being monitored properly, which is attributable in part to difficulty accessing healthcare services and getting medications and lab tests. If she does not receive rapid treatment and more specialized care for the ulcers, they could worsen and require hospitalization ...

The influence of leadership facilitation on relational coordination among primary care team members of accountable care organizations.

Teamwork is a central aspect of integrated care delivery and increasingly critical to primary care practices of accountable care organizations. Although the importance of leadership facilitation in implementing organizational change is well documented, less is known about the extent to which strong leadership facilitation can positively influence relational coordination among primary care team members.

Patient experience of an integrated care model in a family practice clinic and Federally Qualified Health Center (FQHC)

Behavioral health issues are daily challenges in all primary care settings. The integration of programs and strategies translates into better global results, which optimizes the effort of health workers. In this study, user satisfaction is evaluated, through validated surveys, in 727 patients from different centers, family practice clinic and a Federally Qualified Health Center.