Models of outpatient care delivery in inflammatory bowel disease: a scoping review

Noelle Rohatinsky; M Ellen Kuenzig; James Im; Melissa Huestis; Tasbeen Akhtar Sheekha; Cynthia H Seow; Gilaad G Kaplan; Geoffrey C Nguyen; Eric I Benchimol

doi:10.1093/jcag/gwaf031

. 2025 Nov 19;8(6):267–287. doi: 10.1093/jcag/gwaf031

Models of outpatient care delivery in inflammatory bowel disease: a scoping review

Noelle Rohatinsky ^1,^✉,², M Ellen Kuenzig ^2,^3,^4,^5,^6,^✉,², James Im ^7,⁸, Melissa Huestis ^9,¹⁰, Tasbeen Akhtar Sheekha ¹¹, Cynthia H Seow ¹², Gilaad G Kaplan ¹³, Geoffrey C Nguyen ^14,^15,¹⁶, Eric I Benchimol ^17,^18,^19,^20,²¹

¹ College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 2Z4, Canada

² SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada

³ Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada

⁴ Department of Paediatrics and Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, N6G 2M1, Canada

⁵ Children’s Health Research Institute, London, Ontario, N6C 2V5, Canada

⁶ ICES, Toronto, Ontario, M4N 3M5, Canada

⁷ SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada

⁸ Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada

⁹ SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada

¹⁰ Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada

¹¹ College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 2Z4, Canada

¹² Departments of Medicine & Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada

¹³ Departments of Medicine & Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada

¹⁴ ICES, Toronto, Ontario, M4N 3M5, Canada

¹⁵ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, M5T 3M6, Canada

¹⁶ Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, M5G 1X5, Canada

¹⁷ SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada

¹⁸ Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada

¹⁹ ICES, Toronto, Ontario, M4N 3M5, Canada

²⁰ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, M5T 3M6, Canada

²¹ Department of Paediatrics, University of Toronto, Toronto, Ontario, M5G 1X8, Canada

^✉

Corresponding authors: Noelle Rohatinsky, PhD, College of Nursing, University of Saskatchewan, 4342 Health Sciences Building, 104 Clinic Place, Saskatoon, Saskatchewan S7N 2Z4, Canada (noelle.rohatinsky@usask.ca) and M. Ellen Kuenzig, PhD, Department of Paediatrics and Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, 1151 Richmond St, London, Ontario N6A 3K7, Canada (ellen.kuenzig@schulich.uwo.ca).

N. Rohatinsky and M.E. Kuenzig are co-first authors.

PMCID: PMC12698233 PMID: 41393992

Abstract

Background

As inflammatory bowel disease (IBD) becomes increasingly common worldwide, optimizing service delivery is critical to ensuring timely access to high-quality IBD care. We conducted a scoping review to understand the extent and type of evidence related to models of outpatient IBD care.

Methods

We searched MEDLINE, EMBASE, CINAHL, and PsycINFO from inception to April 29, 2025 to identify English-language studies describing or evaluating models of care delivery for individuals with IBD in outpatient settings. Eligible peer-reviewed articles included publications of any type (primary studies, reviews, perspectives) focusing on any age group, timepoints in care (eg, transition from pediatric to adult care), and context (eg, remote delivery).

Results

Of the 14,202 records searched, 243 met the inclusion criteria, including 89 studies evaluating models of care, 141 studies describing models of care without formal evaluation, and 13 consensus statements/guidelines. Models discussed included value-based multidisciplinary teams (with either biomedical or biopsychosocial approaches), care provided by nurses and other allied healthcare professionals (HCPs), remote monitoring and healthcare delivery, and rapid access clinics. Models increased patient satisfaction, enhanced collaboration between patients and HCPs, reduced health services utilization (eg, emergency department visits, hospitalizations), and improved patient outcomes (ie, disease activity, mental health, quality of life). Gastroenterologists, IBD nurses, and allied HCPs were consistently identified as key team members.

Conclusions

Innovative outpatient models of IBD care have been proposed and evaluated. These models of care can guide modifications to IBD care globally to help address the rising demand of IBD on healthcare systems, increasing the efficiency of care.

Keywords: care delivery, Crohn’s disease, ulcerative colitis

Graphical abstract

Introduction

Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis, is increasingly common around the world.^1–5 IBD is a chronic ambulatory care-sensitive condition, requiring ongoing interactions with the healthcare system. The introduction of advanced therapies has coincided with reductions in hospitalizations and surgeries,⁶ but healthcare costs continue to rise rapidly.⁷^,⁸ Furthermore, the number of gastroenterologists in Canada has not kept pace with the growth in IBD prevalence.⁹ Therefore, sole provider IBD care may not be realistic or sustainable. Alternative models of care that improve the accessibility, efficiency, and quality of care are needed.

Models of care refer to healthcare design and delivery–providing people with the right care, at the right time, by the right healthcare professional (HCP).¹⁰ Examples of IBD care delivery models include integrated models of care where multidisciplinary care teams (MCTs) provide care to individuals with IBD and medical homes. Integrated models of care are often considered best practice, reducing hospitalizations, surgeries, and direct and indirect healthcare costs.¹¹^,¹² Medical homes originated in primary care and are patient-centred, holistic, and involve MCTs that provide accessible and coordinated care.^13–15

Best practices for the delivery and organization of IBD care, as well as the composition of MCTs (and the role of each HCP within the team) remain unknown.¹¹ We conducted a scoping review to synthesize the literature on models of outpatient IBD care, with the goal of providing HCPs and healthcare organizations with the knowledge required to enhance the accessibility, efficiency, and quality of care delivery while optimizing patient outcomes.

Methods

The scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews¹⁶ and in accordance with a preregistered protocol.¹⁷

Eligibility criteria

Eligible studies included individuals of any age living with IBD and/or HCPs involved in the management of individuals with IBD.

Included studies focused on the overarching concept of models of care delivery, defined as healthcare design and delivery providing care to individuals throughout their condition.¹⁰ Models included integrated models of care, shared care models, collaborative care models, medical homes, skill mix models, care delivery models, models of service delivery, and care coordination models. We did not include papers describing payment methods during service delivery or treatment approaches.

Included studies described or evaluated IBD care provided in outpatient, ambulatory care, and community care settings. We excluded studies describing inpatient care. There were no limitations on gender, sex, ethnicity, or location.

All quantitative, qualitative, mixed methods, systematic reviews, and opinion papers published in English in any year were included. Studies describing or evaluating models of care in multiple chronic diseases were included, provided models of IBD care were described independently. Conference abstracts were excluded. Grey literature was not reviewed.

Search strategy

We searched MEDLINE, Embase, CINAHL, and PsycInfo from inception to April 29, 2025. The search strategy, including terms for IBD and models of care, was reviewed by a librarian using the PRESS guidelines (Table S1).¹⁸

Study selection

Duplicates were removed using Systematic Review Accelerator.¹⁹ Following pilot testing, titles/abstracts and full-texts were screened for eligibility by 2 independent reviewers using InsightScope (https://insightscope.ca/). Disagreements were resolved through discussion or a third independent reviewer.

