Literature Collection

INTRODUCTION: Stanford Medicine is working to better coordinate care across the Stanford healthcare system, as well as improve patient and provider experiences in seeking and receiving care. This study aimed to explore the complexities of moving from a fragmented to an integrated academic healthcare system and to identify and explain factors (e.g., facilitators and barriers) of the implementation of three interventions meant to improve patient experience, reduce staff burden, and integrate health care systems across faculty and community settings. METHODS: We conducted qualitative semi-structured interviews via Zoom with faculty and community physicians. Interviews were audio-recorded, professionally transcribed, and analyzed using the Consolidated Framework for Implementation Research (CFIR) and open coding. Using consensus coding approaches, researchers met regularly to discuss themes and adaptations to CFIR. RESULTS: We analyzed transcripts from interviews with physicians (n = 26). Factors impacting integration included the following: (1) physicians supported the interventions, promoting mission alignment; (2) physicians were motivated for change, reporting the existing system was intolerable; (3) physicians reported different priorities between clinics: faculty versus community and primary care versus specialty; (4) physicians prioritized interpersonal versus system solutions; (5) specialists were wary of unintended consequences of integration, specifically inappropriate bookings or patients being redirected to other clinics. Broadly speaking, facilitator factors 1-2 focused on the openness to, and tension for, change; and barrier factors 3-5 promoted or sustained variation across specialties and faculty/community clinics. CONCLUSIONS: Our results illustrate the challenges and opportunities of moving from a fragmented to an integrated healthcare system and emphasize the importance of building shared culture, collaboration, and coordinated actions across and within an integrated healthcare network.

BACKGROUND: Children with cerebral palsy (CP) and their families need coordinated services. Accordingly, integrated care models have been introduced as the standard for service provision. However, situations with coordination and collaboration challenges occur leading to fragmented services that do not meet the care needs of children and families. This study aimed to identify stakeholders involved in the care and follow-up of children and their families and explore their roles, responsibilities, and relationships to inform the improvement of integrated care for children with CP. METHODS: A stakeholder analysis was conducted based on interviews with children, parents, and service providers; observations in multidisciplinary coordination meetings; and a review of documents. Six families with a child aged between 8 and 12 years with a primary diagnosis of CP participated. Relevant service providers were identified through family interviews and were invited to individual or focus group interviews. RESULTS: The results identified 42 stakeholders categorized into 14 groups offering healthcare, educational, social, and family support services. Stakeholders become involved in the families' long-term care at different times and provide services within various time spans according to specific emerging challenges. Stakeholders' responsibilities include diagnosing and referring patients, providing short-term treatment, and providing long-term care. Additionally, responsibilities can be overlapping and unclear, and the involved stakeholders operate under different regulations and institutional contexts, leading to gaps in patient follow-up. Relationships between the stakeholders vary from full integration to no contact. CONCLUSION: Long-term care for children with CP and their families is complex, involving numerous stakeholders across various sectors, governed by regulations within different institutional contexts, challenging integrated care. Stakeholders' affiliation with different sectors and their varying roles has the potential to contribute to a holistic approach. However, without clear guidance this seems hard to achieve, which may lead to a lack of collective understanding and unmet needs for children and families. There is still a need for further research on collaborative experiences among children, families, and service providers, and their impact on integrated services.

Children from circumpolar regions must travel long distances to southern tertiary care centres for specialised care. While there are initiatives underway to support care closer to home, medical travel remains a necessity for many families. The Aakuluk clinic has been operating since 2019 at a tertiary hospital in Ottawa, Canada, to provide care to children from Nunavut. The clinic team includes nurse case managers, physicians, social workers, interpreters, and several community partners. This project aimed to identify the strengths and the challenges of the clinic from the perspectives of parents and healthcare providers. The study was conducted in collaboration with healthcare professionals and community members and was guided by Inuit research approaches. Fifty-one participants (parents and healthcare providers) in Nunavut and Ottawa were interviewed. The main strengths and challenges of the clinic that were reported are related to the following themes: access to holistic care, supporting the role of Inuit professionals as part of the care team, and resources needed to continue offering programmes such as Aakuluk to Inuit families. From the perspectives of parents and healthcare providers, there are several components of the Aakuluk model that can be considered when developing services for Inuit families in other tertiary care centres.

OBJECTIVE: To explore initial outcomes (treatment entry and completion and staff feedback) for an interdisciplinary military traumatic brain injury (TBI) treatment program with individualized support for co-occurring substance use (SU). DESIGN: A quality improvement effort was undertaken to develop an integrated model of care for TBI with support for service members and veterans (SM/Vs) with co-occurring SU. We describe treatment entry and completion outcomes, along with staff feedback, collected over 26 months of program implementation. SETTING: An intensive outpatient program (IOP) for SM/Vs with TBI, administered by a not-for-profit hospital. PARTICIPANTS: Three hundred and sixty-four (N=364) SM/Vs applying for TBI treatment (85.2% men, 28.3% active service, median age of 41 (interquartile range, ±12)). INTERVENTIONS: An Integrated Care Model for TBI + SU was developed and flexibly applied to support client needs, including modifications to assessment, intervention, and follow-up support related to SU. MAIN OUTCOME MEASURES: We report on instances of noncompletion because of SU, percentage of admission denials because of SU, demographic and clinical predictors of entering care, and qualitative feedback from treating clinicians. RESULTS: Over 26 months, 188 individuals entered care, and just 7 who entered the IOP did not complete, with 1 of these instances because of SU. Clinician attitudes indicate optimism about the Integrated Care Model. Predictors of entering care, analyzed using logistic regression with recursive feature elimination, included multiple demographic (sex, race, location, service status) and clinical (SU and psychiatric history, brain injury symptom severity) characteristics. CONCLUSIONS: An interdisciplinary TBI treatment environment holds promise as a setting for incorporating SU-related support to enhance entry and completion for more SM/Vs.