Digital Commons Network^™

Implementation Strategies For Evidence-Based Healthcare Interventions In Rural And Remote Settings: A Scoping Review, Anna Chapman, Cadeyrn J. Gaskin, Hannah Beks, Charlene Wright, Skye Marshall, Elizabeth A. Johnston, Rebecca J. Bergin, Sharina Riva, Fiona Crawford-Williams, Camille E. Short, Nicole Kiss, Sze Lin Yoong, Nicolas H. Hart, Anna Wong Shee, Helena Rodi, Hannah Jongebloed, Anna Ugalde

Research outputs 2022 to 2026

Globally, people living in rural and remote areas experience poorer healthcare access and outcomes than urban populations. Applying implementation strategies that support the translation of evidence-based healthcare interventions may help reduce these inequities; however, real-world implementation is complex, and it remains unclear how strategies are applied and tailored to rural and remote contexts. This scoping review synthesised evidence on implementation strategies for healthcare interventions in rural and remote settings of high-income countries. Five databases (Ovid MEDLINE, Embase, Cochrane CENTRAL, CINAHL, Web of Science) were searched for peer-reviewed studies published between 1/1/2000 and 25/10/2024. Extracted data were synthesised using a descriptive …

Alcohol Advertising At The Beach: Insights From Young People In Western Australia, Renee N. Carey, Gemma Crawford, Nicola D'Orazio, Gina S.A. Trapp, Lauren Nimmo, Tina Lam, Jonine Jancey, Justine E. Leavy

Research outputs 2022 to 2026

Background: Advertising and marketing by the alcohol industry serve to normalise alcohol use, with exposure to alcohol advertising linked to earlier and riskier drinking among young people. Advertising that portrays alcohol use in and around waterways is of particular concern, with one in five fatal drownings being associated with alcohol. Objective: This study aimed to explore the types of alcohol advertising that young people were exposed to, and to determine whether exposure to alcohol advertising was related to their alcohol use in aquatic environments. Methods: We surveyed 102 young people aged 18 to 25 years attending a free event at …

An Evaluation Of Programmatic Assessment Across Health Professions Education Using Contribution Analysis, Janica Jamieson, Claire Palermo, Margaret Hay, Rachel Bacon, Janna Lutze, Simone Gibson

Research outputs 2022 to 2026

Programmatic assessment is gaining traction in health professions education. Despite this popularity, educators continue to grapple with complex contextual factors that impact implementation and outcome attainment. We used contribution analysis, a theory-informed evaluation method, to understand the mechanisms underpinning successful implementation. Applying the six steps of contribution analysis, we developed a postulated theory of change (ToC) and then conducted a qualitative study with programmatic assessment stakeholders (graduates n = 15, supervisors n = 32, faculty n = 19) from four Australian dietetic programs. These data were analysed using the Framework Analysis method and integrated with data derived from a literature …

Longitudinal Prediction Of Bmi Using Explainable Ai: Integrating Polygenic Scores, Maternal, Early-Life And Familial Factors, Fuling Chen, Phillip E. Melton, Kevin Vinsen, Trevor Mori, Lawrence Beilin, Rae Chi Huang

Research outputs 2022 to 2026

Background/objectives: This study aimed to predict body mass index (BMI) trajectories from childhood to early adulthood using explainable artificial intelligence, integrating adult BMI polygenic scores (PGS), maternal, early-life, and familial factors to identify key predictors of obesity risk and inform prevention strategies. Subjects/methods: We analyzed longitudinal data from the Raine Study Gen2 cohort, recruiting 2868 participants. This observational study, without randomization or case-control design, collected BMI measurements at ages 8, 10, 14, 17, 20, 23, and 27 years. We applied Kolmogorov–Arnold Networks (KAN) alongside conventional machine learning models, integrating epidemiological variables (maternal and paternal anthropometrics, parental education, early-life skinfold measurements) …

Sexuality Education In An Age Of Resistance: Reflections At The Nexus Of Education, Health And Rights, Sarah Vrankovich, Katrina Marson, Giselle Woodley, Jordina Quain, Hanna Saltis

