Literature Collection

BACKGROUND: Emerging adults with type 1 diabetes (T1D) struggle with glycemic management that can be exacerbated by a disorganized transition process. Substantial gaps in care have been noted during this transition period and have been shown to lead to suboptimal health care utilization, worsening glycemic management, increased incidence of serious complications, and mental health challenges. A formal transition program can help prevent gaps in care, improve disease self-management skills, decrease disease burden, and reduce diabetes complications. PURPOSE: There is an increased focus within the pediatric community to formally prepare young adults with T1D as they transition to the adult health care setting. The purpose of the quality improvement initiative was to develop a transition program for adolescents with T1D in a pediatric endocrinology clinic within an academic medical center. METHODS/INTERVENTIONS: The Institute for Healthcare Improvement Model for Improvement was used to guide this project. Got Transition's® Six Core Elements of Health Care Transition were adapted to the unique needs of the pediatric endocrinology setting by incorporating diabetes-specific transition guidelines recommended by the American Diabetes Association (ADA). A new program was designed to target patients between the ages of 16-18 offering structured transition visits focused on enhancing knowledge and skills related to the management of T1D and improving the transfer of care process between pediatric and adult providers. Key elements of the program were integrated into the electronic health record. A focus group with clinical partners was used to evaluate the acceptability and practicality of the program. RESULTS: Transition activity within the clinic increased from 12/32-28/32 on the Current Assessment of Healthcare Transition Activities tool. Four themes were identified from clinical partner feedback supporting the acceptability and practicality of program design. CONCLUSIONS: The integration of the Got Transition® framework and the ADA recommendations supports clinicians in meeting the unique needs of adolescents with T1D. Incorporating the transition activities into the electronic health record facilitated integration into the workflow of the clinic providers. This initiative can serve as a model to expand transition activities across pediatric specialty care settings.

BACKGROUND: Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited. METHODS: We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians. DISCUSSION: The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

BACKGROUND: The interaction between dementia and changes in health status accelerates the progression of dementia and health deterioration. Although health indicators exist for older adults, comprehensive ones for dementia are lacking. OBJECTIVE: To (1) establish core health indicators for older adults with dementia, (2) develop an integrated health assessment toolkit for older adults with dementia, and (3) test the feasibility and applicability of the integrated health assessment toolkit. METHODS: This study involved two phases. In the first phase, using the Delphi method, opinions from 10 experts were synthesized to establish core health indicators for older adults with dementia. In the second phase, with a descriptive research approach, an integrated health assessment toolkit was developed, evaluated by 10 daycare case managers for feasibility, and then pilot tested with 50 older adults with dementia across three daycare centers. RESULTS: The core health indicators for older adults with dementia covered 18 indicators in five domains: (1) cognitive and behavioral impairment, (2) sensory and perceptual impairment, (3) disease and dysfunction, (4) functional fitness deterioration, and (5) social isolation. After two rounds of assessments, experts rated the criteria's importance and clarity at 0.94 and 0.89 on the scale-level content validity index/universal agreement (S-CVI/UA), respectively. In the second phase, the integrated health assessment toolkit was developed, which integrated five observational assessment scales and six physical function measures. The average applicability scores ranged from 7.80 to 9.90 out of 10. In the pilot test, the assessment process proceeded smoothly without any adverse events. However, 10 participants did not comply with wearing the actigraphy device. LINKING ACTION TO EVIDENCE: The core health indicators and the corresponding health assessment toolkit are feasible to assess the health of older adults with dementia that could provide valuable insights and guide future interventions to enhance their well-being.