An innovative approach for health care delivery to obese patients: from health needs identification to service integration

In Europe, more than half of the population is overweight or obese, and effort to design, validate, and implement innovative approaches is required to address social and health unmet needs of obese patients in terms of health promotion, disease prevention, and integration of services. The challenge is improving the collaboration between the different health and care stakeholders involved in the lives of obese patients, changing the socio-cultural attitude towards food intake and other behaviours leading to a negative impact on their health-related quality of life. The digital transformation of health and care can support changes in healthcare systems, healthy policy, and approaches to patient care and better implementation of the different health promotion and disease prevention strategies between all the stakeholders and support obese patients. Based on the previously experience adopted by Blueprint Partners with the Blueprint persona and user scenario in the context of models of care and prevention, health policies and analysis of risk factors affecting health and quality of life of obese subjects, the study aimed to simulate an integrated care pathway, through a multidisciplinary approach, developing and applying solutions and good clinical practices addressing the social and health unmet needs of obese patients. A pilot study assessed the quality of life (QoL), adherence to the Mediterranean diet, efficacy and interoperability of a digital health platform, Paginemediche. it. A qualitative approach has been adopted to identify and specify key digital solutions and high-impact user scenarios in Active and Healthy Ageing (AHA). To achieve a successful result, an iterative and collaborative approach has been followed to develop a user-centred perspective to the identification of solutions addressing health needs with different complexity along the entire life-course. Four initial key topic areas were chosen and used to identify different digital solutions that may meet the needs of the population segments defined by both age and the complexity of their health status. All data, derived from the industry representatives in the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA), were collected via a survey to how digital solutions best met the needs of the various population segments represented by personas. Subsequently, innovative solutions were designed based on how a user from a target group interacts with technologies, developing "personas" belonging to specific "population segments" with different conditions and needs. Then, a high-impact user scenario, based on the correlation of personas' needs, good clinical practices and digital solutions available targeting needs which playing a role in the health and care delivery for the persona, has been developed. In the end, to evaluate how digital solutions and technologies can support obese patients during their weight loss or management of their related comorbidities in current service provision, ten obese patients were enrolled to evaluate a Digital Health platform, pagininemediche.it, developed. Matilde, the Blueprint persona developed, highlighted some of the main needs (social support, development of a health-friendly environment and educational program on healthy nutrition and physical activity) that may be addressed by integrating innovative solutions in the care of obese patients. Based on her profile, a high-impact user scenario diagram correlates health and social needs with digital solutions and can help key actors in the creation of a well-integrated care approach. Moreover, the evaluation of the digital platform, paginemediche.it, demonstrated how digital solutions can motivate and support obese patients in changing habits towards a healthy lifestyle, although no further statistical significance has been identified in the quality of life assessment because of the limited number of the patients, and short period of observation. Overweight or obese patients tend to be marginalized and the subject of a real social stigma. Digital solutions may be useful to overcome psychological factors that prevent obese patients from starting their journey for a lifestyle change. The suggested approach, which considers health needs, IT skills, socioeconomic context, interoperability, and integration gaps that may influence the adoption of innovative solutions tailored to improve health outcomes is person-centred, and identify what is important for obese patients. The implementation of a persona and user scenario approach may also be useful for the early involvement of end-users in solutions' design and adaptation, increasing adherence, and the effectiveness of digital solutions. Persona profiles, the user scenario, and the related digital solution also consider the potential benefits that can derive for both patients and health system in term of reduced emergency room admissions, waiting lists, and health related expenditures

Characterization and Representation of Patient Use of Virtual Health Technology in Primary Care

Purpose. Advances in virtual care technology have made healthcare more convenient and accessible. The goal of this study was to elucidate current patient portal behaviors by examining the pattern of time and service type use of patients, via data provided by access logs within electronic health records, to increase communication and care coordination through online healthcare portals. Methods. We conducted a retrospective study of patients in an academic healthcare center over a 5-year period using access log records in electronic health records (EHR). Dimensionality reduction analysis was applied to group portal functionalities into more interpretable and meaningful feature domains, followed by negative binomial regression analysis to evaluate how patient and practice characteristics affected the use of each feature domain. Results. Patient portal usage was categorized into four feature domains: messaging, health information management, billing/insurance, and resource/education. Individuals having more chronic conditions, lab tests or prescriptions generally had greater patient portal usage. However, patients who were male, elderly, in minority groups, or living in rural areas persistently had lower portal usage. Individuals on public insurance were also less likely than those on commercial insurance to use patient portals, though Medicare patients showed greater portal usage on health information management features and uninsured patients had greater usage on viewing resource/education features. Having Internet access only affected the use of messaging features, but not other feature. Conclusions. Efforts in enrolling patients in online portals does not guarantee patients using the portals to manage their health. While promoting the use of virtual health tools as part of patient-center care delivery model, primary care clinicians need to be aware of technological, socioeconomic, and cultural challenges faced by their patients

