Publications by Project Teams
A Cross-Institution Protocol for Virtual, Transdiagnostic, Group Gut-Directed Hypnotherapy
Gut-directed hypnotherapy (GDH) is an evidence-based intervention for numerous gastrointestinal (GI) conditions. Although much of the literature focuses on its use for refractory irritable bowel syndrome (IBS), research also supports its use across other disorders of gut-brain interaction (DGBI) and for sustaining remission in ulcerative colitis. GDH involves a verbally guided induction of a “trance-like” state, followed by autogenic (ie, self-generated) relaxation, visualization, and suggestions for alterations in gut-related sensations and perceptions as well as cognitive, behavioral, and emotional responses. Historically, the most widely used protocol for GDH has been Olafur Palsson’s North Carolina protocol. This scripted protocol was originally designed for IBS and has since been adapted to other DGBIs. The protocol involves a hypnosis-trained clinician delivering a course of 7 biweekly GDH sessions, traditionally individually and in person. Patients receive a self-hypnosis audio recording to practice at home at least 5 times per week.
Engagement in GI Behavioral Health Is Associated with Reduced Portal Messages, Phone Calls, and ED Visits
Background and Aims: Chronic digestive disorders are associated with increased costs for healthcare systems and often require provision of both urgent care and non-face-to-face (non-F2F) care, such as responding to patient messages. Numerous benefits of integrated gastroenterology (GI) behavioral health have been identified; however, it is unclear if integrated care impacts healthcare utilization, including urgent care and non-F2F contact. We sought to investigate the association between patient engagement with GI behavioral health and healthcare utilization.
Methods: We performed a retrospective chart review study of adult patients who were referred for and completed at least one behavioral health appointment between January 1, 2019 and December 21, 2021 in the Gastroenterology and Hepatology department of a large academic medical center. Data on electronic medical record (EMR) messages, phone calls, and Emergency Department utilization were collected 6 months before and 9 months after patient engagement with GI behavioral health.
Results: 466 adult patients completed at least one behavioral health visit from 2019 to 2021. Overall, messages, phone calls, and ED visits all decreased significantly from the 6 months before behavioral health treatment to 6 months after (all P values < 0.001).
Conclusion: Engagement with integrated GI behavioral health is associated with reduced non-F2F care and emergency department utilization in patients with chronic digestive disorders. Increasing access to GI behavioral health may result in reduced provider workload and healthcare system costs.
Human-Centered Design to Improve Care for Youths Experiencing Psychiatric Boarding
The number of children and adolescents presenting to hospitals with mental health conditions has increased markedly over the past decade. A dearth of pediatric mental health resources prevents delivering definitive psychiatric care to this population at many hospitals; thus, children and adolescents must wait at a medical facility until appropriate psychiatric care becomes available (an experience described as psychiatric “boarding”). Clinicians caring for youth experiencing psychiatric boarding report inadequate training and resources to provide high-quality care to this population, and patients and caregivers describe significant frustration with the current standard of care. Recognizing these issues and the unique emotional components associated with psychiatric boarding, we employed human-centered design (HCD) to improve our hospital’s approach to caring for youth during this period. HCD is an approach that specifically prioritizes the assessment and integration of human needs, including emotional needs, as a means to inform change. We used an HCD framework encompassing 5 stages: (1) empathize with those affected by the issue at hand, (2) define the problem, (3) ideate potential solutions, (4) prototype potential solutions, and (5) test potential solutions. Through these stages, we elicited broad stakeholder engagement to develop and implement 2 primary interventions: A modular digital health curriculum to teach psychosocial skills to youth experiencing boarding and a comprehensive clinical practice guideline to optimize and standardize care across clinical environments at our hospital. This manuscript describes our experience applying HCD principles to this complex health care challenge.
Redesigning a GI Behavioral Health Program to Improve Patient Access
Gastrointestinal (GI) conditions impact quality of life and can result in missed work, emergency room visits, lengthy hospitalizations, and life-altering surgeries. GI conditions also are associated with an increased risk of mental health concerns, including increases in anxiety, depression, and insomnia. There is increasing awareness of a psychologist or behavioral health provider’s role in managing GI symptoms and patients’ quality of life. Brain–gut behavior therapies (eg, cognitive behavioral therapy; gut-directed hypnotherapy) effectively improve both GI symptoms and quality of life across GI conditions. Clinical practice guidelines recommend including mental health support on multidisciplinary teams.
Although many patients with GI conditions may benefit from working with a psychologist or other mental health provider with GI-specific expertise, access to these providers is limited, leading to lengthy wait times and inadequate patient access. We sought to redesign our behavioral health (BH) program at a large academic medical center and better integrate it into the care of patients with several common GI disorders. At the time of the project launch, the wait time for a new patient was 8 months. Here, we share how this work can be incorporated into GI practices, the resulting improvements in patients’ access to care, and the lessons learned from this work.