Data extraction

Data were extracted from included papers using a reviewer-developed tool. Extracted data included specific details about the participants, concept, context, study methods, and key findings.

Analysis and presentation of results

Data are presented in tabular form. Heat maps were created to quantify the evidence evaluating models of care and their outcomes, as well as the involvement of specific HCPs within MCTs. A narrative summary describes how the results relate to the review’s objective.

Results

Our search yielded 14,202 results; 243 publications were included (Figure 1). Studies evaluated the impact of diverse array of models of care, described providers and patient perceptions of care, described various models of care and the roles of specific HCPs within MCTs. Detailed descriptions of all included studies are provided in Table S2. Most studies were from the United States and the United Kingdom (Figure 2A). Included articles were published between 2000 and 2025 (Figure 2B).

Figure 2. — Bar charts describing the (A) country in which studies were conducted and (B) the year in which they were published. When there were fewer than 5 studies from a given country, these were grouped into the “Other” category.

Models of outpatient care delivery

We identified 89 studies evaluating models of care delivery, including MCTs, remoting monitoring systems, remote health healthcare delivery, advice/help lines, rapid access or flare clinics, care led by nurses and other allied HCPs, and models focused on the transition from pediatric to adult care (Figure 3). Study designs were heterogeneous and included randomized controlled trials, studies comparing outcomes before and after intervention (including those using quasiexperimental difference-in-difference methods), prospective and retrospective cohort studies, matched case-control studies, mixed methods studies, qualitative studies (eg, interviews, focus groups), feasibility studies, quality improvement initiatives, and decision analyses (Table S2A and B). Outcomes included health services utilization, costs (direct, indirect, and out-of-pocket), patient-reported outcomes (eg, satisfaction, quality of life), mental health, disease activity (patient-reported, biomarkers), and medication utilization. The remaining studies described models of care without formal evaluation (n = 141) or provided consensus/guidelines on the composition of models of care or the roles of individuals HCPs within the healthcare team (n = 13). To summarize the extent and type of evidence in relation to models of outpatient care delivery, data were categorized into the following headings: approaches to care delivery, outcomes of models of care, components of models of care, roles of HCPs, barriers to models of care, and facilitators of models of care.

Figure 3. — Heat map describing the frequency of studies evaluating models of care and their associated outcomes.

Approaches to model of care delivery

Multidisciplinary, team-based IBD care was repeatedly identified as an approach to provide comprehensive care to individuals with IBD, including both value-based and shared care models (Table 1). These care models are outlined for routine IBD care, with modifications for surgical care, transition from pediatric to adult care, and care during preconception, pregnancy, and postpartum periods. Authors also described models of care emphasizing mental health (described under “Mental Health Professionals”).

Table 1.

Approaches to multidisciplinary models of care for people living with inflammatory bowel disease.

Approach	Features
Value-based care	• Led by gastroenterologists • Aim to meet biopsychosocial healthcare needs²⁰^,⁴⁴^,⁶⁰^,⁶⁶^,^73–75^,⁷⁷^,⁸⁶^,⁸⁷^,⁹²^,⁹⁴^,¹⁰⁵^,^216–218 • Focus on health outcomes rather than payment²⁰^,⁴⁴^,⁶⁰^,⁶⁶^,^73–75^,⁷⁷^,⁸⁶^,⁸⁷^,⁹²^,⁹⁴^,¹⁰⁵^,^216–218 • Care is standardized²⁰^,⁷³^,⁸¹ but includes shared decision-making⁵⁰^,⁶⁶^,⁷³^,⁷⁵^,⁸⁰^,⁸⁶^,⁸⁷^,⁹²^,⁹⁶^,¹⁰⁹^,²¹⁶^,²¹⁷ • Includes remote monitoring and care¹⁴^,⁷³^,⁷⁴^,⁷⁷^,⁸²^,⁸⁵^,⁸⁶^,⁹⁶^,²¹⁶^,²¹⁷ • Early recognition and intervention of changes in patient condition²¹⁹ • Quality of care indicators and clinical outcomes are evaluated¹⁴^,⁷⁷^,⁸²^,⁸⁶^,⁸⁸^,⁹⁴^,⁹⁶^,²²⁰ • Examples include the University of Pittsburgh Medical Center,⁷⁰^,⁷¹^,⁷⁴^,⁸¹ The University of California, Los Angeles,⁵⁵^,⁸¹ Illinois Gastroenterology Group,⁸¹ and 360 IBD care⁸⁹
Shared care	• Gastroenterologists and PCPs are mutually responsible for some aspects of care (eg, recognizing disease flare, therapeutic drug monitoring, adherence, addressing joint pain)²²¹ • Gastroenterologists are solely responsible for prescribing biologic drugs, ensuring patient safety after beginning a new therapy, and addressing abdominal pain²²¹ • Primary care providers are responsible for other sources of pain and non-IBD related illnesses²²¹
Mental health-focused care models	• Mental health professionals (psychologists, psychiatrists, and/or social workers) are key team members^196–200 • Gastroenterologists should assess patient mental health and refer patients to mental health care when needed^196–200 • When mental health professionals are not available, gastroenterologists should be able to provide some mental health care (eg, explain the brain-gut axis and targeted therapies)^196–200
Transition from pediatric to adult care	• Critical in supporting and managing the individualized biopsychosocial needs of young adults^20–30 • Involves collaboration between pediatric and adult HCPs^26–31^,³⁸^,²²² • Often involves nursing support²⁸^,⁹³^,¹⁰⁶^,²²² • Starts as soon as possible²⁶^,²⁸ • Fosters progressive independence²⁶^,³¹^,⁴⁰ • Provides age-appropriate support²⁷^,²⁸^,³⁰^,³¹ • Should occur when patients are in remission²⁷^,³¹ • Transition readiness should be assessed, monitored, and evaluated³⁰^,³⁸^,⁴⁰ • Should address transition and transfer process,³⁰^,⁴⁰ independent healthcare behaviors and self-care,²⁸^,³¹^,³⁶ self-advocacy,³⁶ and education related to IBD and treatments²⁸^,³⁰^,³¹^,³⁸^,⁴⁰; sexual health, contraception, and pregnancy are also important but discussed less often²⁸^,³⁶
Joint medical-surgical IBD clinics	• Streamline care with combined clinic appointments with a gastroenterologist and surgeon⁴² ^, ⁴⁴ ^, ⁴⁵
Perioperative surgical home	• Comprehensive preoperative assessment, education, consultation, and nutritional information⁴³ • Postoperative pain reduction medication, enteral nutrition, single dose antibiotics, urinary catheter removal, early mobilization, and oral feeding⁴³
Preconception, perinatal, and postpartum clinics	• Multidisciplinary care⁴⁷ and counselling at IBD diagnosis and 3-6 months before attempting conception⁴⁸^,⁴⁹ • Often involves nurses⁹³^,¹⁰⁶ • Joint pregnancy clinics, including a gastroenterologist, obstetrician, and IBD nurse, with referrals to other specialists as needed⁴⁹

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Abbreviations: HCP, healthcare professional; IBD, inflammatory bowel disease; PCP, primary care physicians.

