BMC Health Services Research

BackgroundApproximately 33% of U.S. Veterans live in rural areas, often facing significant barriers to accessing healthcare due to staffing shortages at VA facilities. The Contract Buyout (CBO) program, authorized under the PACT Act of 2022, was designed to address rural healthcare staffing shortages by enabling Veterans Health Administration (VHA) facilities to buy out existing service contracts to work in rural VA facilities. Despite its potential, uptake of the program has been limited, with just 18 hires and $1.5M in expenditures, despite a congressional spending authorization of up to $40M. This evaluation explores the barriers and facilitators in implementation of the CBO program across rural VA facilities. MethodsUsing the RE-AIM framework, we conducted a mix-method qualitative evaluation. Semi-structured interviews were completed by 15 interviewees across 8 rural VA facilities, including hiring leaders and physicians. Data were analyzed using rapid qualitative analysis, supported by a descriptive survey to capture the CBO program awareness and experience. We conducted 15 interviews across 8 rural VA medical centers with facility-level hiring leaders and clinicians who were familiar with or involved in using the CBO program. ResultsHR-related delays and procedural ambiguities disrupted contract execution and undermined the CBO programs effectiveness globally. However, sites with strong internal champions and proactive HR teams reported greater success. Interviewees reported the CBO program as a promising tool, though its lack of dedicated funding and resource dissemination hindered broader adoption. ConclusionThe CBO program holds potential as a flexible rural recruitment incentive but faces structural barriers that limit its reach and adoption. Future evaluations should Evaluate whether individual rural VA sites have budgetary flexibility, funding mechanisms, and related resources required to effectively utilize the CBO program.

BackgroundRural emergency departments (EDs) are critical to ensuring equitable access to acute care, yet face persistent systemic challenges. In Quebec, Canada, reforms to healthcare governance, funding and resource allocation, and service delivery have transformed rural ED operations. This study aimed to document characteristics, challenges, and improvement priorities for all rural EDs in the province. MethodsA participatory mixed-methods design was used. 26 rural EDs in Quebec were included. Data sources comprised administrative statistics, structured site surveys, individual stakeholder semi structured interviews, and a validation survey of identified local champions. Analyses comprised a triangulation of the quantitative and qualitative data using transversal thematic analysis to determine common issues. Potential solutions identified were validated through stakeholder questionnaires. The study was reported in accordance with the COREQ reporting guideline. ResultsMost respondents were women (64%) and professionals with more than 5 years of experience. Four main themes were identified: governance, healthcare organization, access to resources, and professional practice. Governance challenges included reduced local autonomy, administrative complexity, and budgeting models poorly adapted to rural realities. Participants emphasized the need for standardized but locally flexible administrative processes, regional emergency service managers, and rural-sensitive performance metrics. Organizational barriers included geographic isolation, limited access to primary care, and difficulties with interfacility transfers due to referral-center capacity and ambulance shortages. Resource constraints centered on shortages of human resources, diagnostic services and specialty coverage, especially anesthesia, obstetrics, and psychiatry. Professional practice was shaped by the need to maintain broad competencies in low-volume contexts, while contending with professional isolation and proximity to patients. Local champions prioritized expanding telemedicine, strengthening prehospital services, enhancing continuing education, and implementing tailored recruitment strategies. ConclusionThis study provides the first province-wide documentation of characteristics, challenges, and improvement priorities for all rural EDs. Findings highlight the need for systemic reforms that restore local decision-making authority, strengthen transfer and prehospital capacity, expand telehealth and specialty access, and support professional development. These results provide a foundation for evidence-based policies and actions to sustain equitable emergency care in rural regions.