Designing a Patient-Centered Clinical Workflow to Assess Cyberbully Experiences of Youths in the U.S. Healthcare System

Cyberbullying or online harassment is often defined as when someone repeatedly and intentionally harasses, mistreats, or makes fun of others aiming to scare, anger or shame them using electronic devices [296]. Youths experiencing cyberbullying report higher levels of anxiety and depression, mental distress, suicide thoughts, and substance abuse than their non-bullied peers [360, 605, 261, 354]. Even though bullying is associated with significant health problems, to date, very little youth anti-bullying efforts are initiated and directed in clinical settings. There is presently no standardized procedure or workflow across health systems for systematically assessing cyberbullying or other equally dangerous online activities among vulnerable groups like children or adolescents [599]. Therefore, I developed a series of research projects to link digital indicators of cyberbullying or online harassment to clinical practices by advocating design considerations for a patient-centered clinical assessment and workflow that addresses patients’ needs and expectations to ensure quality care. Through this dissertation, I aim to answer these high-level research questions:RQ1. How does the presence of severe online harassment on online platforms contribute to negative experiences and risky behaviors within vulnerable populations? RQ2. How efficient is the current mechanism of screening these risky online negative experiences and behaviors, specifically related to cyberbully, within at-risk populations like adolescent in clinical settings? RQ3. How might evidence of activities and negative harassing experiences on online platforms best be integrated into electronic health records during clinical treatment? I first explore how harassment is presented within different social media platforms from diverse contexts and cultural norms (study 1,2, and 3); next, by analyzing actual patient data, I address current limitations in the screening process in clinical settings that fail to efficiently address core aspect of cyberbullying and their consequences within adolescent patients (study 4 and 5); finally, connecting all my findings, I recommend specific design guidelines for a refined screening tool and structured processes for implementation and integration of the screened data into patients’ electronic health records (EHRs) for better patient assessment and treatment outcomes around cyberbully within adolescent patients (study 6)

Food insecurity and residential segregation among adults in the United States: the national health and nutrition examination survey 2017- March 2020 pre-pandemic data.

Food insecurity is when a household has insufficient food supply due to limited economic resources. It is a public health issue that continues to persist. The health, social, and economic impact affects millions of people nationwide. Residential segregation is a primary cause of inequities and health disparities. It shapes the differences in socio-economic conditions between Blacks and Whites living in the U.S. This country is segregated across racial lines in many of our most populated metropolitan cities. Americans worship in different churches, learn in disparate schools, and live in separate neighborhoods. Residential segregation has consequences that impact the economy, professional and social networks, and cause resource inequalities. As food insecurity and residential segregation continue to plague our country, public health researchers must investigate these issues and use theory to guide them toward solutions. Using extensive data samples to understand better the impact of residential segregation on food insecurity rates across the country is essential. This study used the National Health and Nutrition Examination Survey (NHANES) 2017-March 2020 pre-pandemic data, the U.S. Census, Feeding America’s Map the Meal Gap, and Brown University’s Dissimilarity Index to assess food insecurity and residential segregation in adults in the U.S. Additionally, the data was used to examine food insecurity and levels of segregation across three metropolitan cities with high, medium, and low dissimilarity indices. Variables for the study were identified from the individual, community, and societal levels of the social-ecological model. Logistic regression analyses were conducted to assess predictors of food insecurity among adults in the U.S. Findings showed statistical significance in many of the variables predicting food insecurity. Research was also conducted on local programs, policies, and interventions to combat food insecurity in the selected metropolitan cities. This study adds to the growing body of literature on residential segregation and its association with food insecurity rates in the U.S. The findings from this research indicate the need for improvements in public health, health promotion, and education efforts regarding these issues. It can prompt the creation of better policies, programs, and interventions to address this country\u27s growing food insecurity and residential segregation

An Evaluation of Computational Methods to Support the Clinical Management of Chronic Disease Populations

Innovative primary care models that deliver comprehensive primary care to address medical and social needs are an established means of improving health outcomes and reducing healthcare costs among persons living with chronic disease. Care management is one such approach that requires providers to monitor their respective patient panels and intervene on patients requiring care. Health information technology (IT) has been established as a critical component of care management and similar care models. While there exist a plethora of health IT systems for facilitating primary care, there is limited research on their ability to support care management and its emphasis on monitoring panels of patients with complex needs. In this dissertation, I advance the understanding of how computational methods can better support clinicians delivering care management, and use the management of human immunodeficiency virus (HIV) as an example scenario of use. The research described herein is segmented into 3 aims; the first was to understand the processes and barriers associated with care management and assess whether existing IT can support clinicians in this domain. The second and third aim focused on informing potential solutions to the technological shortcomings identified in the first aim. In the studies of the first aim, I conducted interviews and observations in two HIV primary care programs and analyzed the data generated to create a conceptual framework of population monitoring and identify challenges faced by clinicians in delivering care management. In the studies of the second aim, I used computational methods to advance the science of extracting from the patient record social and behavioral determinants of health (SBDH), which are not easily accessible to clinicians and represent an important barrier to care management. In the third aim, I conducted a controlled experimental evaluation to assess whether data visualization can improve clinician’s ability to maintain awareness of their patient panels