Transition care

Multidisciplinary care during the transition from pediatric to adult care was critical to supporting and managing the individualized, biopsychosocial needs of young adults with IBD (Table 1).^20–31 Studies evaluating transition programs used a variety of methods, including comparisons of patient outcomes before and after the introduction of a transition program,³¹^,³² mixed methods designs,²²^,^33–35 surveys,²⁸^,²⁹^,³⁶ a quality improvement initiative,³⁵ a feasibility study,³⁷ and a systematic review.³⁸ Additional studies describing best practices in transition programs included narrative reviews,²⁴^,²⁵ author perspectives,²⁰^,²¹^,²³^,³⁹ and consensus statements.²⁶^,²⁷^,³⁰ Gradual, stepwise transition processes result in greater confidence among young adults in self-managing their IBD²⁰^,³²^,³⁵^,³⁶^,³⁸^,³⁹ and greater quality of life and resiliency.³⁷ However, not all clinics had access to a multidisciplinary transition team²²^,³³ or utilized formal transition guidelines.²⁸^,²⁹^,³³ Barriers to multidisciplinary transition care include lack of utilization of formal guidelines,³³ lack of financial resources and personnel, and other logistical challenges,²²^,³³^,³⁴^,⁴⁰ geographic limitations,³³ low attendance in transition clinics by adult HCPs,²⁹^,³⁴ resistance from young adults or parents,⁴⁰ and young adults deemed not ready for transfer.⁴⁰ Youth without access to transition care were more likely to experience disease relapses or miss appointments.³¹^,³⁴

Surgical care

Joint medical-surgical IBD clinics (Table 1) are convenient for patients requiring medical and surgical care.⁴¹ Articles evaluating these joint clinics included a prospective cohort study,⁴¹ survey,⁴² and retrospective study comparing outcomes before and after the introduction of joint clinics⁴³; authors also provided perspectives on the value of these joint clinics.^44–46 They were positively received by persons with IBD and HCPs,⁴²^,⁴⁴^,⁴⁵ assisting treatment decisions⁴² and reducing patient anxiety,⁴² hospitalizations,⁴⁶ and steroid use.⁴⁶ A study reported reduced postoperative complications and length of stay among people with CD after the introduction of a perioperative surgical home (Table 1).⁴³

Preconception, perinatal, and postpartum care

Evidence related to preconception, perinatal and postpartum care was derived from a quality improvement initiative,⁴⁷ survey,⁴⁸ and consensus statement.⁴⁹ It was recommended that persons with IBD of child-bearing age receive multidisciplinary care⁴⁷ and counselling at diagnosis and 3-6 months prior to attempting to conceive⁴⁸^,⁴⁹ and be seen at multidisciplinary clinic during pregnancy (Table 1).⁴⁹ Barriers to implementing routine preconception care included shortages of providers, knowledge, and resources.⁴⁸

Outcomes of models of care

Articles discussing the outcomes of models of care were heterogenous and included systematic¹² and narrative reviews,^50–53 quasiexperimental⁵⁴ and observational studies (including those comparing outcomes before and after changes in care delivery),^55–61 qualitative⁶² and mixed methods studies,^63–65 a survey,⁶⁶ and author perspectives.⁴⁴^,^67–78 MCTs were the most beneficial way to care for individuals with IBD. Value-based care models increased patient satisfaction,⁴⁴^,^63–65^,⁶⁷ collaboration between patients and HCPs,⁵⁰^,⁶²^,⁶⁵^,⁶⁸^,⁶⁹ medication adherence,⁴⁴^,⁵¹ health outcomes and disease activity,⁵²^,⁵⁴^,⁵⁵^,^69–71 quality of life,¹²^,⁴⁴^,⁵⁴^,⁶⁸^,^70–72 mental health,⁵⁴^,⁶⁸^,⁷⁰^,⁷¹ IBD-related knowledge,⁴⁴^,⁶⁸ and self-management,⁵⁰^,⁵¹^,⁶⁵ while reducing health services utilization (eg, emergency department [ED] visits, hospitalizations) and associated direct, indirect, and out-of-pocket costs (Table 2),¹²^,⁴⁴^,⁵²^,⁵³^,^55–61^,^64–77 length of stay,⁵⁷^,^59–61 and steroid use.⁵⁵^,⁵⁸ Value-based IBD care also improved multidisciplinary collaboration, standardized care delivery, facilitated care transitions, reduced medical errors and unnecessary testing, and improved healthcare quality.⁶⁷^,⁷⁸

Table 2.

Summary of the direct, indirect, and out-of-pocket costs associated with different models of care.

Intervention	Direct (healthcare) costs	Indirect and out-of-pocket costs
Advice/help line	• Studies reported cost savings attributed to reductions in outpatient visits with both GPs and GIs, ED visits, and hospitalizations after accounting for the costs related to administering the advice/help line¹⁵⁹^,¹⁶³^,¹⁶⁴^,²²³ • A systematic review described advice/help lines as cost-effective from the perspectives of both patients and hospitals⁹⁹	No data
Multidisciplinary teams with a general focus	• Studies reported numerical (not significant) reductions in healthcare costs, attributed to reductions in health services utilization (hospitalizations, ED visits), endoscopies, cross-sectional imaging, and disease flares⁵⁵ ^, ⁵⁷	No data
Multidisciplinary teams with a mental health focus	• A study reported in cost savings attributed to reduced ED visits and overall treatment costs, after accounting for the costs of incorporating a psychologist into the multidisciplinary team²²⁴	No data
Nurse-led clinics	• A systematic review highlighted the economic benefit of involving nurses in IBD care²²⁵ • Studies reported cost savings attributed to decreased outpatient visits, ED visits, and hospitalizations; this included conventional care¹⁵⁸^,¹⁶⁸^,²²⁶ and a biologic service²²⁷ • An RCT reported no differences in direct healthcare costs when adding quarterly nurse consultations to conventional care¹⁵⁶	• People with IBD receiving nurse-led follow-up care had a similar number of sick days compared to those with conventional follow-up¹⁵⁷
Open access follow-up	• People with IBD with open access follow-up had reduced investigation and secondary care costs, but higher primary care costs²²⁸ • Overall costs were similar for people with IBD with and without open access follow-up²²⁸	• People with IBD with open access follow-up had reduced patient-borne costs²²⁸
Rapid access or flare clinic	• Costs of assessment at rapid access clinics were lower than those assessed in the ED²²⁹	No data
Remote healthcare visits	No data	• Studies evaluating remote healthcare programs designed for people living in rural/remote regions reported significant reductions in travel time, travel costs, missed work, and/or lost earnings¹³⁵^,¹⁴⁰^,¹⁴⁵ • Studies comparing virtual/telephone visits with in-person appointments (most conducted in the pandemic era), reported that telehealth reduced the time required for appointments (particularly when including time required for travel), with fewer people requiring taking time off work¹³⁴^,¹⁴⁹^,²³⁰
Remote monitoring	• The impact of remote monitoring on direct healthcare costs are mixed, with some studies reporting no differences in IBD-related healthcare costs,²³¹ while others report cost savings due to diverted appointments¹²⁴ • Standard care combined with remote monitoring has higher QALYs at a lower cost than standard care on its own but this is dependent on maintaining patient adherence²³²	• A remote monitoring platform that replaced clinic visits reduced personal costs, including those related to travel and missed work¹¹⁵ ^, ¹²⁹ ^, ¹³⁰