BackgroundTimely access to healthcare is vital especially during childbirth, as it affects unplanned out-of-hospital births, survival and morbidity outcomes. In Germany, the number of maternity wards decreased since 2014, potentially increasing travel times for pregnant women. We examined changes in the travel times after maternity ward closures from 2014 to 2024 and addressed spatial disparities, providing essential information to ensure maternal and newborn care accessibility. MethodsMaternity ward closures in Germany from 2014 to 2024 were identified, and travel time to the nearest ward was calculated for women of reproductive age (15 to 49 years) using the Open Source Routing Machine. Critical driving time was defined as 40 minutes or longer. ResultsSince 2014, the number of maternity wards in Germany decreased by 172 (-23.1%), leaving 573 in 2024. Consequently, the number of women facing critical travel times increased by 112%, from 47,770 (0.27% of all women at risk) to 101,163 (0.60%). 27 closures were responsible for 90% of the increase in critical travel times, with seven accounting for over 50%. Northern and eastern parts of Germany were affected most which was reflected in an increasing Gini coefficient measuring the inequalities in travel times across Germany. ConclusionMost maternity ward closures had minimal effect, but a few substantially increased travel time, especially in regions without nearby alternatives. These closures exacerbated regional disparities and potentially increased the risks of unplanned out-of-hospital births and other adverse birth outcomes. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSLong travel time to the nearest maternity ward is associated with unplanned out-of-hospital births and negative maternal, fetal and neonatal birth outcomes. What this study addsFrom 2014 to 2024, the number of maternity wards in Germany decreased by 23.1%. As a result the number of women between 15 and 49 facing travel times of 40 minutes or more increased by 112%, reaching 101,163 in 2024. Regional disparities in critical travel times were exacerbated. How this study might affect research, practice or policyThis study underscores that further decisions on maternity ward closures should assess the impact on travel times and policy responses should create accessible accommodation options in areas where travel distance cannot be otherwise reduced. Further studies are needed to monitor the impact on increased travel time to obstetric care in Germany.

Objectives: Emergency department (ED) overcrowding is a persistent issue in European healthcare systems. A previous randomized controlled trial (RCT) concerning out of hours care in Antwerp (2019) demonstrated that a nurse-led triage tool, extending the Manchester Triage System (eMTS), could safely redirect low-acuity ED patients to a co-located General Practitioner Cooperative (GPC). This study reports a six-year follow-up assessing long-term efficiency, safety, and sustainability of this intervention. Methods: We performed a retrospective observational analysis of routine clinical data. Patients triaged at the ED and referred to the GPC were identified through electronic health records. Efficiency outcomes included the proportion of ED patients managed at the GPC, the proportion of GPC patients originating from the ED and their clinical characteristics. To assess safety, we analysed rates and characteristics of patients referred back from the GPC to the ED. A detailed case review was conducted for all back-referred patients. Results: Of the 110,941 triaged patients, 6,722 (6.1%) were managed at the GPC, accounting for 11% of all GPC consultations. Diverted patients typically presented with digestive, respiratory, and musculoskeletal complaints and had a clinical urgency which was mostly comparable to the overall GPC population. Only 3% of the patients diverted to the GPC were referred back to the ED, versus 5% of other GPC patients. Most back-referrals (83%) were managed on an outpatient basis; four major and 18 minor triage issues were identified, without evidence of increased morbidity. Conclusions: Six years post-trial, the nurse-led eMTS triage tool remains integrated into routine practice, with increasing efficiency and remaining safety without dedicated research resources nor a post implementation plan. Sustained adoption highlights its clinical feasibility and long-term safety. Future trials on triage and primary care should embed explicit post-trial implementation strategies to promote continuity and scalability of successful healthcare interventions. ClinicalTrials.gov Identifier: NCT03793972

Background: Out-of-pocket healthcare expenditure (OOPHE) remains a major challenge to accessing adequate medical service, often discouraging individuals from seeking necessary medical services. The extent of OOPHE in Jigjiga city is unknown. This study aimed to assess the magnitude and associated factors of OOPHE among outpatients visiting public hospitals in Jigjiga city, Somali region, Eastern Ethiopia. Methods: A hospital-based cross-sectional study was conducted among 406 outpatients selected through systematic random sampling from three public hospitals in Jigjiga city. Data were collected through interviews-administered questionnaires and analysed by SPSS version 25.0. Binary and multivariable logistic regression analyses were performed to identify factors associated with OOPHE among outpatients (p < 0.05). Results: Overall, 89.5% of respondents incurred out-of-pocket healthcare payments at the point of service delivery. The mean OOPHE per outpatient was 485.6 {+/-} 349 birr ($3.12 {+/-} $2.24). Female [AOR = 3.38, 95% CI (1.54-7.42)], unmarried [AOR = 5.32, 95% CI (1.77-16.03)], and traveled [&ge;]5 km [AOR = 7.07, 95% CI (1.46-34.29)] and higher educational attainment (college and above) [AOR = 7.07, 95% CI (1.55-32.28)] were independently associated with higher odds of incurred OOPHE. Conclusion: The magnitude of out-of-pocket healthcare payments among outpatients was high. Sex, marital status, educational level, and distance to reach a public health facility were significant predictors of OOPHE. Policy action to reduce OOPHE in this setting should include strengthening and expanding the Community-Based Health Insurance scheme and promoting prepayment mechanisms, such as Social Health Insurance, for formal sector employees, specifically for government employees.

