Delivering Complex Care: Designing for Patients and Physicians

Epstein, Jeremy A.; Wu, Albert W.

doi:10.1007/s11606-020-06212-3

Cited by 9 publications

(6 citation statements)

References 21 publications

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“…Systems‐based structural change and attention to design How do system‐level and community‐level factors affect engagement in clinical encounters? How do system‐ and community‐level factors support or impede individual engagement (e.g., user‐friendly technology interfaces, reducing the fragmentation of care, using uniform and clear language)? How do system‐ and community‐level factors support or impede clinicians' ability to foster engagement (e.g., incentives, appointment lengths, education, and formalized roles such as comprehensivists as proposed by Tinetti, Fried, and Boyd 39 or intensive outpatient care specialists, with formal fellowship training as such, as recently described by Epstein and Wu 40 )? What structural changes, if any, overcome the intention–behavior gap as suggested by Nease et al? 26 …”

Section: Discussion: Opportunities To Further the Field Of Engagement Among Persons With MCCmentioning

confidence: 99%

A scoping review of person and family engagement in the context of multiple chronic conditions

Vick

Wolff

2021

Health Services Research

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Objective To review definitions, concepts, and evidence regarding person and family engagement for persons with multiple chronic conditions (MCCs) in order to identify opportunities to advance the field. Data Source Ovid MEDLINE. Study Design We performed a two‐step process as follows: (1) a critical review of conceptual models of engagement to identify key concepts most pertinent to engagement among persons with MCC as a “launch pad” to our scoping review and (2) a scoping review of reviews of engagement for persons living with MCC. Data Collection/Extraction Methods First, we critically reviewed six models of engagement. Second, our scoping review identified 1297 citations, with 67 articles meeting criteria for inclusion. Of these, we focused on reviews, of which there were nine titles/abstracts retained for full‐text consideration. Six full‐text reviews were included in the final analysis. The purpose, review type, population, number/type of included studies, theoretical framework, and findings of each study were extracted and analyzed thematically. Principal Findings Conceptual models of engagement differ with respect to areas of emphasis (e.g., systems or clinical encounters) as well as attention to vulnerable populations, involvement of family, consideration of cost–benefit trade‐offs, and attention to outcomes that matter most. Our scoping review of reviews identified just one article explicitly focused on engagement interventions for those with MCC. Other reviews examined elements of self‐management and involvement in decision making, conceptually related to engagement without explicit use of the word. We find that existing evidence has predominantly described individual‐level strategies rather than targeting organizations, systems, or policies. Barriers to engagement are not well described nor are potential downsides to engagement. Family engagement is rarely considered. Conclusions Promising areas of future work include attention to barriers to engagement including trust, goal‐based care, the design of structural changes to care delivery, trade‐offs between benefits and costs, and family engagement.

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Section: Discussion: Opportunities To Further the Field Of Engagement Among Persons With MCCmentioning

confidence: 99%

A scoping review of person and family engagement in the context of multiple chronic conditions

Vick

Wolff

2021

Health Services Research

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“… Study design [ 1 ]. For analysis purposes, the population was limited to allow for 12-month outcome data [ 2 ]. Either (1) ≥ 3 no-shows in 12 months or (2) an 18-month gap between visits.…”

Section: Methodsmentioning

confidence: 99%

“…Despite widespread availability of antiretroviral therapy (ART) in the United States, difficulties with engagement in care continue to persist for some people with human immunodeficiency virus (PWH) [ 1 ], particularly those with housing instability, substance use, and concomitant psychiatric illness [ 2–7 ]. Multiple strategies to re-engage PWH in care, including patient navigation, appointment alerts, psychosocial support, transportation assistance, and data-to-care, have been implemented with varying success [ 8 , 9 ].…”

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confidence: 99%

The Impact of a Walk-in Human Immunodeficiency Virus Care Model for People Who Are Incompletely Engaged in Care: The Moderate Needs (MOD) Clinic

Kumbhakar

Budak

Tao

et al. 2022

Open Forum Infectious Diseases

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Background The MOD Clinic in Seattle, Washington provides walk-in primary care for people with HIV who are incompletely engaged in standard care. Methods We evaluated HIV outcomes among patients enrolled in the MOD Clinic (within group analysis) and, separately, among MOD patients vs. patients who were MOD-eligible but did not enroll (comparison group analysis) during 1/1/2018-9/30/2021. The primary outcome was viral suppression (VS; viral load <200 copies/mL); secondary outcomes care engagement (≥ 2 visits ≥60 days apart) and sustained VS (≥2 consecutive suppressed viral loads ≥60 days apart). In the within group analysis, we examined outcomes at time of MOD enrollment vs. 12 months post-enrollment. In the comparison group analysis, we examined outcomes at the time of MOD eligibility vs. 12 months post-eligibility. Both analyses used modified Poisson regression. Results Most patients in MOD (N = 213) were unstably housed (52%) and had psychiatric comorbidities (86%) or hazardous substance use (81%). Among patients enrolled ≥12 months (N = 164), VS did not increase significantly from baseline to post-enrollment (63% to 71%, p = 0.11), but care engagement and sustained VS both improved (37% to 86%, p < 0.001; and 20% to 53%, p < 0.001, respectively) from pre-enrollment to 12 months post-enrollment. In the comparison group analysis, VS worsened in non-enrolled patients (N = 517) from baseline to 12-months post-eligibility (82% to 75%, p < 0.001). MOD patients who met criteria for the comparison group analysis (N = 68) were more likely than non-enrolled patients to be engaged in care at 12 months post-eligibility (RR 1.29; 95% CI 1.03-1.63). Conclusions MOD Clinic enrollment was associated with improved engagement in care. This model adds to the spectrum of differentiated HIV care services.

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“…Complexity arises from the interdependence of multiple interconnected elements. When it comes to the patient, the complexity arises from his or her capacity as a person to receive available help, which is influenced by social determinants and the mental health state of the person ( 9 - 11 ).…”

Section: More Of the Same: Difficult Or Complex?mentioning

confidence: 99%