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Abbreviations: ED, emergency department; GI, gastroenterologist; GP, general physician/pediatrician; IBD, inflammatory bowel disease; QALY, quality-adjusted life year; RCT, randomized controlled trial.

Components of models of care

Several elements of optimal care delivery were described within the articles and categorized based on aspects of clinical care including preventative care, proactive disease monitoring, and patient support (Figure 4).¹⁴^,²⁰^,⁴⁴^,⁵⁴^,⁶⁶^,⁷⁵^,⁷⁷^,^79–96 Access to community-based supports through allied HCPs (ie, disease education, mental health, nutrition) were also identified as important.⁵⁸^,⁸³^,⁸⁷^,⁹⁰^,⁹⁴^,⁹⁷

Figure 4. — Hub and spoke diagram highlighting key elements of optimal models of care for people living with inflammatory bowel disease, identified from studies included in the scoping review and categorized into themes based on aspects of clinical care.

Rapid access clinics and advice lines

Author perspectives,⁴⁴^,⁷⁹^,⁸¹^,⁹¹^,⁹⁸ a systematic review,⁹⁹ an organizational audit,⁹⁰ qualitative¹⁰⁰ and quantitative surveys,¹⁰¹^,¹⁰² and observational studies¹⁰³^,¹⁰⁴ described rapid access clinics and advice lines. Rapid access clinics and advice lines enabled quick intervention for disease flares or other disease-related challenges (Table 3).⁴⁴^,⁷⁹^,⁸¹^,⁸⁵^,⁸⁷^,⁹⁰^,⁹¹^,⁹⁹^,^101–103^,^105–107 Individuals with IBD desired more readily accessible IBD nurses and gastroenterologists¹⁰⁰ and were satisfied with the use of advice lines.¹⁰⁴ Suggestions for effective advice lines included using a voice mail and call back system⁹⁸ and documentation of the care and follow-up plans.⁹⁸ As a result, consensus statements recommend rapid access clinics and advice lines been incorporated into models of care.⁸⁵^,⁸⁷^,^105–107

Table 3.

Components of models of care used in the care of people with inflammatory bowel disease.

Component	Features	Benefits	Limitations
Rapid access clinics	• Clinics accessible to patients experiencing an acute disease flare • Often have prespecified criteria for clinic access • Facilitates quick intervention • Often managed by nurses	• Increased disease monitoring²²⁹^,²³³ and medication optimization¹⁰³^,²³³ • Decreased steroid use,¹⁰³^,²²⁹ healthcare costs, health services utilization (ie, hospitalizations, ED visits, outpatient visits), and length of stay¹⁰³^,¹⁰⁴^,¹⁶⁵^,²²⁹^,²³⁴
Advice lines	• Telephone and/or email access to the IBD healthcare team, most often facilitated by nurses • Patients contact advice lines for concerns about their medication,¹⁵⁹^,¹⁶¹^,¹⁶⁴^,¹⁶⁹^,²³⁵ disease-related questions and education,¹⁵⁹^,²²³^,²³⁶^,²³⁷ disease exacerbations,¹⁵⁹^,¹⁶¹^,¹⁶⁴^,¹⁶⁶^,¹⁶⁹^,²³⁵^,²³⁶ psychosocial support,¹⁵⁹ test results,¹⁶¹^,²³⁵^,²³⁶ and administrative support such as scheduling appointments¹⁵⁹^,¹⁶⁴^,¹⁶⁹^,²²³^,²³⁶	• Increased quality of life⁹⁹ and communication with HCPs¹⁰⁴ • Decreased healthcare costs, health services utilization (ie, hospitalizations, ED visits, outpatient visits), and length of stay¹⁰⁴^,¹⁵⁹^,¹⁶³^,¹⁶⁴^,¹⁶⁹^,²²³^,²³⁵
Open access clinics	• Patient-initiated appointments and scheduling⁸²^,¹⁰⁹^,¹⁴⁴^,²²⁸^,²³⁸ • After-hours care⁸²	• Equivalent or better health-related quality of life and psychological outcomes and decreased healthcare utilization^110–112 ^, ²²⁸	• Less structure and predictability¹⁰⁸ • Concerns about being lost to follow-up²²⁸
Remote monitoring systems	• Online reporting through smartphone or web portal applications of symptoms, medication adherence, etc.⁸⁹^,¹¹⁷^,¹¹⁸^,¹²⁰^,¹²⁴^,¹²⁵^,¹²⁸ • Includes system triggers for increased disease activity and individuals in need of routine monitoring (eg, bloodwork, fecal calprotectin)⁸⁹^,¹¹⁷^,¹¹⁸^,¹²⁵^,¹²⁸ • Typically monitored by nurses who collaborate with other members of the healthcare team⁸⁹^,¹¹⁷^,¹¹⁸^,¹²⁵^,¹²⁸ • Used as an adjunct to or in place of in-person appointments⁸⁹^,¹¹⁷^,¹¹⁸^,¹²⁵^,¹²⁸ • Can include an educational component¹²⁰^,¹²⁴	• Improved collaboration, communication, and shared decision making between patients and HCPs,¹¹³^,¹²³^,¹²⁵^,¹³²^,¹³³^,²³⁹^,²⁴⁰ disease monitoring,¹²¹^,¹²⁶^,¹²⁷^,²³⁹ medication adherence,²³⁹^,²⁴⁰ disease self-management,¹²⁰^,¹²⁴^,¹²⁵^,¹²⁷^,¹³²^,²⁴⁰ disease-related knowledge,¹¹⁴^,¹²³ quality of life,¹¹^,¹¹³^,¹¹⁷^,¹¹⁹ health outcomes,¹¹^,¹¹⁸ patient involvement in care,¹¹³^,¹²¹^,¹³² and patient-initiated follow-up¹²⁴ • Decreased time off work and travel costs to attend appointments¹¹⁵^,^128–130 • Greater accessibility to care during a disease flare¹¹⁵^,¹²⁷^,¹²⁸ • Reduced number of outpatient visits,¹¹⁴^,¹²¹^,¹²⁴^,¹³² gastroenterologist visits,¹¹³ telephone consultations,¹³² healthcare costs,¹¹⁹^,¹²²^,¹²⁴ disease activity,¹¹³^,¹¹⁷^,¹¹⁹^,²³¹ and time to care or treatment with remote monitoring¹¹⁵; reduction in these outcomes was not universal^113–115^,¹¹⁷^,¹¹⁸^,¹³¹^,¹³²^,²³¹^,²⁴¹ • Time savings for nurses¹²⁴ • Cost-effective²³²	• Risk of confidentiality or data breaches¹³³ • Inability to perform a physical examination¹³³ • Unrealistic expectations of HCP response times¹³³ • No documentation of structured disease management plans with telephone calls¹²⁸ • Financial costs of integrating telemonitoring²³² • Technical difficulties with platforms¹¹³^,¹²⁴ and compatibility across operating systems¹²⁰ • Lack of motivation and time¹¹³ • Poor symptom recall¹¹³ • Decreasing adherence to remote monitoring over time¹¹⁷^,²³² • Nurses (often responsible for monitoring systems), reported significant time required for system administration¹³²
Remote healthcare	• Telephone or video appointments	• Decreased healthcare costs and hospitalizations¹³⁵^,¹³⁷^,¹⁴⁵^,¹⁵²^,²⁴²^,²⁴³ • Improved or equivalent quality of care and quality of life¹⁴⁰^,¹⁴¹^,¹⁴³^,¹⁵²^,¹⁵⁵ • Increased adherence to treatment¹⁵² • Shorter disease flare duration¹⁵² • Decreased out of pocket costs (ie, travel costs) for patients¹³⁴^,¹⁴³^,²⁴² • More convenient for patients (ie, not having to take time off work to travel)¹³⁴^,¹⁴³^,¹⁴⁵^,¹⁴⁷^,¹⁴⁹ • Some studies reported no impact on patient appointment absenteeism¹⁴⁹^,²³⁰	• Information technology security¹⁵² and privacy concerns¹³⁴^,²⁴² • Internet connection stability¹⁵²^,¹⁵³^,²⁴² • Lack of provider remuneration for virtual appointments¹⁴¹^,¹⁵²^,¹⁵³ • Multiple remote healthcare platforms to choose from¹⁵² • Complexity of platforms²⁴² • Logistics of testing (eg, bloodwork, stool tests),¹⁴⁷ obtaining prescriptions¹⁴⁷ • Concerns about identifying patients most appropriate for virtual care¹³⁷ • Lack of physical exam¹⁴⁷^,¹⁷¹ • Communication challenges¹⁴⁷^,¹⁷¹ • One study reported decreased attendance for telemedicine visits¹³⁹

