Reflections on 3 Years of Innovation: Recognizing the Need for Innovation Beyond the Clinical Care Pathway

The Susan and Richard Levy Healthcare Delivery Incubator is designed to bring about rapid, sustainable, scalable, and transformational health care redesign. All 10 projects in the initial 3 cohorts of teams embraced the Incubator process-forming diverse teams and following a design-thinking informed curriculum-and each successfully implemented improvements or innovations by the end of their project. The purpose of this article is to identify the key features of teams' work that may help account for projects' success. For the 10 projects completed, findings from debrief interviews and staff observations were examined to identify processes key to project's success. Analysis highlighted cross-project learnings that indicate nonclinical aspects of care delivery that play a critical role in project innovation success. Innovating health care delivery requires considering social and political determinants of health. The Incubator's process and structures enable teams to identify and respond to a broad range of health determinants.

Problematic Integration: Racial Discordance in End-of-Life Decision Making

We describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients' religion and support systems; (3) epistemological uncertainty as ambivalence in which providers' feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.

Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report

BACKGROUND

People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs.

OBJECTIVE

This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges.

METHODS

Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges.

RESULTS

Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes.

CONCLUSIONS

While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

Assessing and Identifying Improvements for Lung Cancer Screening in a Rural Population: A Human-Centered Design and Systems Approach

Although lung cancer claims more lives than any other cancer in the United States, screening is severely underutilized, with <6% of eligible patients screened nationally in 2021 versus 76% for breast cancer and 67% for colorectal cancer. This article describes an effort to identify key reasons for the underutilization of lung cancer screening in a rural population and to develop interventions to address these barriers suitable for both a large health system and local community clinics. Data were generated from 26 stakeholder interviews (clinicians, clinical staff, and eligible patients), a review of key systems (Electronic Health Record and billing records), and feedback on the feasibility of several potential interventions by health care system staff. These data informed a human-centered design approach to identify possible interventions within a complex health care system by exposing gaps in care processes and electronic health record platforms that can lead patients to be overlooked for potentially life-saving screening. Deployed interventions included communication efforts focused on (1) increasing patient awareness, (2) improving physician patient identification, and (3) supporting patient management. Preliminary outcomes are discussed.

Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study

INTRODUCTION

Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration.

METHODS

Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices.

RESULTS

Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of "favorable" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care.

CONCLUSION

Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.

Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot

Background

Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system.

Aim

To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies.

Method

We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study.

Results

Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth.

Conclusion

A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.

US Ventilator Allocation and Patient Triage Policies in Anticipation of the COVID-19 Surge

Before the predicted March 2020 surge of COVID-19, US healthcare organizations were charged with developing resource allocation policies. We assessed policy preparedness and substantive triage criteria within existing policies using a cross-sectional survey distributed to public health personnel and healthcare providers between March 23 and April 23, 2020. Personnel and providers from 68 organizations from 34 US states responded. While half of the organizations did not yet have formal allocation policies, all but 4 were in the process of developing policies. Using manual abstraction and natural language processing, we summarize the origins and features of the policies. Most policies included objective triage criteria, specified inapplicable criteria, separated triage and clinical decision making, detailed reassessment plans, offered an appeals process, and addressed palliative care. All but 1 policy referenced a sequential organ failure assessment score as a triage criterion, and 10 policies categorically excluded patients. Six policies were almost identical, tracing their origins to influenza planning. This sample of policies reflects organizational strategies of exemplar-based policy development and the use of objective criteria in triage decisions, either before or instead of clinical judgment, to support ethical distribution of resources. Future guidance is warranted on how to adapt policies across disease type, choose objective criteria, and specify processes that rely on clinical judgments.

Intimate partner violence screening and counseling in the health care setting: Perception of provider-based discussions as a strategic response to IPV

Intimate partner violence (IPV) affects women worldwide, and is addressable in the health care setting not only via screening, but also through provider-based counseling and referral to legal or social services, as appropriate. We conducted a study in Pennsylvania (USA) examining factors associated with receipt of IPV screening and women's perceptions of counseling discussions as a strategic response. We found that women with past-year IPV were more likely to receive screening (aOR: 2.0, 95%CI: 1.2,3.5) and to consider counseling discussions to be a strategic response to IPV exposure (aOR: 2.7, 95%CI: 1.008,7.2) than women with a more distant history of IPV. Scholars and clinicians may learn that, especially for women with a recent history of IPV, screening may provide a conduit to meaningful counseling discussions and referrals that women view as a helpful strategy in responding to IPV.

The impact of social support on the risk of eating disorders in women exposed to intimate partner violence

BACKGROUND

Eating disorders (EDs) are often found among women exposed to intimate partner violence (IPV). The role of social support (SS) as a protective factor against ED among IPV-exposed women is not firmly established.

OBJECTIVE

The objective of this study is to determine the distribution of risk of EDs among women exposed to IPV and to examine the impact of SS on risk of ED among IPV-exposed women.

METHODS

Women (aged 18-64 years) exposed to IPV during their lifetimes (defined by the Humiliation-Afraid-Rape-Kick instrument) were recruited from primary care and domestic violence service agencies and surveyed on demographics, mood/anxiety disorders, psychosocial/community factors, and strategies used in response to IPV. The Eating Disorder Screen for Primary Care assessed the risk of ED. A modified Medical Outcomes Study Social Support Survey assessed overall functional support (scale range: 0-32; categorized into quartiles). Ordinal logistic regression examined the risk of ED based on SS, controlling for prespecified demographics (age, race/ethnicity, marital status, near-poverty level), and health-related factors significant in bivariate analyses (risky alcohol use).