In an era in which population ageing, rising healthcare costs and growing global health challenges are pressing global issues, the main aim of our article is to analyze trends in preventive care expenditures from 2004 to 2023 in 22 European countries, examining whether specific health systems are associated with different time trends in preventive care expenditures over the considered time. Although there are few studies investigating this issue adopting the standard tripartite classification, to our knowledge, this is the first study to explore the topic using the latest classification of healthcare systems proposed by Bohm. We performed a time trend analysis using secondary data from 22 European OECD countries during a twenty-year period (2004-2023); in addition, a hierarchical semi-log polynomial mixed-effects regression analysis has been performed, including annual country-level % preventive expenditures in association with the three structural dimensions -- regulation, financing and provision -- according to Bohms classification as explanatory variables. Our results indicate that, in terms of compound annual rate, most countries exhibited an increase in % of preventive expenditures (between 0.2% and 3.7%), while seven countries denounced a decrease (between -6.3% and -0.2%) during the considered period. The regression analysis shows that the trend of % preventive expenditures did not differ in two of the three dimensions under study: financing and provision. In contrast, in countries with statal regulation, the curvilinear trend was more pronounced than in countries with statal regulation (b=0.0035; 95% CI= 0.0013, 0.0057). In conclusion, there is no correlation between the type of healthcare system and the share of expenditure allocated to prevention activities in the countries analysed; a resulting implication is that investment in prevention is not intrinsically determined by the organisational structure of the healthcare system, but responds to external factors. Key questionsO_ST_ABSWhat is already known on this topic?C_ST_ABSPreventive care represents a relatively small share of total health expenditure in most OECD countries, despite its recognized importance in addressing public health issues. Previous studies attempted to explore cross-country differences in preventive spending and the potential role of healthcare system organization, often using traditional classifications (e.g., Beveridge or Bismarck). However, evidence remains limited and no studies have examined long-term trends using current multidimensional classifications of healthcare systems. What does this study add?By analyzing trends in preventive care expenditures over a twenty-year period across 22 European OECD, our study showed trends in the share of spending on prevention were largely independent of the structural characteristics of healthcare systems. Among the analyzed dimensions, only the regulation showed a more pronounced curvilinear trend in countries with societal regulation. How this study might affect research, practice or policy?Since the findings suggest that investment in prevention may depend more on contextual factors such as political priorities and public health strategies rather than structural characteristics of healthcare systems, policymakers should therefore promote prevention through targeted policy commitment instead of relying on health system design alone.

OBJECTIVE: To evaluate the return on investment (ROI) of a community based Diabetes Self Management Program (DSMP) enhanced with health related social needs (HRSN) screening and referrals, implemented by the New York City (NYC) Department of Health and Mental Hygiene with three community based organizations in highly impacted, under resourced neighborhoods. RESEARCH DESIGN AND METHODS: A retrospective cost benefit analysis from a public sector payer perspective was conducted among 171 adults with type 2 diabetes who completed a six week, peer led DSMP delivered by community health workers (CHWs) in English, Spanish, and Korean during 2018 2019. A time driven, activity based costing model captured direct implementation costs, CHW workforce turnover, and administrative overhead. Monetized benefits included avoided diabetes related complications, reductions in self reported emergency department (ED) visits and hospitalizations, and quality adjusted life year (QALY) gains from improved medication adherence. Univariate sensitivity analyses tested robustness under conservative assumptions. RESULTS: Total program costs were $179,224; monetized benefits totaled $1,824,213, yielding a net benefit of $1,644,989 and an ROI of 918%, approximately $10 returned per $1 invested. Excluding QALY gains, ROI remained 551%. Self reported ED visits declined from 149 to 82 and hospitalizations from 93 to 24 in the six months following intervention. Over 80% of participants reported housing instability; 72% were Medicaid covered and 16% uninsured. Sensitivity analyses confirmed a positive ROI under all conservative scenarios. CONCLUSIONS: A CHW led, community based DSMP integrated with HRSN screening and referrals delivered substantial economic and public health value among adults facing housing instability and structural barriers to care. Findings support inclusion of DSMP as a covered benefit in Medicaid managed care, value based payment arrangements, and housing access initiatives to advance equitable diabetes outcomes.