Research outputs 2022 to 2026

Comprehensive sexuality education (CSE) is internationally recognised as essential to public health and young people’s rights. Yet its implementation in Australia and globally is increasingly undermined by conservative backlash, moral panic and political interference. This paper offers a critical reflection on the current landscape of CSE, drawing on insights from a panel discussion at the 2025 World Association for Sexual Health congress, and collaborative analysis. As early-career researchers, sexologists and practitioners working across education, communications, public health and sexual violence prevention, we utilise our collective experience to examine how various influences shape and constrain the delivery of CSE. We map …

Thorium Lung Burdens Of Norm Workers Revisited, Gregory S. Hewson, Martin I. Ralph, Marcus Cattani

Research outputs 2022 to 2026

Historical thorium bioassay data collected from Australian mine workers in the 1990s, including in vivo lung counting and thoron-in-breath (TIB) measurements, were re-evaluated using current dosimetric and biokinetic models. Revised daily thorium intakes from bioassay were compared with previous estimates to assess changes in the dose profile and potential implications for contemporary operations. Reanalysis revealed lower estimates of annual dose, including the number of workers assessed as exceeding 20 mSv. However, it was found that intakes derived from industry personal air sampling (PAS) underestimated intake by up to three-fold. This study determined that sensitive bioassay techniques, such as TIB using …

Chronic Disease Prevalence And Modifiable Risk Factors Among Undergraduate Students At Ha’Il University: A Population-Level Cross-Sectional Study, Collins Otieno Asweto, Sehar Un Nisa Hassan, Mohamed Ali Alzain, Bandar Alsaif, Mohammed Elshiekh Saeed, Ahmed Kassar, Kamal Elbssir Mohammed Ali, Mouna Ghorbel, Rafat Zrieq, Monzer Hamed, Wei Wang

Research outputs 2022 to 2026

Background: Rising rates of chronic conditions among Saudi youth underscore the need for early prevention. Using a public‑health lens focused on demographic, academic, and lifestyle influences, this study investigates the risk and protective factors for chronic disease among students at the University of Ha’il to guide youth‑centered health policies and long‑term wellbeing initiatives. Methods: A cross-sectional survey was conducted among 10,775 undergraduate students studying in bachelor’s degree programs at Ha’il University, Saudi Arabia. Descriptive analyses were used to assess demographic characteristics, academic status, health status, and health-related lifestyles. Multiple logistic regression models were applied to determine which demographic, academic, and …

Global, Regional, And National Burden Of Epilepsy, 1990–2021: A Global Burden Of Disease Study, Jinqing Zhao, Qiannan Chen, Jiahan Dong, Meng Gao, Siqi Ge, Anxin Wang

Research outputs 2022 to 2026

Background: Epilepsy is a common neurological disorder characterised by spontaneous seizures without an identifiable cause, leading to high morbidity and a significant public health burden. Understanding trends in its incidence, prevalence, mortality, and disability-adjusted life years (DALYs) is essential for developing effective prevention and treatment strategies. We aim to describe global trends in epilepsy over the past 32 years and explore the impact of sociodemographic index (SDI) levels on disease burden using the Global Burden of Disease 2021 data. Methods: We analysed the global burden of epilepsy (1990–2019) using age-standardised rates (ASRs) and their 95% uncertainty intervals (UI). We assessed …

Scope And Adherence To The Consider Statement In Aboriginal And Torres Strait Islander Injury Prevention Research In Australia, Bep Uink, Michelle Barrett, Courtney Ryder, Aleina Humphreys, Graham Peter Barker

Research outputs 2022 to 2026

Introduction: Effective injury prevention for Aboriginal and Torres Strait Islander people hinges on the availability of culturally safe policies, resources and programmes, alongside best-practice research. Contemporary injury prevention research has increasingly centred Aboriginal and Torres Strait Islander knowledges, yet there is still room for improvement. Identification of relevant resources, policies and programmes, as well as the extent to which injury prevention research meets international criteria for ethical research with Aboriginal and Torres Strait Islander peoples will provide practitioners with critical insights into best-practice injury prevention initiatives. Method: We examined the breadth and scope of Aboriginal and Torres Strait Islander injury-related …

Combined Effects Of Cumulative Triglyceride-Glucose And Blood Pressure On Stroke In Middle-Aged And Older Chinese Adults: A Longitudinal Analysis, Xinyue Wang, Wen Zheng, Xiangqian Jin, Hongzhi Liu, Jiheng Hao, Liyong Zhang, Yuanyuan Gu, Haifeng Hou, Wei Wang

