Primary Care-Led Transition Clinics Hold Promise in Improving Care Transitions for Cancer Patients Facing Social Disparities: A Commentary

Malebranche, Mary; Sarivalasis, Apostolos; Peters, Solange; Mathevet, Patrice; Cornuz, Jacques; Bodenmann, Patrick

doi:10.1177/2150132720957455

Cited by 3 publications

(2 citation statements)

References 21 publications

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“…6 It is multimodal and contains as building blocks elements that have previously been associated with positive outcomes, including leveraging a transitional care nurse coordinate efforts across the continuum of care, tailored care plans, and patient education regarding their conditions and medications. 6,26 Several design and operational elements contributed to the success of the transitions primary care clinic we have described. First, this clinic was staffed by an experienced nurse care coordinator who was able to effectively manage the care of the medically and socially complex patients seen in the clinic alongside PCP colleagues.…”

Section: Discussionmentioning

confidence: 99%

Development of a Primary Care Transitions Clinic in an Academic Medical Center

et al. 2021

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INTRODUCTION:Transitions of care experiences leave patients vulnerable to adverse outcomes, including readmissions, worsening symptoms, and reductions in functional status. AIM: To describe and evaluate a primary care transitions clinic that serves patients with medical and/or social needs that must be addressed prior to establishment of primary care. SETTING: Brigham Health, an academic medical center in Boston, MA. PROGRAM DESCRIPTION: The transitions clinic opened within an existing primary care practice in January 2019. It employs one full-time nurse care coordinator and one full-time medical assistant, and is staffed by one primary care physician (PCP) or nurse practitioner each weekday afternoon. Both medical and social diagnoses that require follow-up post-discharge are addressed. Patients with any insurance are seen as many times as necessary until PCP care is established. PROGRAM EVALUATION: In the year after its establishment (January 20, 2019, to January 19, 2020), the transitions clinic received 498 referrals (73.2% from the emergency department (ED), 23.3% from inpatient), with 207 patients ultimately seen. Patients were seen 5 (median; IQR 4-6) work days post-discharge, with 2 (median; IQR 1-3) visits per patient. Patients seen in the transitions clinic had significantly fewer ED visits than a comparator cohort referred to Brigham Health Primary Care after ED or hospital discharge in the year prior (January 20, 2018, to January 20, 2019. Patients seen in the transitions clinic additionally had significantly fewer ED visits and hospitalizations in the three months post-referral than in the three months pre-referral. The most common social determinants addressed by the clinic's nurse coordinator were insurance, transportation, and housing. DISCUSSION: A primary care transitions clinic can provide accessible, attentive care post-discharge with positive effects on healthcare utilization. Availability of a multidisciplinary team that can see patients for repeated visits until establishment of PCP care was a key success factor for the transitions clinic.

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Section: Discussionmentioning

confidence: 99%

Development of a Primary Care Transitions Clinic in an Academic Medical Center

et al. 2021

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“…Diabetes is best managed in primary care, with a regular primary care provider (typically a family physician) supported by an interprofessional team. 1–3 However, because of the increasing complexity of diabetes management, the care needs of patients with diabetes may exceed the capacity for the skills and knowledge of their family physicians to adequately address them on their own. 4–8 …”

Section: Introductionmentioning

confidence: 99%

Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design

Mathews,

Lyons,

Harris

et al. 2024

BMJ Open

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IntroductionThe growth and complexity of diabetes are exceeding the capacity of family physicians, resulting in the demand for community-based, interprofessional, primary care-led transition clinics. The Primary Care Diabetes Support Programme (PCDSP) in London, Ontario, is an innovative approach to diabetes care for high-risk populations, such as medically or socially complex and unattached patients. In this study, we will employ a quadruple-aim approach to evaluate the health system impacts of the PCDSP.Methods and analysisWe will use multiple methods through a convergent parallel design in this project across five unique studies: a case study, a patient study, a provider study, a complications study and a cost-effectiveness study. The project will be conducted in a dedicated stand-alone clinic specialising in chronic disease management, specifically focusing on diabetes care. Participants will include clinic staff, administrators, family physicians, specialists and patients with type 1 or type 2 diabetes who received care at the clinic between 2011 and 2023. The project design will define the intervention, support replication at other sites or for other chronic diseases and address each of the quadruple aims and equity. Following the execution of the five individual studies, we will build a business case by integrating the results. Data will be analysed using both qualitative (content analysis and thematic analysis) and quantitative techniques (descriptive statistics and multiple logistic regression).Ethics and disseminationWe received approval from the research ethics boards at Western University (reference ID: 2023–1 21 766; 2023–1 22 326) and Lawson Health Research Institute (reference ID: R-23–202). A privacy review was completed by St. Joseph’s Healthcare Corporation. The findings will be shared among PCDSP staff and patients, stakeholders, academic researchers and the public through stakeholder sessions, conferences, peer-reviewed publications, infographics, posters, media interviews, social media and online discussions. For the patient and provider study, all participants will be asked to provide consent and are free to withdraw from the study, without penalty, until the data are combined. Participants will not be identified in any report or presentation except in the case study, for which, given the number of PCDSP providers, we will seek explicit consent to identify them.

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Exploring Transitions in Care Among Patients with Head and Neck Cancer: A Multimethod Study

Kersen,

Roach,

Chandarana

et al. 2024

Preprint

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Background: Patients with head and neck cancers (HNC) experience many transitions in care (TiC), occurring when patients are transferred between healthcare providers and/or settings.  TiC can compromise patient safety, decrease patient satisfaction, and increase healthcare costs. The evidence around TiC among patients with HNC is sparse. The objective of this study was to improve our understanding of TiC among patients with HNC to identify ways to improve care. Methods: This multimethod study consisted of two phases: Phase I (retrospective population-based cohort study) characterized the number and type of TiC that patients with HNC experienced using deterministically linked, population-based administrative health data in Alberta, Canada (January 1, 2012, to December 1, 2019), and Phase II (qualitative descriptive study) used semi-structured interviews to explore the lived experiences of patients with HNC and their healthcare providers during TiC. Results: There were 3,752 patients with HNC; most were male (70.8%) with a mean age at diagnosis of 63.3 years (SD 13.1). Patients underwent an average of 1.2 (SD 1.0) treatments, commonly transitioning from surgery to radiotherapy (21.2 %). Many patients with HNC were admitted to the hospital during the study period, averaging 3.3 (SD 3.0) hospital admissions and 7.8 (SD 12.6) emergency department visits per patient over a median follow up of 7 years (IQR 4,8). Visits to healthcare providers were also frequent, with the highest number of physician visits being to general practitioners (average=70.51 per patient). Analysis of sixteen semi-structured interviews (ten patients with HNC and six healthcare providers) revealed three themes: 1) Navigating the healthcare system including challenges with the complexity of HNC care amongst healthcare system pressures, 2) Relational head and neck cancer care which encompasses patient expectations and relationships, and 3) System and individual impact of transitions in care. Conclusions: This study identified challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within cancer care, which was perceived to have an impact on quality of care. These findings provide crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of TiC within this patient population.

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Primary Care-Led Transition Clinics Hold Promise in Improving Care Transitions for Cancer Patients Facing Social Disparities: A Commentary

Cited by 3 publications

References 21 publications

Development of a Primary Care Transitions Clinic in an Academic Medical Center

Development of a Primary Care Transitions Clinic in an Academic Medical Center

Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design

Exploring Transitions in Care Among Patients with Head and Neck Cancer: A Multimethod Study

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