BackgroundPakistans fertility rate remains among the highest in South Asia, while its progress toward FP2030 goals has been slow. Poor urban populations, which comprise nearly a third of the countrys population, are often missed by conventional health and family planning service delivery systems. The Akhter Hameed Khan Foundation, with funding from the Punjab government, had demonstrated a community outreach model where family planning access was increased for 278,000 population. The current paper describes its scale up to expand coverage to an additional 800,000 population, through community outreach by local women to adapt to the local context and technology to ensure near 100% coverage, enhance the quality of monitoring and lower the costs. InterventionThis digitally monitored, community-led outreach model ("Aapi") was scaled across 23 urban and peri-urban union councils of Rawalpindi District between November 2022 and December 2024. Locally recruited female outreach workers (Aapis) conducted household mapping and counseling, provided short-term FP methods, and referred clients for long-acting methods. Real-time dashboards, GPS verification, and automated data checks enabled continuous supervision and adaptive management. Implementation ResultsThe program registered nearly 100,000 married women of reproductive age, achieving near-universal coverage in the intervention area. Contraceptive prevalence rose from 36% to 45% within two years, and 37% of short-term users adopted long-acting methods. Average implementation cost was PKR 1,981 (US$7.10) per user - less than half that of comparable national FP outreach programs. Digital monitoring helped improve data completeness, worker accountability, and program efficiency. Lessons LearnedEmbedding digitally supported outreach workers that are from the community in urban neighborhoods can achieve universal FP coverage at low cost. Key enabling factors included local recruitment, simplified digital tools (including digital automation), frequent feedback loops, and flexible supervision. Challenges included staff attrition and sustainability of incentive mechanisms. The Aapi model describes a feasible, scalable approach for improving FP access and accountability among underserved urban populations in Pakistan and similar low- and middle-income country (LMIC) settings.

Introduction. Current best practice is for primary care physicians (PCPs) to screen patients for problematic substance use at checkups. However, this practice is not routine, is done in an unstandardized manner, and contributes to the overburdening of PCPs. Screening practices also target current, potentially problematic use behaviors, thus limiting their capacity to help patients prevent problems before they start. Recent scientific advances in identifying people at high risk for substance use problems as a means of facilitating prevention efforts have not yet been integrated into medical practice. To address these issues, our research team developed a freestanding platform called the Comprehensive Addiction Risk Evaluation System (CARES). CARES provides personalized information about genetic and behavioral/environmental risk for substance use disorder (SUD) and connects individuals to resources based on their risk profile. The present study evaluated the potential for adoption and implementation of CARES within a health care system through qualitative interviews with key stakeholders. Methods. Semi-structured interviews were developed using the Consolidated Framework for Implementation Research (CFIR) and conducted with N=15 interviewees. Transcripts were analyzed using rapid qualitative analysis. Results. Key themes included perceived need for new SUD screening tools, current SUD screening procedures and their pros/cons, openness to new ideas and clinical tools, fit of CARES with organizational goals and priorities, considerations for use of CARES with adolescent populations, anticipated patient response to CARES, barriers to implementation and uptake of CARES, changes required for implementation, and possibility for medical record integration. Interviewees generally expressed need for new screening tools and openness to using new tools, but expressed concern that existing provider burden, lack of SUD knowledge, and discomfort/stigma could stymie efforts to implement CARES. Conclusions. There is a clear need for a low-burden, easy-to-use tool for substance use screening. CARES appears to be an acceptable and feasible approach to fill this gap. These findings will be used to inform pilot implementation of CARES in a clinical care setting.