Research outputs 2022 to 2026

Background: The triglyceride-glucose (TyG) index has increasingly been recognised an indicator for stroke risk. We aimed to explore the relationship between TyG and blood pressure (BP) and the combined effects of cumulative TyG (CumTyG) and cumulative BP (CumBP) on stroke risk in a cohort of Chinese middle-aged and older adults. Methods: We enrolled 5138 participants from the 2011–2018 waves of the China Health and Retirement Longitudinal Study. Cumulative TyG and BP exposures were recorded between 2011 and 2015, and stroke incidence was then followed up until 2018. We conducted a cross-lagged panel analysis to address the temporal and directional relationships …

Machine Learning Derived Abdominal Aortic Calcification Is Associated With Physical Frailty In Community-Dwelling Adults: The Uk Biobank Imaging Study, Abadi K. Gebre, Marion Mundt, Elsa Dent, James Webster, Afsah Saleem, Syed Zulqarnain Gilani, Yuandan Zhang, Cassandra Smith, Parminder Raina, John P. Kemp, William D. Leslie, John T. Schousboe, Nicholas C. Harvey, Joshua R. Lewis, Marc Sim

Research outputs 2022 to 2026

Clinical cardiovascular disease (CVD) is often present in frail individuals. However, it remains unclear whether subclinical CVD, e.g., abdominal aortic calcification (AAC), is associated with frailty. This study investigated the cross-sectional relationship between AAC scored using a validated machine learning model (ML-AAC24) and physical frailty. 49,081 participants from the UK Biobank Imaging Study without atherosclerotic CVD (ASCVD) diagnosis were included. ML-AAC24 extent was categorised as low, moderate and high, based on established severity categories. Physical frailty was based on a modified Fried’s frailty phenotype comprising weak hand grip strength, slow walking speed, weight loss, exhaustion, and physical inactivity. Individuals with …

Reduced Physical Activity During Submarine Deployment: Health And Performance Consequences And Feasible Countermeasures—A Narrative Review, Benjamin J.C. Kirk, Georgios Mavropalias, Anthony J. Blazevich, Jodie L. Cochrane Wilkie, Aus Molan, Kazunori Nosaka

Research outputs 2022 to 2026

Objectives: Submarine environments pose unique challenges to maintaining physical activity due to space constraints, operational demands, and prolonged confinement. This review aims to synthesize existing literature on the health and performance consequences of reduced physical activity in submarine personnel and to examine feasible strategies to mitigate these effects during deployment. Methods: A narrative overview methodology was adopted, with peer-reviewed studies identified from PubMed, Scopus, and Google Scholar. Articles examining physical activity patterns, health outcomes, and exercise or movement-based interventions in submarine environments and comparable confined operational settings were included. Results: Submarine deployments are consistently associated with reduced physical activity, low …

The Basis For Recommending The Selection Of Samplers In Determining Occupational Exposures To Aerosols, Martin Harper, Pieter Bertier, Marcus Cattani, Karen Galea, Darrah Sleeth, Steven Verpaele

Research outputs 2022 to 2026

Measurements are considered to be the basis of exposure assessments used to determine risks to workers. Inhalation exposure poses the greatest risk for most airborne chemicals, and measurements are based on collecting (sampling) and analyzing air samples. Samplers have been developed for more than 120 years. Each new design has been intended to address flaws perceived in earlier designs. Users are faced with a varied array of samplers from which to choose. Comparisons are difficult to make because tests of sampler performance were not standardized until recently and have not been applied consistently. The existing large body of work does …

Baseline Body Mass Index Category And Incident Treated Hypertension In Australian Men: A Linked Prospective Cohort Study Using Pbs/Mbs Data, Ebenezer Afrifa-Yamoah

Research outputs 2022 to 2026

Background: Excess adiposity is a major modifiable risk factor for hypertension; however, the incremental prognostic value of body mass index (BMI) beyond standard predictors remains unclear. We examined the associations between baseline BMI category and incident treated hypertension, and assessed whether BMI improved risk prediction.