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Abbreviations: ED, emergency department; HCP, healthcare professional; IBD, inflammatory bowel disease.

Open access clinics

Open access clinics were described in a qualitative study,¹⁰⁸ a cohort study,¹⁰⁹ and systematic reviews.^110–112 Open access clinics with patient-initiated scheduling (Table 3) were an important component of responsive, patient-centred care that increased patient satisfaction,¹¹⁰^,¹¹² giving patients autonomy and confidence to self-manage their condition.¹⁰⁸^,¹⁰⁹^,¹¹¹

Remote monitoring systems

Articles describing remote monitoring systems included randomized controlled trials,^113–116 a single-arm trial¹¹⁷, a quality improvement initiative,¹¹⁸ systematic¹¹⁹^,¹²⁰ and narrative reviews,¹²¹^,¹²² a feasibility study,¹²³ a mixed methods study,¹²⁴ qualitative studies,^125–127 cross-sectional studies and surveys,^128–130 and observational studies (including one that compared outcomes before and after the introduction of remote monitoring systems).¹³¹^,¹³² Two additional articles provided perspectives on the integration of remote monitoring systems.⁸⁹^,¹³³ Remote monitoring systems involve online symptom reporting, in addition to or in place of in-person appointments (Table 3).⁸⁹^,^117–121^,^124–128 Generally, patients and HCPs are satisfied with using remote monitoring,^113–115^,¹¹⁸^,^122–124^,^129–133 found them empowering, and preferred to continue using these systems.¹¹³^,¹³² One study focusing specifically on mental health reported improvements among all participants, but no difference in the degree of improvement among those randomized to intervention and control arms.¹¹⁶

Remote monitoring experiences can be enhanced by providing adequate training to HCPs and patients¹¹³^,¹²⁸^,¹³³ and involving patients in the co-design of applications.¹²⁵ However, individuals who were older, retired, or had hearing loss were less supportive of remote monitoring.¹²⁸ Barriers also include compatibility across operating systems and security concerns.¹²⁰

Remote healthcare

A variety of study designs were used in the articles related to remote healthcare including a randomized controlled trial,¹³⁴ observational,^135–140 mixed methods¹⁴¹ and qualitative studies,^142–144 and surveys.^145–149 Narrative reviews^150–152 and author-reported perspectives^153–155 on remote healthcare delivery also provided evidence on the topic. Remote healthcare is often used to increase access to IBD specialist care,¹⁴²^,¹⁴³ particularly for individuals living in rural and remote areas,^135–137^,¹⁴²^,¹⁴⁵^,¹⁵⁰^,^153–155 and has been increasingly adopted since the COVID-19 pandemic.¹³⁸^,¹³⁹^,¹⁴⁶^,¹⁵¹^,¹⁵⁵ Patients and HCPs are generally satisfied with remote gastroenterology care,¹³⁴^,¹³⁸^,¹⁴⁰^,¹⁴¹^,¹⁴⁴^,^146–150^,¹⁵⁵ preferring a combination of remote and in-person care¹⁴⁷; 1 study noted a preference for in-person care.¹⁴⁶ Patient-HCP communication can be effective and efficient when using remote healthcare.¹⁵¹ However, remote healthcare may be best suited for individuals with stable IBD,¹⁴³^,¹⁵⁰^,¹⁵⁵ who do not require a physical examination,¹⁴³ or when there is an established patient-HCP relationship.¹⁴¹^,¹⁴³

Remote healthcare can be improved by enhancing cybersecurity and ensuring remuneration and equitable access to remote healthcare.¹⁵² Hybrid options, including both virtual and in-person formats, are suggested.¹⁴³ Video appointments are preferred so that there is a visual connection between the patient and HCP.¹³⁸

Roles of HCPs

Many HCPs contributed to the care of individuals with IBD (Figure 5). Gastroenterologists were most often responsible for the coordination of IBD care delivery. Other HCPs most often mentioned were IBD nurses, surgeons, psychologists, dietitians, and social workers. Pharmacists, nurse or administrative coordinators, pediatricians, rheumatologists, enterostomal therapy nurses, radiologists, histopathologists, family physicians, obstetricians, psychiatrists, peers, pain specialists, health coaches, immunologists, research nurses, dermatologists, and ophthalmologists were mentioned less often. Some articles delineated the roles and responsibilities delivered by specific HCPs.