BackgroundHealth facility financial autonomy enables facilities to retain their revenue and use it to meet facility level needs and priorities to ensure responsiveness, accountability and efficiency. Public facilities need to develop public finance management (PFM) compliant budgets before spending this revenue. However, existing constraints such as lack of competencies and capacities among facility managers in developing budgets and limited political goodwill have influenced the existence of autonomy. This study presents a case study of Nakuru county which implemented an intervention to enhance the capacity of facility managers in developing, implementing and monitoring budgets. MethodsWe used a qualitative case study approach, with data collected through participant observations and document analysis. We utilized process evaluation in examining the motivations for the intervention, its implementation, early outcomes and the role of context in these outcomes. ResultsThe emergence of the intervention was guided by technical, legal and political motivations. The implementation was done in four phases. The first phase targeted the Level four (4) and five (5) facilities who had greater experience with revenue management and already had some level of autonomy, while the second phase built on the lessons learnt and targeted level three (3) and two (2) facilities. The last phase focused on institutionalization and continuous improvement of the standard budgeting process. Early findings showed improvements in budgeting practices in higher level facilities but minimal in level two (2) facilities with some contextual factors such as availability of management staff playing a role. ConclusionThe experience of Nakuru county in building budgeting capacity for facility financial autonomy demonstrates that sustained progress requires a multi-year, adaptive approach that combines training with standardized tools, institutional support, and routine performance monitoring. This journey offers valuable lessons for effective decentralization: tailor support by facility level, embed monitoring and accountability mechanisms, and foster strong leadership and partnerships to sustain gains and enable responsive, autonomous health service delivery.

PurposeAlthough numerous research studies have demonstrated the positive impact of clinical pharmacy services, these benefits do not translate into sustained practice changes without support from hospital pharmacy leaders. Factors influencing leadership decisions to expand pharmacy services remained unclear. This study aimed to identify barriers to implementing pharmacy practice model changes and gain insights on potential methods of overcoming these barriers from the hospital pharmacy leader perspective. SummaryWe conducted a national, cross-sectional survey of hospital pharmacy leaders using the REDCap platform, distributed via email over three weeks between September to October 2025. The survey included questions about perceptions related to implementation of practice model changes, resources/evidence used to justify clinical positions, barriers to expanding clinical pharmacy services, and demographics of healthcare systems they represented. The survey included Likert-scales and open-ended questions. The primary outcome was types of evidence most compelling to justify clinical pharmacist positions. Secondary outcomes included resources currently in use for decision-making and perceived barriers. The survey highlighted key factors influencing administrative decision-making regarding the expansion of clinical pharmacy services and revealed significant barriers to justifying clinical positions related to knowledge gaps, underscoring the need for further research to develop evidence-based metrics that capture the comprehensive benefits that clinical pharmacists can offer. ConclusionThis survey provided valuable insights into hospital pharmacy leader perspectives on resources and evidence needed to support expanded pharmacy services and justify clinical pharmacist positions. These insights can inform future research by ensuring that metrics that are both clinically and administratively significant are included in outcomes. Key pointsO_LIWhile clinical pharmacy services are known to improve patient care, their benefits do not lead to expanded and/or sustained practice changes without hospital pharmacy leader support. C_LIO_LIThis cross-sectional survey of hospital pharmacy leaders identified perceptions, resources and barriers to justifying clinical pharmacist positions. C_LIO_LIThis study highlights gaps in hospital pharmacy leader perceptions and knowledge, providing a foundation for developing evidence-based tools and targeted strategies to expand clinical pharmacy services, improve quality of care, and support clinician sustainability. C_LI

