The Utilization of Video-Conference Shared Medical Appointments in Rural Diabetes Care

Aim To explore whether Video-Shared Medical Appointments (video-SMA), where group education and medication titration were provided remotely through video-conferencing technology would improve diabetes outcomes in remote rural settings. Methods We conducted a pilot where a team of a clinical pharmacist and a nurse practitioner from Honolulu VA hospital remotely delivered video-SMA in diabetes to Guam. Patients with diabetes and HbA1c ≥7% were enrolled into the study during 2013–2014. Six groups of 4–6 subjects attended 4 weekly sessions, followed by 2 bi-monthly booster video-SMA sessions for 5 months. Patients with HbA1c ≥7% that had primary care visits during the study period but not referred/recruited for video-SMA were selected as usual-care comparators. We compared changes from baseline in HbA1c, blood-pressure, and lipid levels using mixed-effect modeling between video-SMA and usual care groups. We also analyzed emergency department (ED) visits and hospitalizations. Focus groups were conducted to understand patient’s perceptions. Results Thirty-one patients received video-SMA and charts of 69 subjects were abstracted as usual-care. After 5 months, there was a significant decline in HbA1c in video-SMA vs. usual-care (9.1 ± 1.9 to 8.3 ± 1.8 vs. 8.6 ± 1.4 to 8.7 ± 1.6, P = 0.03). No significant change in blood-pressure or lipid levels was found between the groups. Patients in the video-SMA group had significantly lower rates of ED visits (3.2% vs. 17.4%, P = 0.01) than usual-care but similar hospitalization rates. Focus groups suggested patient satisfaction with video-SMA and increase in self-efficacy in diabetes self-care. Conclusion Video-SMA is feasible, well-perceived and has the potential to improve diabetes outcomes in a rural setting. Abbreviations ACE-inhibitor, angiotensin converting enzyme-inhibitor; ARB, angiotensin receptor blocker; CBOC, community-based outpatient clinic; DM, diabetes mellitus; ED, emergency department; PACIC, patient assessment of care in chronic conditions; VAMC, Veterans Affairs Medical Center; VHA, Veterans Health Administration; video-SMA, video-shared medical appointment

Health Status and Adults Willingness to Encounter A Provider by Telehealth

Telehealth has proven to be a growing sector providing on-demand health services for consumers. A long history of development and refinement precede what we now know as telehealth technology. Access to telehealth technology has become widely available changing the landscape of healthcare. However, does that mean that consumers desire to use the technology? How does a factor such as health status play a role in the consumers’ willingness to encounter a provider using telehealth as the method for delivery of care? This research project aims to compare self-selected health status to consumers’ willingness to engage with telehealth services

N.C. Medicaid Reform: A Bipartisan Path Forward

The North Carolina Medicaid program currently constitutes 32% of the state budget and provides insurance coverage to 18% of the state’s population. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education, and race. The Duke University Bass Connections Medicaid Reform project gathered to consider how North Carolina could use its limited Medicaid dollars more effectively to reduce the incidence of poor health, improve access to healthcare, and reduce budgetary pressures on the state’s taxpayers. This report is submitted to North Carolina’s policymakers and citizens. It assesses the current Medicaid landscape in North Carolina, and it offers recommendations to North Carolina policymakers concerning: (1) the construction of Medicaid Managed Care markets, (2) the potential and dangers of instituting consumer-driven financial incentives in Medicaid benefits, (3) special hotspotting strategies to address the needs and escalating costs of Medicaid\u27s high-utilizers and dual-eligibles, (4) the emerging benefits of pursuing telemedicine and associated reforms to reimbursement, regulation, and Graduate Medical Education programs that could fuel telemedicine solutions to improve access and delivery. The NC Medicaid Reform Advisory Team includes: Deanna Befus, Duke School of Nursing, PhD ‘17Madhulika Vulimiri, Duke Sanford School of Public Policy, MPP ‘18Patrick O’Shea, UNC School of Medicine/Fuqua School of Business, MD/MBA \u2717Shanna Rifkin, Duke Law School, JD ‘17Trey Sinyard, Duke School of Medicine/Fuqua School of Business, MD/MBA \u2717Brandon Yan, Duke Public Policy, BA \u2718Brooke Bekoff, UNC Political Science, BA \u2719Graeme Peterson, Duke Public Policy, BA ‘17Haley Hedrick, Duke Psychology, BS ‘19Jackie Lin, Duke Biology, BS \u2718Kushal Kadakia, Duke Biology and Public Policy, BS ‘19Leah Yao, Duke Psychology, BS ‘19Shivani Shah, Duke Biology and Public Policy, BS ‘18Sonia Hernandez, Duke Economics, BS \u2719Riley Herrmann, Duke Public Policy, BA \u271