Nurses

Many articles discussed the roles and responsibilities of nurses in models of care delivery including 1 randomized controlled trial,¹⁵⁶ cohort studies,^157–165 surveys,⁶⁶^,^166–169 cross-sectional studies,¹⁷⁰^,¹⁷¹ qualitative studies,¹⁷²^,¹⁷³ an audit,¹⁶⁶ a quality improvement initiative,¹⁷⁴ a cost-effectiveness analysis,¹⁶⁸ and many narrative¹⁵²^,^175–177 integrative,¹⁷⁸ and systematic reviews,¹⁷⁹^,¹⁸⁰ author perspectives,⁴⁴^,⁷⁵^,⁷⁷^,⁹²^,^181–183 and consensus statements.¹⁰⁶^,¹⁰⁷ Nurses—including registered nurses, nurse clinicians, IBD nurse specialists, wound care nurses, and nurse practitioners—were key members of IBD care teams with several roles, including facilitating care, collaborating with patients, and advocating for patients (Table 4).⁴⁴^,⁶⁶^,⁷⁵^,⁷⁷^,⁹²^,¹⁰⁶^,¹⁰⁷^,^156–159^,¹⁶⁶^,¹⁶⁷^,¹⁶⁹^,^172–178^,^181–183 Patients were satisfied with the care nurses provide.¹⁵⁶^,¹⁵⁷^,¹⁶⁰ Nurses had more frequent or increased contact with patients than gastroenterologists when nurses were part of the care team.¹⁵⁷^,^159–161^,¹⁶⁶^,¹⁶⁸^,¹⁷⁰ Nurse-led clinical care and patient monitoring reduced gastroenterologist workloads.⁸⁰^,¹⁵⁸^,^162–165^,¹⁷¹^,¹⁷⁴^,¹⁷⁹^,¹⁸⁰

Table 4.

Description of the roles of allied healthcare professionals involved in models of care, including the benefits of incorporating these individuals into care.

Healthcare professional	Role	Benefits
Nurses	• Knowledgeable about disease pathophysiology, therapies, and management strategies⁹³^,¹⁰⁶^,¹⁷³^,¹⁷⁶^,²⁴⁴ • Build therapeutic relationships with patients¹⁰⁶^,¹⁵⁹^,¹⁶⁸^,¹⁷⁵^,¹⁷⁶^,¹⁸¹^,¹⁸³^,^244–247 • Conduct holistic biopsychosocial assessments⁷⁷^,⁸⁰^,⁹³^,⁹⁴^,¹⁰²^,¹⁰⁶^,¹⁰⁷^,¹⁵⁶^,¹⁵⁸^,¹⁶⁷^,¹⁷⁶^,¹⁷⁸^,¹⁸³^,²⁴⁴^,²⁴⁷ • Monitor test results⁴⁴^,⁹³^,¹⁰²^,¹⁰⁷^,¹⁶⁷^,¹⁶⁸^,¹⁷³^,¹⁷⁶^,¹⁷⁸^,¹⁸³^,²⁴⁸^,²⁴⁹ • Perform diagnostic procedures¹⁸⁰^,²⁴⁹ • Adjust treatment plans in consultation with the patient and gastroenterologist¹⁶⁷^,¹⁷³^,¹⁷⁸^,¹⁸³ • Provide preventive health screening¹⁰⁶^,¹⁶⁶^,¹⁶⁷^,²⁴⁹ • Provided education and resources to patients⁴⁴^,⁶³^,⁸⁰^,⁹³^,⁹⁴^,¹⁰²^,¹⁰⁷^,^158–160^,^166–168^,¹⁷²^,¹⁷³^,¹⁷⁵^,¹⁷⁶^,¹⁷⁸^,¹⁸¹^,¹⁸³^,²⁴⁴^,²⁴⁷^,²⁴⁸^,²⁵⁰^,²⁵¹ • Encourage disease self-management⁶³^,⁶⁴^,¹⁰²^,¹⁰⁷^,¹⁶⁶^,¹⁶⁷^,¹⁷³^,¹⁷⁶^,¹⁷⁸^,²²⁵^,²⁴⁴^,²⁵⁰ • Facilitate medication administration⁹³^,⁹⁴^,¹⁰²^,¹⁶⁷^,¹⁷⁸ and medication management⁸⁰^,⁹³^,¹⁰⁶^,¹⁰⁷^,¹⁵⁶^,^167–169^,¹⁷⁶^,¹⁷⁷^,¹⁸²^,²⁴⁸^,²⁵⁰ • Provide specialized care for individuals with fistulizing disease,⁹³^,¹⁷⁶ wound and ostomy care,⁹³^,¹⁰²^,¹⁷² and assist with managing fecal incontinence⁹³ • Manage email and telephone advice lines⁴⁴^,¹⁰¹^,¹⁰⁶^,¹⁰⁷^,¹⁵⁸^,¹⁵⁹^,¹⁶¹^,^163–167^,^169–171^,¹⁷⁴^,¹⁷⁶^,¹⁷⁷^,¹⁸²^,²²³^,²²⁹^,²³⁴^,²³⁶^,²⁴⁶^,²⁴⁹ • Provide nurse-led clinics⁴⁴^,⁸⁰^,¹⁰⁶^,¹⁰⁷^,¹⁵⁶^,¹⁶⁶^,¹⁷⁴^,¹⁸²^,²⁴⁹^,²⁵²	• Streamlined health service delivery and enhanced patient outcomes and care quality⁸³^,¹⁵⁷^,¹⁵⁸^,¹⁷⁰^,¹⁷³^,¹⁷⁴^,¹⁸¹^,²²³^,²²⁵^,²⁴⁵ • Reduced wait times for medical appointments or interactions with other MCT members, diagnostic procedures, and treatments⁵³^,¹⁰⁶^,¹⁷¹^,¹⁷⁴^,¹⁸¹^,¹⁸²^,²⁴⁶^,²⁴⁸^,²⁵³ • Early identification and treatment of flares⁵³^,¹⁷⁴ • Enhanced monitoring¹⁶¹^,²²⁷ • Improved patient education and informed decision making related to IBD⁶³^,²⁴⁵^,²⁵³ • Decreased inpatient stays¹⁷⁴^,¹⁷⁷ • Reduced appointment no show rates¹⁶⁰ • Nursing assistance with self-management initiatives reduced healthcare costs and health services utilization⁶⁴^,¹⁵⁸^,¹⁶⁸^,²²⁶^,²²⁷^,²⁵⁰^,²⁵⁴ • Higher patient self-efficacy²⁵⁵ • Fewer IBD-related difficulties in the daily lives of people living with IBD and higher HRQoL¹⁷⁷^,²⁵⁵
Pharmacists	• Provide medication-related education^184–186^,^189–191^,^256–261 • Ensure baseline screening tests and vaccinations are completed prior to the individual starting on IBD medications^189–191^,²⁵⁶ • Coordinate and assess therapeutic drug monitoring and optimize IBD-related medications¹⁸⁴^,¹⁸⁵^,¹⁸⁹^,¹⁹¹^,²⁵⁹^,²⁶⁰ • Ensure prescriptions were ordered and renewed¹⁸⁶^,¹⁹⁰^,¹⁹¹ • Perform routine follow-up¹⁹¹^,²⁵⁶ • Assist with medication procurement and approvals for medication coverage¹⁸⁵^,¹⁸⁶^,¹⁸⁹^,¹⁹¹^,²⁵⁶^,²⁶⁰^,²⁶² • Monitor medication adherence¹⁸⁶	• Reduced disease activity,²⁵⁸^,²⁶⁰ steroid use,²⁵⁸^,²⁶⁰ ED visits,²⁵⁹^,²⁶⁰ and drug-related adverse events (eg, development of anti-drug antibodies)²⁶¹ • Improved medication adherence¹⁸⁶^,¹⁸⁹^,²⁵⁹ • Reduced workloads for IBD nurses and gastroenterologists¹⁹⁰ • Faster medication initiation²⁶² • Increased satisfaction with medication-related information²⁶¹
Primary care physicians (PCP)	• Two approaches to incorporating PCPs into IBD care were described¹⁸⁷ ^, ¹⁹⁴ Inclusion of PCP in model of IBD care: PCP provides primary care to individuals without a primary PCP, including health maintenance and screening, evaluation of non-IBD health concerns, facilitation of collaborations between the medical home and external HCPs, and providing follow-up care after hospitalization¹⁹⁴ PCPs were the primary point of contact for any IBD-related concerns¹⁸⁷
Advanced care practitioners	• Complete assessments, provided holistic care and education, advocacy, and screening and access to psychological support¹⁹⁵
Mental health professionals	• Includes psychologists, psychiatrists, and social workers • Assist with screening, assessment, diagnosis, management, and treatment of mental health conditions in individuals with IBD⁵⁴^,⁸⁹^,²⁰⁰^,²²⁴^,²⁶³^,²⁶⁴ • Provide psychological education and coping strategies for mental health symptom management and emotional wellness²⁰⁰^,²²⁴^,²⁶⁴^,²⁶⁵	• Reduced anxiety and depression²⁰⁰^,²²⁴^,²⁶⁴^,²⁶⁶ • Improved quality of life²²⁴^,²⁶⁴^,²⁶⁶ • Increased patient satisfaction²⁶⁴^,²⁶⁷ • Reduced healthcare costs²²⁴^,²⁶⁷ • Individuals with IBD who participated in routine psychological care were more willing to seek out mental health supports again²⁶⁴
Dietitians	• Named as an important allied HCP in IBD models of care, despite limited evidence about their specific role	• More frequent interactions with a dietitian resulted in had higher adherence to EEN and lower disease activity²⁰¹