BackgroundEnsuring a sufficient and motivated health workforce requires not only retaining existing staff but also understanding the intentions of those entering the labour market. In Lao PDR, limited civil-servant quotas, prolonged volunteer pathways, and expanding private sector opportunities shape the early career choices of health professional students. Yet little is known about how final-year students perceive the public sector or what influences their decision to join or avoid government service. MethodsA cross-sectional survey was conducted among 298 final-year students from four major public health-training institutions. The questionnaire assessed demographic characteristics, motivations for choosing a field of study, post-graduation plans, and perceived drivers and barriers to public-sector employment. Descriptive statistics, chi-square tests, and multivariate logistic regression were used to identify factors independently associated with intention to work in the public sector. ResultsResults: Two thirds of students (66.1%) reported willingness to work in the public sector, though nearly as many simultaneously considered private sector employment (64.8%) and 43.3% expressed interest in working abroad, reflecting a "portfolio approach" to career planning under uncertainty. In multivariate analysis controlling age, field of study, and training institution, several factors independently predicted public sector intention. Each additional year of age increased the odds of public-sector preference by 21% (AOR 1.21, 95% CI 1.07-1.38, p = 0.003). Field of study demonstrated significant variation: pharmacy and dentistry students had 62% lower odds of public-sector intention compared to medical doctors (AOR 0.38, 95% CI 0.15-0.98, p = 0.045), while nursing and midwifery students showed equivalent preference (AOR 0.94, 95% CI 0.46-1.91, p = 0.855). Training institution emerged as a powerful predictor: students from provincial colleges demonstrated nearly three-fold higher odds of public-sector intention compared to those at the University of Health Sciences in Vientiane Capital (AOR 2.80, 95% CI 1.38-5.68, p = 0.004). Gender and marital status, while associated in bivariate analysis, did not remain significant in the adjusted model. ConclusionFinal-year health professional students in Lao PDR demonstrate substantial public-sector commitment, but career intentions are shaped by institutional context and opportunity structures rather than motivation alone. To strengthen workforce recruitment, policymakers should leverage provincial training pipelines, implement field specific retention strategies for high risk disciplines, and ensure equitable career pathways that transform structural barriers into accessible entry mechanisms for all motivated graduates.

ObjectiveTo determine the magnitude of obstetric referral and to explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia. DesignExplanatory sequential mixed-methods study. Setting and periodFifty public health centres in Addis Ababa City Administration, January-April 2021. MethodsDelivery and referral registers from 50 health centres were reviewed retrospectively for 12 months (8 July 2019-7 June 2020). Facility observations and interviews with maternity unit heads were conducted in all selected centres. In-depth interviews were conducted with 20 midwives and 13 health-centre managers. Quantitative data were analysed descriptively, and qualitative data were analysed thematically using Colaizzis method. ResultsEighty percent of health centres had a functional referral system. The overall obstetric referral rate was 32%, with substantially higher referral rates in facilities without caesarean section (CS) services compared with those providing CS (39% vs 21%). Qualitative findings indicated that high referral rates were associated with limitations in the predictive capacity of the partograph, variability in providers clinical skills, and risk-averse practices driven by accountability concerns related to maternal and perinatal outcomes. ConclusionAlthough referral systems were largely functional, obstetric referral rates were high, suggesting potential over-referral. Updating labour monitoring tools, strengthening provider competencies, and clarifying accountability mechanisms may reduce unnecessary referrals.

PurposeTo characterize maternal transport patterns in Iowa, a state with levels of maternal care and without formal perinatal regions, and assess whether transport decisions reflect efficient, risk-appropriate coordination. MethodsWe analyzed 2010-2023 Iowa birth records, which included 2,251 maternal transports between obstetric facilities across 106 unique routes. We characterized transport patterns and applied a community detection algorithm to identify "communities" of obstetric facilities that disproportionately transport among themselves. FindingsSuburban and rural counties have elevated transport rates compared to urban counties. 2,189 transports (97%) were from lower-to higher-level facilities. Among these, 2,037 (93%) were to Level III tertiary care centers. 567 transports (25.2%) bypassed a closer facility offering an equivalent or higher level of care than its destination facility. Health system affiliation was associated with bypassing transport, indicating potential organizational rather than purely geographic drivers of transport decisions. Three "communities" of obstetric facilities largely shaped by geographic proximity were identified. ConclusionsAlthough Iowa does not have formal perinatal regions, patterns of maternal transport are mostly in line with three de facto regions. Some potential inefficiencies were identified, such as obstetric facilities transporting to a farther facility when a closer facility offered the same level of care or higher. These findings may help identify opportunities to enhance care coordination among obstetric facilities, optimize maternal transport networks, and improve regionalization of maternal care.

This study explores the influence of social determinants of health (SDOH) on follow-up behavior among patients referred to community-based organizations (CBOs) in the Emergency Department (ED) of Long Island Jewish (LIJ) Medical Center. A retrospective analysis was conducted on data collected from 342 patients who were screened for SDOH between February and July 2023. Descriptive statistics and Chi-squared tests were used to identify potential associations between demographic and social factors (race, language, age, gender, employment status, and insurance status) and follow-up rates. The results revealed several trends: non-White patients (73.2%) and non-English speakers (81.8%) followed up more frequently than their counterparts, as did older adults (80.0%) and insured patients (77.8%). However, none of the variables reached statistical significance (all p-values > 0.05). The findings suggest that while demographic and social factors may influence follow-up behavior, the lack of statistical significance could be attributed to the limited sample size. These trends align with previous literature on SDOH and follow-up behavior, highlighting the need for further research with larger, more representative samples. Addressing the complex interplay of SDOH, including factors such as language, insurance, and cultural differences, is crucial for improving follow-up rates and ensuring better health outcomes for underserved populations. Future research should focus on refining referral systems, exploring additional socioeconomic factors, and conducting longitudinal studies to develop more effective strategies for integrating SDOH interventions in healthcare systems.