Methods: Data were obtained from the Ten to Men longitudinal study (2013–2024) linked to Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) records. The cohort comprised 12,742 men aged ≥ 18 years without treated hypertension at baseline, followed for 133,038 person-years. Adjusted Cox proportional hazards models were fitted. Discrimination, calibration, decision curve analysis, E-values, …

Factors That Impede Women's Contraceptive Care Needs During And Immediately After Incarceration In New South Wales, Australian. Qualitative Perspectives Of Professional Staff Working With Incarcerated Women, Helene Smith, Mandy Wilson, Basil Donovan, Jocelyn Jones, Tony Butler, Paul Simpson

Research outputs 2022 to 2026

Introduction: Women with a history of incarceration report higher rates of pregnancy and abortion, lower contraception use and poorer birth outcomes compared to other women in the community. This suggests family-planning and reproductive-health needs that are not well served by current models of care. Despite this, little is known about how contraception is provided within Australian carceral settings, or the structural barriers experienced by professional staff working in these environments. We report findings from a qualitative study conducted in New South Wales (NSW), Australia, describing professional staff's views of factors that support or impede women's contraceptive care needs both during …

Governing Professional Mobility: An Llm-Assisted Framework And Empirical Taxonomy Of Health-Professional Mobility Agreements, David C. Benton, Andrew D. Benton

Research outputs 2022 to 2026

Background: Health-professional mobility agreements (eg, compacts, mutual recognition arrangements, memoranda of understanding) are increasingly used to address workforce shortages, support crossborder practice, and enable new technology-mediated modes of service delivery. Regulators need rapid, reproducible ways to assess whether such instruments protect the public while facilitating proportionate professional mobility.

Purpose: To develop and internally test a 10-dimension, 41-subdimension assessment framework for health-professional mobility agreements; examine whether large language model (LLM)–assisted coding can approximate expert legal regulatory assessment; and derive an empirical taxonomy of mobility and other similar instruments.

Methods: A focused documentary synthesis of legal instruments, academic literature, and intergovernmental guidance …

Knowledge, Intentions And Attitudes Towards Osteoporosis And Other Health Conditions Among Older Australians, Phuong Dung Lam, Satvinder S. Dhaliwal, Christina M. Pollard, Jonine M. Jancey, Richard L. Prince, Deborah A. Kerr

Research outputs 2022 to 2026

Background: Osteoporosis burden is underdiagnosed and undertreated. While increasing community awareness and education are recognised priorities, research on how older adults view osteoporosis is limited. The aim was to assess osteoporosis-related knowledge, intentions and attitudes in relation to other health conditions in Australian adults aged 50 years and older.

Methods: A validated online questionnaire, developed with an expert panel, was administered to 1432 healthy volunteers, (64.3 ± 9.5 years). The questionnaire assessed knowledge of osteoporosis risk factors, attitudes and intentions. Multivariable logistic regression identified factors associated with low knowledge.

Results: Knowledge score across six topics was 29.5 ± 14.5 (100 …

Sugar Consumption In Aboriginal Children Explored From A Social Practice Perspective, Amy Budrikis, Angela Durey, Dan Mcaullay, Paul Ward, Hanny Calache, Thierry Ng, Roma Winmar, Linda Slack-Smith

Research outputs 2022 to 2026

Australian Aboriginal children have higher sugar intake and are disproportionately affected by sugar-related diseases such as obesity, diabetes and dental caries than non-Aboriginal children. The intention of this paper was to highlight the need for approaches that can capture the complexity of health practices without reducing them to either individual choice or structural determination. We explore sugar consumption in Aboriginal children from a social practice perspective. Here, the unit of analysis is the practice, not the individual, where the elements of a social practice (competence, materials and meanings) are integrated into its performance. We conducted qualitative research using elements of …

A Qualitative Analysis To Identify Implementation Strategies For A Deprescribing Clinical Practice Guideline Using The Cfir-Eric Matching Tool: Perspectives From Consumers And Professional Stakeholders, Hui Wen Quek, Xisco Reus, Kenneth Lee, Veronika Seda, Leon Adams, Osvaldo P. Almeida, Gillian E. Caughey, Jennifer Gowan, Kerryn Hart, Andrew Heredia, Anne Marie Hill, Lisa Kalisch Ellett, Dina Logiudice, Arduino A. Mangoni, Anthony Marinucci, Treasure Mcguire, Nilufeur Mckay, Vasi Naganathan, Christopher Ng, Maz Osborne, Kevan R. Polkinghorne, Constance D. Pond, Sepehr Shakib, Angela Shiu, Andrew Stafford, Tim Whitmore, Christopher Etherton-Beer, Amy Page

Research outputs 2022 to 2026

Introduction: Deprescribing is the planned withdrawal or dose reduction of medicines when harms outweigh benefits or when they are no longer required. Following publication of the Clinical Practice Guideline for Deprescribing in Older People in September 2025, supporting its uptake into routine practice is a critical next step.