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Abbreviations: ED, emergency department; EEN, exclusive enteral nutrition; HCP, healthcare professional; IBD, inflammatory bowel disease; MCT, multidisciplinary care team; PCP, primary care physician; HRQoL, quality of life.

Pharmacists

Although not all MCTs included pharmacists,¹⁸⁴ pharmacists were identified as key members of IBD MCTs (Table 4). Articles discussing the roles and responsibilities of pharmacists included cohort studies,¹⁸⁵^,¹⁸⁶ a survey,¹⁸⁷ focus groups,¹⁸⁸ a narrative review,¹⁸⁹ and author perspectives.¹⁸⁴^,¹⁹⁰ Pharmacists collaborated with MCT members about medication, monitoring results, or changes in patient condition.¹⁸⁵^,¹⁸⁶^,^189–191 Community pharmacists not associated with an IBD MCT were perceived by persons with IBD as less knowledgeable about IBD and relationships were seen as transactional.¹⁸⁷^,¹⁸⁸ Pharmacist involvement in IBD care teams has been recommended in a consensus statement.¹⁹¹

Primary care physicians

Articles highlighting the roles and responsibilities of primary care physicians (PCPs) included a mixed methods study,¹⁸⁷ cohort study,¹⁹² and cross-sectional survey¹⁹³; 1 article provided the perspective of study authors¹⁹⁴ and a consensus document outlined the contributions of primary care in IBD.⁸⁷ Two roles for PCPs in the care of people with IBD were described (Table 4).¹⁸⁷^,¹⁹⁴ PCPs were either integrated into the model of care to assist with care coordination¹⁹⁴ or were first point of contact for IBD-related concerns.¹⁸⁷ Gastroenterologists should provide advice to PCPs to facilitate care pathways.⁸⁷ Parents of children with IBD reported greater access to allied health services when parents perceived their child’s main IBD care professional to be their PCP, rather than gastroenterologists.¹⁹² However, PCPs identified challenges when communicating and coordinating logistics with IBD specialists.¹⁹³

Advanced practice providers

One article provided a perspective of the role of advanced practice providers in IBD care model (Table 4).¹⁹⁵

Mental health professionals

Psychologists, psychiatrists, and social workers were perceived to be integral members of the IBD MCT (Table 4) but were not always members of MCTs or able to see every person with IBD.¹⁹⁶ Gastroenterologists in centres without mental health professionals played an important role in the assessment and treatment of mental health concerns among their patients. Responsibilities included assessing patients’ mental health,¹⁹⁶ explaining the basis for disorders of gut-brain interaction to patients,¹⁹⁶ understanding available gut-brain therapies,¹⁹⁶ referring to mental health professionals when needed,¹⁹⁶^,¹⁹⁷ and having high-level knowledge of prescription psychiatric medications to complement behavioural therapies.¹⁹⁶ Barriers identified from cross-sectional studies/surveys and a cohort study included a limited availability of mental health professionals with expertise in IBD,¹⁹⁸^,¹⁹⁹ lack of insurance coverage or financial costs for accessing these HCPs¹⁹⁸^,²⁰⁰ and hesitation from patients to see these HCPs.¹⁹⁸

Dietitians

Data on the role of dietitians in IBD care were limited. One cohort study reported higher adherence to exclusive enteral nutrition (EEN) and lower disease activity with enhanced dietitian support during EEN therapy in people with CD.²⁰¹

Barriers to models of care

Articles describing barriers to models of care included of qualitative studies,⁶²^,⁸³^,¹⁰⁸^,¹⁴⁴^,²⁰² surveys,¹⁹³^,²⁰³ and a narrative review.¹¹ Lack of communication and coordination between gastroenterologists and PCPs were barriers to effective care.⁸³^,¹⁹³^,²⁰² People with IBD viewed traditional systems of scheduled, prefixed appointments as rigid, inconvenient, and not responsive to their needs.¹⁰⁸^,¹⁴⁴ Lack of remuneration for MCTs was also identified as a barrier.⁶² Patient satisfaction with the model of care being delivered was facilitated by timely access to advice lines, coordination between medical and surgical services, and adequate information being provided to patients.²⁰³ Individuals with IBD wanted increased access to dietitians and mental health professionals, but there were cost barriers in accessing these services when not readily integrated into the model of care.¹¹