BackgroundAdvanced Practice Providers (APPs), including physician assistants and nurse practitioners, represent a growing proportion of the emergency medicine workforce, including in high-acuity community emergency departments (EDs). Despite this growth, many sites lack formal onboarding structures, particularly for new graduate or inexperienced APPs transitioning to practice. Unlike postgraduate residencies and fellowships, limited literature exists on structured onboarding models outside academic settings. This study evaluated the feasibility and perceived impact of a structured onboarding program for APPs in a non-academic community ED. MethodsThis mixed-methods feasibility study was conducted at a single-site community ED without an existing formal onboarding process. New graduate or inexperienced APPs hired within 12 months of program implementation completed a post-intervention survey assessing satisfaction across five domains derived from a conceptual framework of human resource practices and retention. Quantitative data was collected using 5-point Likert-scale items, and qualitative data was obtained through open responses. Leadership and preceptors completed a secondary survey evaluating feasibility and perceived impact. Descriptive statistics and thematic analysis were performed. ResultsFour new graduate APPs (100% response rate) completed the post-implementation survey. Mean scores across domains ranged from 3.33 to 5.00, with highest ratings observed in supervisor support (mean = 5.00), employee engagement (4.33), and alternative training via online modules (4.67). Qualitative themes included clear communication of expectations, value of asynchronous educational modules, and strong mentorship support. Fifteen leaders and preceptors reported that although the program required additional effort, it improved tracking of APP progress, preparedness for transition to practice (4.67), and was perceived as worthwhile to reduce attrition. ConclusionsA structured onboarding program for new graduate APPs in a community ED was feasible, well accepted, and perceived to support transition to practice. These findings support the need for further study of structured onboarding as a scalable strategy to enhance preparedness, engagement, and potential retention in high-acuity clinical settings.

BACKGROUNDThis study evaluates the reach, scalability, and implementation of a large-scale, multi-site tele-buprenorphine program designed to treat opioid use disorder (OUD) within rural carceral settings. Given that individuals transition frequently between jails and the community, these facilities represent a critical window for OUD intervention, yet they often face significant provider shortages and logistical barriers. We conducted a retrospective chart review of 842 unique patients (1,321 treatment episodes) enrolled in the University of Marylands tele-buprenorphine program across six rural county jails between June 2020 and May 2025. Data extracted from jail records and electronic health records were used to analyze patient demographics, prescribing patterns, and program retention. RESULTSThe patient population was primarily male (71.1%) and White (75.7%), with a mean age of 35.4 years. Participants reported high-severity OUD, with an average of 12.6 years of opioid use. Reflecting broad admission criteria, 55.2% of participants were new treatment initiates not receiving MOUD prior to booking. Patients spent a mean of 35.6 days incarcerated before initiation and were retained in the program for an average of 66 days. Buprenorphine doses were titrated from a mean initiation dose of 8.8 mg to 16.2 mg at discharge. The program demonstrated a 99.5% adherence rate among retained patients. Only 3% of the total sample were discharged for medication diversion or hoarding. CONCLUSIONSTelemedicine is a highly feasible and scalable model for delivering evidence-based MOUD in rural jails. By utilizing a "liberal admission policy" that prioritizes both treatment initiation and maintenance, programs can successfully reach high-risk individuals who lack access to community-based care. These findings suggest that tele-buprenorphine can effectively bridge the treatment gap in underserved jurisdictions, potentially reducing the risk of overdose during the high-risk post-release period.