RESULTS

Among 302 women with lifetime IPV, 41 (14%) were at high risk, 127 (42%) were at moderate risk, and 134 (44%) were at low risk of an ED. In bivariate analyses, high risk of an ED was significantly more frequent among women with a low SS score (<19, 24%) versus a high SS score (≥30, 12%) (P=0.03). High risk of an ED was significantly associated with risky alcohol use (18%) versus non-risky alcohol use (13%; P=0.008). In multivariable analysis, a 5-unit increase in overall SS was significantly associated with decreased odds of ED risk (P=0.007).

CONCLUSION

Among IPV-exposed women, low SS is associated with an increased risk of ED. SS may protect against ED by reducing anxiety and promoting positive actions, but further study is needed to confirm this.

"I Just Keep My Antennae Out": How Rural Primary Care Physicians Respond to Intimate Partner Violence

Women in rural communities who are exposed to intimate partner violence (IPV) have fewer resources when seeking help due to limited health services, poverty, and social isolation. Rural primary care physicians may be key sources of care for IPV victims. The objective of this study was to assess the opinions and practices of primary care physicians caring for rural women with regard to IPV identification, the scope and severity of IPV as a health problem, how primary care providers respond to IPV in their practices, and barriers to optimized IPV care in their communities. Semistructured interviews were conducted with 19 internists, family practitioners, and obstetrician-gynecologists in rural central Pennsylvania. Interview transcripts were analyzed for major themes. Most physicians did not practice routine screening for IPV due to competing time demands, lack of training, limited access to referral services as well as low confidence in their effectiveness, and concern that inquiry would harm the patient-doctor relationship. IPV was considered when patients presented with symptoms of mood, anxiety, or somatic disorders. Responses to IPV included validation, danger assessment, safety planning, referral, and follow-up planning. Perceived barriers to rural women seeking help for IPV included traditional gender roles, lower education, economic dependence on the partner, low self-esteem, and patient reluctance to discuss IPV. To overcome barriers, physicians created a "safe sanctuary" to discuss IPV and suggested improved public health education and referral services. Interventions to improve IPV-related care in rural communities should address barriers at multiple levels, including both physicians' and patients' comfort with discussing IPV. Provider training, community education, and improved access to referral services are key areas in which IPV-related care should be improved in rural communities. Our data support routine screening to better identify IPV and a more pro-active stance toward screening and counseling.

"Someone's got to do it" - Primary care providers (PCPs) describe caring for rural women with mental health problems

OBJECTIVE

Little is known about how primary care providers (PCPs) approach mental health care for low-income rural women. We developed a qualitative research study to explore the attitudes and practices of PCPs regarding the care of mood and anxiety disorders in rural women.

METHOD

We conducted semi-structured interviews with 19 family physicians, internists, and obstetrician-gynecologists (OBGYNs) in office-based practices in rural central Pennsylvania. Using thematic analysis, investigators developed a coding scheme. Questions focused on 1) screening and diagnosis of mental health conditions, 2) barriers to treatment among rural women, 3) management of mental illnesses in rural women, and 4) ideas to improve care for this population.

RESULTS

PCP responses reflected these themes: 1) PCPs identify mental illnesses through several mechanisms including routine screening, indicator-based assessment, and self-identification by the patient; 2) Rural culture and social ecology are significant barriers to women in need of mental healthcare; 3) Mental healthcare resource limitations in rural communities lead PCPs to seek creative solutions to care for rural women with mental illnesses; 4) To improve mental healthcare in rural communities, both social norms and resource limitations must be addressed.

CONCLUSION

Our findings can inform future interventions to improve women's mental healthcare in rural communities. Ideas include promoting generalist education in mental healthcare, and expanding access to consultative networks. In addition, community programs to reduce the stigma of mental illnesses in rural communities may promote healthcare seeking and receptiveness to treatment.

Barriers to colorectal cancer screening among women in rural central Pennsylvania: primary care physicians' perspective

INTRODUCTION

Colorectal cancer (CRC) is the third leading cause of death among women in the USA. Rural populations have lower rates of CRC screening than their urban counterparts, and rural women have lower screening rates compared with rural men. The purpose of this qualitative study was to identify (1) beliefs of primary care physicians (PCPs) about CRC screening in rural communities, (2) factors that may cause gender disparities in CRC screening in rural areas, and (3) solutions to overcome those barriers.

METHODS

Semi-structured interviews were conducted with 17 PCPs practicing in rural central Pennsylvania. PCPs were asked about their CRC screening practices for women, availability of CRC screening services, reminder systems for CRC screening, and barriers to screening specific to their rural communities and to gender. Thematic analysis was used to identify major themes.

RESULTS

All 17 PCPs endorsed the importance of CRC screening, but believed that there are barriers to CRC screening specific to women and to rural location. All PCPs identified colonoscopy as their screening method of choice, and generally reported that access to colonoscopy services in their rural areas was not a significant barrier. Barriers to CRC screening for women in rural communities were related to (1) PCPs' CRC screening practices, (2) gender-specific barriers to CRC screening, (3) patient-related barriers, (4) community-related barriers, and (5) physician practice-related barriers. Physicians overwhelmingly identified patient education as necessary for improving CRC screening in their rural communities, but believed that education would have to come from a source outside the rural primary care office due to lack of resources, personnel, and time.

CONCLUSION

Overall, the PCPs in this study were motivated to identify ways to improve their ability to engage more eligible patients in CRC screening. These findings suggest several interventions to potentially improve CRC screening for women in rural areas, including encouraging use of other effective CRC screening modalities (eg fecal occult blood testing) when colonoscopy is not possible, systems-based reminders that leverage electronic resources and are not visit-dependent, and public health education campaigns aimed specifically at women in rural communities.