A case study of survival and presentation of gastroesophageal cancer in local neighbourhoods

This thesis presents a quantitative case study on incidence, survival and presentation of patients diagnosed with gastroesophageal cancer to evaluate whether where people live affects how they present and survive with a gastroesophageal cancer diagnosis. The focus research evolved from studies on gastroesophageal cancer’s ‘geographic affiliation’ and a desire to review whether patient and population attributes could be harnessed to reveal potential ‘hotspots’ to inform targeted health intervention strategies. As the most crucial stage for intervention was associated with patients detecting symptoms early enough for intervention, the focus of this case study was narrowed to survival and presentation.This research analysed data from 2785 patients who presented to a regional referral specialist cancer treatment centre between the years 2000 and 2013. Cohort analysis revealed common attributes and survival, and data were merged with demographic information in a geographic information system to present findings in mapped format.Descriptive analysis revealed an association between later stage presentation and reduced survival outcome. Emergency presentations tended to have worse outcomes. Survival deteriorated with advancing age. Gastroesophageal cancer diagnoses in the under 54 age group was more common in lower socioeconomic groups and survival outcomes were marginally lower than in those patients from the least deprived areas. Spatial analysis revealed variation in incidence, presentation and survival across the region. Though this case study revealed several new findings on gastroesophageal cancer presentation and survival, there remains no single solution to informing and encouraging earlier diagnosis interventions. Though presenting data at finer scales of resolution is more clinically relevant, it threatens patient confidentiality

Identification of Victims of Human Trafficking: Leading Change through a Global Pandemic

Human trafficking is a multi-billion-dollar global industry, generating $150 billion annually (International Labour Organization [ILO], 2014), and driven by the exploitation of victims of all ages, primarily for forced labor or commercial sex. Victims endure frequent and prolonged abuse, suffering illnesses, and injuries. When accessing the health care system, they often go unrecognized by health care providers and nurses. Recognition requires training to raise awareness and the right tools to capture the information necessary to identify victims and address opportunities to improve their safety, care, and support. The aim of this Doctor of Nursing Practice (DNP) evidence-based change project was to improve the recognition and identification of victims of human trafficking by emergency department and labor and delivery clinicians through (1) participation in a standardized training program built on the provision of victim-centered, trauma-informed care, and (2) the creation and use of a screening tool template in the electronic health record (EHR). An important secondary goal included increasing the number of referrals made for community services on the identified victims’ behalf. Unexpectedly, the global pandemic disrupted the project plan and timelines, prompting a re-evaluation of the project and the need to create contingency and collateral workstreams. Activities were re-prioritized, and the Phase II initiative became the Phase I interventions. Three-module training programs for clinical staff were developed: (1) Human trafficking 101: Dispelling the myths, (2) Trauma-informed patient care and services, and (3) PEARR: Five steps to victim assistance in health care settings. Each module included comprehension questions, and a score of 80% was required to complete each learning module successfully. Due to a moratorium on non-essential training during the height of the pandemic, these modules were not assigned to clinicians for completion until September 1, 2020. Clinicians in the emergency departments (ED) of three Dignity Health acute care facilities in southern California were assigned the modules and given 30 days to complete them. Comprehension improved from 87.1% (n=307) at baseline to 91.5% (n=302) for those modules completed by September 30, 2020; the 5.05% improvement (p=.6018; 95% CI) was not statistically significant. It may be clinically significant because these clinicians now have greater knowledge and awareness to recognize victims of human trafficking who present to the ED and then take action to offer services. The benefit-cost ratio for the learning modules was 2.47 based on estimates of the “soft” benefits or intangible benefits to victims and society, indicating this project was feasible and beneficial to the organization. However, to fully measure the benefit-cost ratio of the DNP project, data are needed to determine if clinicians who receive standardized training can better identify victims of human trafficking. Data collection and analyses will be extended beyond the timeframe of this project and compared to the baseline. Additionally, the project plan for creating and implementing the standard screening tool in the EHR was modified to relaunch in the mid-calendar year 2021, pending the status of the COVID-19 pandemic. In summary, human trafficking is a public health crisis and one of the most lucrative crimes in the world (ILO, 2017). Standardized tools and training are needed to aid clinicians in screening and identifying victims. The executive nurse leader can effectively lead change during a global pandemic by using change management theory, nursing theory, demonstration of leadership competencies, and a strong understanding of project management principles. In doing so, care delivery can be improved, even for those most vulnerable and hiding in the shadows