A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination tools

BACKGROUND: Children with traumatic brain injury (TBI) report unmet needs several years after their injury and may require long-term care. However, this chronic health condition is often only treated and monitored in the short-term. Care for young persons with TBI often relies on parents to manage their child’s complex care network. Effective care coordination can close these gaps and facilitate continuity of care for children with TBI. The purpose of this scoping review was to develop a better understanding of tools that improve care coordination for Children with Special Health Care Needs (CSHCN). This, in turn, can inform care for children with TBI. METHODS: A scoping review was conducted following the PRISMA framework and methodology. OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination tools used with CSHCN. RESULTS: 21 articles met the criteria for inclusion in the review, and 6 major categories of care coordination tools were identified: telehealth, online health records and tools, care plans, inpatient discharge protocols, family training, and reminders. DISCUSSION: Studies examining telehealth, online tools, care plans, and family training care coordination interventions for CSHCN have shown positive outcomes and would be relevant strategies to improve the care of children with TBI. Future prospective research should investigate these tools to explore whether they might improve communication, reduce unmet needs, increase service access, and improve long-term outcomes for children with TBI

Mobile-Based Technology App Used to Improve Self-Care Management of Patients with Type 2 Diabetes Mellitus

Billions of dollars are spent on diabetes in healthcare each year. Patients with lower socio-economic-status tend to have poor glycemic control, higher associated diabetic complications, and higher associated mortality rates. In underserved patients with type 2 diabetes, does utilization of a Diabetes app, compared to previous self-care management and clinic education, lower the Hemoglobin A1c over a 3-month period? A 3-month scholarly project was conducted in a small rural town in Virginia with an average median income around $17,000. N=21 were selected for the scholarly project. Inclusive criteria consisted of adults aged 19-70 years with a diagnosis of type 2 diabetes for more than 6 months. Participants were required to have access to iOS/Android cellular devices. Additionally, participants were requested to complete pre and post self-care management and demographics questionnaires, and utilize the Diabetes app daily during the 3 month intervention window. After the 3-month intervention window, participants had an overall decrease in hemoglobin A1c by (2.34%, p = .004). Further evidence demonstrated a direct improvement in self-care management techniques ratings based on average, good, and great with an overall mean increase of 14.3% after the intervention window. Participants who scored poor and bad had an overall mean decrease of 21.38% after the intervention period. Mobile-based technology serves to help patients achieve their target glycemic goals, reduce mortality and morbidity, and promotes more versatile methods of healthcare delivery compared to traditional interventions and educational methods such as oral glycemic agents, diabetic class education, and insulin administration to manage T2DM

Marshfield Clinic: Health Information Technology Paves the Way for Population Health Management

Highlights Fund-defined attributes of an ideal care delivery system and best practices, including an internal electronic health record, primary care teams, physician quality metrics and mentors, and standardized care processes for chronic care management

Diabetes Shared Medical Appointment: An Evidence-Based Innovation Project

The purpose of the evidence-based practice innovation project (EPIP) is to address uncontrolled diabetes by implementing an evidence-based shared medical appointment (SMA) intervention which based on the body of the evidence will help improve diabetes outcomes. A pilot implementation and retrospective chart review were conducted. Data was collected on outcome indicators such as blood pressure, lipid values, body mass index, A1C, and knowledge. The results of a pilot SMA implementation revealed that patients who participated in the weekly SMA saw an improvement in post-mean values compared to pre-mean values. Mean A1c dropped to 7.0% from 7.11%; systolic blood pressure improved to125 mmHg from 128 mmHg; diastolic blood pressure dropped to 77 mmHg from 84 mmHg; body mass index dropped to 33.63 kg/m2 from 35.44 kg/m2; and, knowledge increased from 52% to 93%. Retrospective chart review findings revealed that the number of patients who were at goal A1C increased from 25% to 38% post intervention. The number of patients at goal for hypertension increased from 65% to 88%, and mean HbA1c dropped from 8.0% to 7.5%. These findings are consistent with those represented in the body of the evidence, suggesting SMA as an effective and feasible intervention to helping diabetes patients to meet glycemic goals and improving diabetes outcomes. Therefore, policy and culture change are warranted to adopt and sustain SMA as the standard of diabetes care. New clinic policies, SMA clinic mentors, and utilization of conceptual models will promote sustainability of SMA

A systematic review of health service interventions to reduce use of unplanned health care in rural areas

Rationale, aims and objectives: Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations. Methods: The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively. Results: A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions. Conclusion: Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results

Shared Medical Appointments to Improve Self-Care Actions in the Adult Heart Failure Patient

Approved May 2020 by the faculty of UMKC in partial fulfillment of the requirements for the degree of Doctor of Nursing PracticeHeart failure affects about 5.7 million people in the United States and is the leading cause of hospitalizations of people over 65 years of age. In 2010, the CDC estimated that heart failure costs the nation $30.7 billion each year. The purpose of the quality improvement intervention was to determine if the evidence-based shared medical appointment model improves self-care actions as measured by the Self-Care of Heart Failure Index and decreases heart failure hospital admissions in the adult heart failure population. The quasi-experimental intervention included four adult patients with a diagnosis of heart failure with preserved ejection fraction or heart failure with reduced ejection fraction who receive their primary care at a family medicine clinic associated with a Midwest university hospital. Participants met for their heart failure medical appointments in a group setting once a week for four weeks to engage in a multidisciplinary education program. Due to limited participation, this quality improvement project did not yield an opportunity for outcome evaluation. Although barriers to group appointments exist, shared medical appointments have been shown to have positive effects on both patient outcomes and patient experiences and can be used to help lessen the economic burden of heart failure