Aim: This study aimed to identify implementation strategies, informed by stakeholder-perceived barriers, to support the implementation of deprescribing guidelines.

Method: A qualitative analysis was undertaken of open-text responses collected during the guideline public consultation (24 April–31 May 2025). Inductive thematic analysis identified implementation barriers, which were then deductively mapped to the Consolidated …

Participatory Development Of Innovation And Implementation Strategy: An Action-Oriented Approach, Miae Lee, Lesley A. Anderson, Emilia Piltonen, Abha Maheshwari, Julian Griffin, Seshadri S. Vasan

Research outputs 2022 to 2026

Background: Healthcare and academic institutions face growing challenges in strategic planning due to rapid advances in medicine and technology, alongside fiscal and workforce constraints that limit traditional consultation. Participatory approaches offer a way to integrate diverse stakeholder perspectives under these constraints, generating contextually relevant strategies that can indicate whether current directions are appropriate or whether priorities have been overlooked.

Methods: A structured, time-limited participatory workshop was conducted at the 10th Grampian Research Conference (June 2025), that brought together National Health Service (NHS) staff, academia, industry and patients and public communities. Participants engaged in 14 parallel roundtable discussions, with contributions captured …

Investigating The Relationship Between Drug Overdose Deaths, Excessive Alcohol Drinking, And Adult Smoking In Urban And Rural Ohio Counties In 2025, Sumin Byoun, Anne Griffin

Scholarship in Medicine - All Papers

Deaths from drug overdoses have been increasing each year. Ohio ranks among states with the highest number of drug overdose deaths per year. There is a gap in the literature regarding discussions of how excessive alcohol drinking and cigarette smoking rates may predict drug overdose death rates in a community. First, this study investigates differences in excessive drinking, adult smoking, and drug overdose deaths between urban and rural counties in Ohio. Second, this study explores whether excessive drinking and smoking behaviors can predict drug overdose death rates in urban and rural Ohio counties. Data exclusive to Ohio counties was obtained …

Understanding The Impacts Of Food Insecurity On Education Outcomes In Ohio, Maria El Biri, Sreya Tummalapalli

Scholarship in Medicine - All Papers

Background: Food insecurity has been a growing concern in the United States, and prior research has shown how food insecurity in youth can correspond to negative psychosocial outcomes. Additionally, there are known disparities with access to food based on living in rural or urban counties. Objective: The goal of this study was to determine how differences in food security can impact youth educational outcomes in Ohio. Methods: Data from County Health Rankings & Roadmaps were obtained on variables such as access to healthy foods, food insecurity, high school graduation rates, average grade performance, and percentage of the population living in …

Infant Mortality In Ohio, Isabella Bacon, Alexis Jackson

Scholarship in Medicine - All Papers

Introduction: Infant mortality continues to occur at alarming rates that differ among various groups and states. Despite this, there has been a lack of intersectional examination of risk- and protective-factors. Methods: We examine how smoking status, education level, primary care to population ratio, teen birth rates, and urban vs rural status impact infant mortality rates in Ohio, Kentucky, Michigan, and Indiana using County Health Rankings data. Results: Ohio was shown to have no significant difference between urban and rural infant mortality rates; however,  risk-and-protective factors did differ. In urban counties, high school completion, teen birth rates, and primary care ratios …

Long-Lasting Impact Of Public Health Dentistry, Michal Herman Dds, Facd

Journal of the American College of Dentists

This article reflects on the enduring impact of public health dentistry through the author’s 25-year professional journey serving underserved and marginalized communities. It examines persistent barriers to equitable oral health care, including workforce shortages, inadequate insurance coverage, racial disparities, and limited access in rural and low-income populations. Drawing on experiences in nonprofit and community dentistry, the article highlights the importance of mentorship, advocacy, leadership, and community engagement in addressing oral health inequities. It argues that public health dentistry represents a form of professional altruism grounded in service and social responsibility, and calls on dental professionals to expand access, support workforce …