Our redesign effort was guided by a design-thinking approach, which encourages multidisciplinary teams to use an empathetic lens to understand the user experience. This GI BH redesign work occurred at Dartmouth-Hitchcock Medical Center (DHMC) from January to December 2022. DHMC is a large, rural academic medical center located in Northern New England. The Section of Gastroenterology and Hepatology averages 15,000 outpatient visits per year, representing 11,000 distinct patients. At the time this improvement work was launched, our section included 16 physician providers and 8 advanced practice providers. Our team consisted of 2 gastroenterologists, 2 psychologists, a practice manager, a patient navigator, a clinical secretary, an a student in a joint doctor of medicine/masters of business administration program, and a patient representative.
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
Abstract: 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.
Outpatient Intravenous Diuresis in a Rural Setting: Safety, Efficacy, and Outcomes
Purpose: To evaluate the safety, efficacy, and outcomes of outpatient intravenous diuresis in a rural setting and compare it to urban outcomes.
Methods: A single-center study was conducted on 60 patients (131 visits) at the Dartmouth-Hitchcock Medical Center (DHMC) from 1/2021–12/2022. Demographics, visit data, and outcomes were collected and compared to urban outpatient IV centers, and inpatient HF hospitalizations from DHMC FY21 and national means. Descriptive statistics, T-tests and chi-squares were used.
Results: The mean age was 70 ± 13 years, 58% were male, and 83% were NYHA III-IV. Post-diuresis, 5% had mild-moderate hypokalemia, 16% had mild worsening of renal function, and 3% had severe worsening of renal function. No hospitalizations occurred due to adverse events. The mean infusion-visit urine output was 761 ± 521 ml, and post-visit weight loss was −3.9 ± 5.0 kg. No significant differences were observed between HFpEF and HFrEF groups. 30-day readmissions were similar to urban outpatient IV centers, DHMC FY21, and the national mean (23.3% vs. 23.5% vs. 22.2% vs. 22.6%, respectively; p = 0.949). 30-day mortality was similar to urban outpatient IV centers but lower than DHMC FY21 and the national means (1.7% vs. 2.5% vs. 12.3% vs. 10.7%, respectively; p < 0.001). At 60 days, 42% of patients had ≥1 clinic revisit, 41% had ≥1 infusion revisit, 33% were readmitted to the hospital, and two deaths occurred. The clinic avoided 21 hospitalizations, resulting in estimated cost savings of $426,111.
Conclusion: OP IV diuresis appears safe and effective for rural HF patients, potentially decreasing mortality rates and healthcare expenses while mitigating rural-urban disparities.
Patients’ Experiences with Virtual Group Gut-directed Hypnotherapy: A Qualitative Study
Background: Hypnotherapy is a useful treatment for a variety of gastrointestinal conditions. While there is strong evidence for delivering other treatments virtually and in groups, there is no research thus far on delivering hypnotherapy in this format. Given the growth of both psychogastroenterology and telehealth, these methods should be explored as they have great potential for increasing access and cost-effectiveness of intervention.
Aims: This qualitative study was developed to help understand patients experiences in virtual, group-based, gut-directed hypnotherapy (GDH) in two different institutions.
Methods: Authors developed a qualitative interview with the assistance of two patient partners and then recruited patients from New York University and Dartmouth Health to participate. Interviews were completed one-on-one with patients who started and then completed GDH (≥5 visits) and who did not complete GDH (≤3 visits). Data were coded and then analyzed using thematic analysis.
Results: Twenty-one patients from NYU and Dartmouth participated in qualitative interviews. Broadly, patients reported coming to GDH because they believed in the importance of the mind-body connection or were desperate for treatment. Regardless of why patients came to GDH, they generally reported positive outcomes for GI symptoms and for other physical and mental health conditions. Most patients appreciated the group and virtual formats, though some concerns about inflexible schedules and lack of anonymity were voiced. Despite these concerns, there was broad support for virtual, group-based GDH and general excitement for behavioral health programming.
Conclusion: Virtual, group-based GDH is an acceptable treatment for patients from rural and urban settings. Given the possible improvements in access and cost-effectiveness that this treatment modality can provide, GI practices may want to consider it in lieu of or in addition to the traditional one-on-one treatment format. Barriers and facilitators and recommendations for practice are discussed.
Evan Cavanaugh and Jessiy Salwen-Deremer
present at the Dartmouth Master in
Health Care Delivery Science Symposium 2023
I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding
Purpose: Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE.
Methods: A mixed-methods approach was used to evaluate I-CARE, offered to youth 12–17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically.
Results: Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5–12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents’ prior knowledge of psychosocial skills and clinicians’ competing demands were reported barriers.
Discussion: I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.
Multi-stakeholder perspectives on interventions to support youth during mental health boarding
Objective: To identify and prioritize opportunities to improve the psychiatric boarding experience for youth awaiting admission or transfer to inpatient psychiatric care.
Study design: This study utilized an exploratory mixed methods design. The study team convened multidisciplinary stakeholder focus groups to discuss proposed hospital-based solutions to mental health boarding, potential psychosocial interventions deliverable during boarding, and outcomes measurement. Focus group responses were transcribed and analyzed to extract themes pertaining to these improvement opportunities. These results informed a follow-up survey which was then sent to the stakeholders to rate the feasibility and importance of modifications using a modified RAND-UCLA Appropriateness Method.