Background Kenya's facility autonomy reforms are intended to improve health system equity, efficiency, and responsiveness to community needs by shifting decision-making to the frontline. This study evaluates the implementation process and experience of facility autonomy reforms in Kenya post devolution of health services. Methods We conducted a concurrent mixed methods study of counties (n=6) in Kenya, selected based on their implementation of facility financial autonomy reforms as of June 2023. For the quantitative aspect, we assessed 141 randomly selected public health facilities across all levels of service provision. We then did a descriptive analysis to measure the level and perceptions of autonomy. For the qualitative aspect, we reviewed documents and interviewed purposively selected stakeholders (n=71) involved with autonomy reforms at national, county, and facility levels, cutting across health, finance, legal, political and community actors. We analyzed the transcripts thematically using NVivo 12. Results The emergence of the FIF reforms in Kenya was driven by the convergence of political, technical, and public needs. While counties have developed their own facility autonomy laws to fit local contexts, some provisions are not fully aligned with the national legislation. Some aspects of both the county specific and national laws are not implemented. These include allocation of matching funds from the exchequer and reimbursing facilities for expenses incurred from providing care to indigents and for unpaid bills. The implementation of autonomy also varies, with some aspects partially or not implemented. Autonomy reforms have contributed to improved decision-making, staff satisfaction, availability of essential medicines, and facility maintenance. However, challenges have emerged, including the failure of counties to provide matching funds, which disproportionately affects lower-level facilities that do not generate revenue. Additionally, the absence of waiver repayment mechanisms has led to inequities, and the risk of increased service costs threatens financial accessibility for marginalized populations. Conclusion Facility autonomy reforms support people-centered decision-making and aligns with PHC principles. While these reforms hold promise for improving service delivery and access, their success depends on complementary measures such as sustainable funding mechanisms and stronger protections for vulnerable populations.

Safety is a foundational concern in adolescent behavioral health crisis units (BHCUs), where therapeutic care must be delivered in complex, rapidly evolving environments. However, limited research has explored how key personnel involved in shaping the environment of care in such units, such as clinicians and healthcare designers, understand and prioritize safety. To address this gap, one-hour, online semi-structured interviews were conducted with a panel of experts (N = 13) at a national level in the U.S., comprising of eight designers (healthcare designers and medical planners) and five clinicians (psychologists and psychiatric nurses) actively involved in designing or construction of BHCUs or providing care in these units for adolescent patients in the past five years. The interviews were recorded, transcribed verbatim, and analyzed via MAXQDA (2024) for qualitative content analysis. Analysis of interviews revealed 592 codes forming four preliminary categories related to safety in adolescent BHCUs: 1) Barriers and facilitators to patient safety and comfort (f = 52%), 2) Care processes and clinical workflows (f = 21%), 3) Care outcomes (f = 19%), and 4) Laws, regulations, and guidelines (f = 7%). Findings highlighted several points of divergence in clinicians versus designers perception of safety related to environmental features, such as nursing station designs, patients access and control over unit features, and furniture type or layout in the unit. Results also showed differences in understanding care processes and outcomes related to safety among the two groups. Addressing such discrepancies can contribute to the development of safer BHCUs that support adolescents healing.

BackgroundA Hospital Medicine Advanced Practice Provider (HMAPP)-led care model developed in response to the high acuity and increased patient volumes associated with the Covid-19 pandemic. Although anecdotally perceived as a successful model, questions remained if there was adequate pre-planning and formal implementation strategy for stakeholder buy-in. ObjectiveTo elicit HM physicians and APPs perceptions of the HMAPP-led care model implementation and consider necessary steps for optimal future APP care model development and operation. Design, Setting and ParticipantsThis qualitative study used 10 (5 physicians and 5 APPs involved in the care model pre- and post-implementation) individual semi-structured, virtual interviews based on the Consolidated Framework for Implementation Research (CFIR). Deductive and inductive rapid analysis was utilized to analyze the data. ResultsTwo themes emerged as strengths: 1) Experienced APPs delivered the care model, 2) Acceptance of the care model evolved over time. Four themes suggested opportunities for future development: 1) Guidelines should expand from patient distribution to include minimal collaboration and escalation expectations, 2) Culture change was a barrier to model implementation and acceptance, 3) Intentional collaboration between APPs and Physicians is necessary, 4) Investment in standardized onboarding enhances buy-in of the care model. ConclusionThe impact of an APP care model can be elevated if implemented with key principles and strategies. This is critical in an evolving health care landscape where all providers need to collaborate and practice with their full expertise to maximize safe, efficient and quality patient care.