Creating An Abortion Safe Harbor Using The Doctrine Of Double Effect, Evelyn M. Tenenbaum

American University Journal of Gender, Social Policy & the Law

[INTRODUCTION] In the three years since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization (Dobbs) holding that women no longer have a constitutional right to an abortion, many family physicians, obstetricians, and gynecologists have refrained from—or delayed—providing abortion services to pregnant women, even when that restraint created a substantial risk of causing serious injury or death. This reluctance to provide care is labeled physician hesitancy, which is defined as physicians acting in their own professional or personal interest to deny or delay care that would otherwise be provided under the prevailing standard of care.

It …

Civil Rights In Theory, Health Disparities In Practice: Affordable Care Act Section 1557 And The Maternal Mortality Crisis, Grace Hall

American University Journal of Gender, Social Policy & the Law

[INTRODUCTION] On a hot Fourth of July in 2021, Harmony Ball-Stribling spent her final day laughing with her husband, hours before preeclampsia killed her. Harmony was eight months pregnant and living in Belzoni, Mississippi, where she celebrated the holiday with her church congregation. Her congregation prayed over her and her baby for a safe delivery, as she was scheduled to have a cesarean section in five days.

Later that evening, Harmony woke in agony, vomited, and complained of chest pain to her husband, Mr. Stribling. Harmony’s husband put his wifein their car and began the more than thirty-mile drive to …

Overcoming And Preventing The Devastation Of Burnout In The Patient Care Setting, Deepesh Patel Ds, Mdjf, Dip, Imp, Dent, Mclindent (Pros), Fpros (Rcs Ed), Mpros (Rcs Eng), Facd, Reena Pankhania Mpharm, Pgdip, Pgcertip, Mrpharms

Journal of the American College of Dentists

Healthcare professionals commonly prioritize patients’ well-being over their own. In settings where stressful situations are common, combined with the pressures of modern-day society, this can lead to chronic stress and burnout. When one experiences burnout, their ability to perform at an optimum level is impaired. This affects the team around them and the care patients receive, making mistakes more likely. It is therefore essential to recognize the early signs of burnout and address them before the situation deteriorates. Better still, preventing burnout by prioritizing oneself fosters a happier work environment, strengthens leadership, and ultimately helps patients receive better care.

There …

When A Toothache Becomes Deadly: The Ethical Consequences Of Marginalizing Oral Health In American Medicine, Sarah F. Walsh

Journal of the American College of Dentists

The Ozar-Hasegawa Annual Student Ethics Award recognizes an outstanding scholarly submission in dental ethics, published annually in the Journal of the American College of Dentists (JACD). This article highlights the winning work, selected for its significant contribution to advancing ethical reflection and professional responsibility in dentistry.

Exploring Demographic Factors Relating To Low Birth Weight In Rural Vs Urban Ohio, Meghan Curran, Jessica Terrell

Scholarship in Medicine - All Papers

Although medical advancements have improved the outcomes for infants born with low birth weight (LBW), these interventions are very expensive and low birth weight still was attributed to 16.1% of infant deaths in the United States in 20201. By understanding the factors that influence the incidence of low birth weight in the United States, preventative measures can be implemented to reduce the need for costly interventions and enhance infant health outcomes. In this study, we focused on 38 counties in Ohio that had either 75% or greater rural regions or 30% or less rural regions. Additionally, we focused on four …

Hardin Health Link: A Community-Integrated Paramedicine (Cip) Program In Hardin County, Kentucky, Samantha Jones

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Rural and mixed rural–urban communities face persistent disparities in access to timely emergency medical services (EMS), contributing to preventable morbidity and mortality from time-sensitive conditions such as cardiovascular disease, stroke, and injury. Hardin County, Kentucky, reflects these challenges due to its geographically dispersed population, high burden of chronic disease, and variability in EMS response times. This capstone proposes Hardin Health Link, a Community-Integrated Paramedicine (CIP) program designed to expand the traditional role of EMS providers through in-home health assessments, chronic disease monitoring, post-discharge follow-up, medication reconciliation, and connection to clinical and social services.

Guided by an evidence-informed framework, the program …