Results: Qualitative analyses revealed 9 themes across 2 domains related to psychiatric boarding care: in-hospital improvements and transitions of care. The follow-up survey identified 6 improvement opportunities rated as both feasible and important. Additionally, 6 psychosocial interventions, 2 delivery modalities, and 5 outcomes were rated as both feasible and important.
Conclusions: Stakeholders concerned with the psychiatric boarding of youth identified numerous opportunities for improving the boarding process within 2 domains of in-hospital improvements and transitions of care. Most of the improvements were considered feasible and important with several serving as particularly viable strategies. These have the potential for implementation to improve the care of this vulnerable population and inform local and national quality improvement efforts.
Improving care for individuals with serious infections who inject drugs
Background: Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences.
Methods: A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator.
Results: The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider.
Conclusion: An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.
Cognitive impairment and frailty screening in older surgical patients: a rural tertiary care centre experience
Introduction Despite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment and frailty screening programme to meet the unique needs of our rural academic centre.
Methods Through stakeholder interviews, we identified five primary drivers underlying screening implementation: staff education, technology infrastructure, workload impact, screening value and patient–provider communication. Based on these findings, we implemented cognitive dysfunction (AD8, Mini-Cog) and frailty (Clinical Frailty Scale) screening in our preoperative care clinic and select surgical clinics.
Results In the preoperative care clinic, many of our patients scored positive for clinical frailty (428 of 1231, 35%) and for cognitive impairment (264 of 1781, 14.8%). In our surgical clinics, 27% (35 of 131) and 9% (12 of 131) scored positive for clinical frailty and cognitive impairment, respectively. Compliance to screening improved from 48% to 86% 1 year later.
Conclusion We qualitatively analysed stakeholder feedback to drive the successful implementation of a preoperative cognitive impairment and frailty screening programme in our rural tertiary care centre. Preliminary data suggest that a clinically significant proportion of older adults screen positive for preoperative cognitive impairment and frailty and would benefit from tailored inpatient care.
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.
Publications by Levy Incubator Staff
Reflections on 3 Years of Innovation: Recognizing the Need for Innovation Beyond the Clinical Care Pathway
Abstract: 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 olitical determinants of health. The Incubator’s process and structures enable teams to identify and respond to a broad range of health determinants.
Hurdles of innovation—insights from a new healthcare delivery innovation program
Introduction: Healthcare systems are actively working to innovate their care delivery models, seeking to improve service quality, improve patient and provider satisfaction, and reduce cost.
Methods: By critically evaluating our experiences to date, this article highlights challenges systems may face in the process of trying to redesign healthcare and offers insights on how to navigate hurdles. We identify barriers to—and ultimately approaches to promote—rapid, scalable, sustainable, and transformative care redesign.
Results: Dedicated electronic health record IT and analytic support, and ongoing leadership engagement and communication, play a valuable role in enabling redesign efforts. Flexible, but guided, innovation support helps teams stay accountable and motivated, while accommodating new project needs and directions. Understanding the change ecosystem and evaluating and sharing outcomes on an ongoing basis, enables teams to adapt as needed. Facilitation and support help realize the value of diverse, engaged teams; novel approaches and techniques draw out innovative perspectives and promote creative thinking.
Conclusions: Although not an exhaustive list of challenges or strategies to overcome them, we hope these insights will contribute to a culture of innovation and support other institutions in their healthcare redesign initiatives.
Designing a Health Care Delivery Innovation Lab: Reflections From The First Year
Abstract: This article shares initial experiences designing and operating a new health care delivery innovation program at a rural academic medical center. The program was designed with the belief that dedicated team member time, senior leadership engagement, deliberate project/team selection, and robust, tailored project support would enable rapid and transformative health care redesign. Three teams were supported in the initial 1-year funding cycle; all 3 teams successfully designed, implemented, and tested new care models for different serious illness populations. Results demonstrated improved satisfaction, decreased length of stay, and a positive return on investment. Critical evaluation of current structures and processes will help identify refined strategies to support diverse teams that will challenge the norms of health care delivery and explore novel partnerships, approaches, and settings for care delivery. This article helps advance the conversation on how to think strategically and critically about current and future health care innovation efforts.
Publication by a Student
Innovation pathways to preserve: Rapid healthcare innovation and dissemination during the COVID-19 pandemic
Abstract: During the COVID-19 pandemic, healthcare systems rapidly responded to challenges in healthcare delivery with innovation. Innovations developed during the COVID-19 pandemic have filled needed gaps in medical care and many may be sustained long term. The unique conditions and processes that facilitated such rapid, successful, and collective innovation should be explored to support future change in healthcare. Decentralized decision making, crowdsourcing, and nontraditional information sharing may be valuable for ongoing innovation in healthcare delivery. Shared, collective purpose in solving challenges in healthcare appear critical to this work. Health care systems aiming to sustain rapid healthcare delivery innovation should consider these processes and focus on facilitating shared purpose to sustain ongoing innovation.