Facilitators of models of care

Suggestions for enhancing models of care delivery were outlined in several studies, including surveys,⁹⁴^,²⁰³ qualitative studies,⁹⁷^,¹⁰⁰^,¹⁷²^,²⁰² and observational studies,¹⁹⁷^,²⁰⁴ as well as a consensus statement⁸⁷ and author perspectives.⁴⁶^,⁸⁹ These recommendations included providing care as closely as possible to the patient’s home,⁴⁶ streamlined communication between HCPs,²⁰² direct lines of communication between HCPs and patients or parents,²⁰²^,²⁰³ guidance for patients as to the roles and responsibilities of different HCPs,²⁰² and which HCP to contact for a specific purpose.²⁰² Individuals with IBD desired for greater coordination of care between and within IBD care facilities and services¹⁰⁰ and a dedicated immune-mediated inflammatory disease clinic improved care efficiency for those with multiple conditions (in addition to their IBD).²⁰⁴ Greater access to mental health and dietitian care was recommended to enhance care delivery.⁸⁷^,⁸⁹^,⁹⁴^,⁹⁷^,¹⁰⁰^,¹⁷²^,¹⁹⁷

Discussion

This scoping review focused on understanding the extent and type of evidence in relation to models of outpatient care delivery for individuals living with IBD. Articles addressed specific models of care, components and outcomes of models of care, and the HCPs involved. Value-based models, involving MCTs, were discussed in most articles (specifically or in some capacity) and were often suggested to be the ideal model of care. These teams were led by gastroenterologists and address the comprehensive biopsychosocial needs of individuals with IBD, resulting in positive health outcomes, decreased healthcare utilization and costs, and increased quality of life. Some authors provided suggestions on the organization and components of comprehensive value-based models of care. However, the logistics of fulsomely operationalizing this type of model were less developed.

With the growth of IBD prevalence¹^,² outpacing the number of gastroenterologists⁹ and decreased specialist access among people living in rural and remote areas,^205–207 creative solutions are needed to provide optimal care. Advances in technology and increased use of remote healthcare²⁰⁸ are addressing these gaps, but implementation barriers need to be addressed. Allied HCPs should be accessible remotely. Inclusion of nurse-led rapid access clinics and advice lines facilitate access to care, enhancing patient outcomes and decreasing healthcare utilization.

Healthcare institutions often lack the human, financial, and infrastructure resources to operationalize the multidisciplinary value-based model, despite the ultimate cost savings and positive outcomes. HCPs and IBD advocacy organizations should continue to harness their collective expertise to improve system-level care delivery, including funding for allied HCPs, ensuring universal availability of these professionals to all IBD patients without cost or other accessibility barriers which results in more personalized and cost-efficient care.⁸^,²⁰⁹ Standardizing care models and clinical care pathways can optimize IBD care delivery, while improving quality and cost-efficiency of care, ensuring care is sustainable.²¹⁰

Many articles discussed the roles and contributions of specific HCPs, offering suggestions for these individuals to embrace their full scope of practice to provide the best outcomes to persons living with IBD and maximize care efficiency. In addition, the involvement of multiple HCPs within a model of care improves efficiency. For example, pharmacists are knowledgeable about the IBD armamentarium and can support gastroenterologists and nurses with patient decision making, monitoring, and pretreatment screening and vaccinations.¹⁸⁹^,¹⁹¹

While evidence around dietary therapies for IBD remains inconclusive, persons with IBD who make dietary modifications to manage their symptoms should be supported from IBD-specialist dietitians, though information on their exact roles and responsibilities remains limited.^211–213 Dietitians also play key roles in nutritional assessment and support, particularly during disease flares, in the presence of disease complications, EEN treatment, and after surgery.

There is a growing interest in and evidence integrating psychosocial HCPs in MCTs as the bidirectional relationship between mental health and IBD is increasingly understood.²¹⁴ However, poor availability of mental health professionals, limited insurance or out-of-pocket costs, and a hesitancy by persons with IBD to see these psychosocial providers due to stigma surrounding mental health disorders remain barriers for fully integrated mental health care.¹⁹⁸^,²¹⁴^,²¹⁵

Limitations

We restricted our search to studies published in English, potentially excluding studies published in other languages describing innovative models of IBD care in non-English-speaking countries. Further, most articles in this review originated from tertiary or quaternary academic centres in high-income countries; the experiences and contexts from low- and middle-income countries and community gastroenterologists are not accounted for. Our findings may lack generalizability to countries with different healthcare systems and remuneration practices. Due to the volume of articles within the scoping review, data from each article were extracted by a single reviewer, but a subset of extracted studies were double checked to confirm accuracy and consistency. The wide breadth of the scoping review question and inclusion criteria yielded many heterogeneous articles. The literature searched was limited to peer-reviewed articles; information from the grey literature may have been missed. Finally, there is no rating of the quality of evidence in a scoping review according to the JBI framework, and therefore studies of lower methodological quality may have been considered alongside those of high quality.

Implications for practice and future research

Within the Canadian healthcare context, access to multidisciplinary teams and collaborative care approaches are not universal. While full uptake of a comprehensive value-based model of care may not be feasible in all geographic locations, integrating key components (eg, rapid access clinics, advice lines, remote monitoring, and remote healthcare) or integrating allied HCPs could enhance IBD care delivery.

Our review identified several knowledge gaps that should be addressed through ongoing research. The feasibility and cost-effectiveness of integrating models of care in resource-limited settings and in community gastroenterology practices should be examined further. Models of care in equity deserving groups and the potential outcomes, barriers and facilitators to care should also be explored. The role and impact of primary HCPs in outpatient IBD care are limited and warrant further research. Some barriers to models of care delivery were described in the literature, but drawbacks or negative outcomes of using certain models of care were not identified. Lastly, describing the current IBD care landscape in Canada, including identifying any gaps in care and associated outcomes could be helpful to highlight areas for improvement.

Conclusions

Several IBD care models have been proposed; the value-based model of care focused on meeting the biopsychosocial needs of people living with IBD was the most comprehensive. Gastroenterologists and IBD nurses were the primary HCPs. Allied HCPs play critical roles, reducing workload for gastroenterologists and nurses, improving patient care and quality of life, decreasing disease activity and healthcare costs. Combining in-person and remote healthcare appointments and monitoring can increase access to care and facilitate a sustainable healthcare system that meets the individual needs of persons living with IBD. Implementation of these comprehensive models of care into IBD clinical practice is essential in managing the growing number of people living with IBD.

Supplementary Material

gwaf031_Supplementary_Data

gwaf031_supplementary_data.zip^{(1.1MB, zip)}

Contributor Information

Noelle Rohatinsky, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 2Z4, Canada.

M Ellen Kuenzig, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada; Department of Paediatrics and Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, N6G 2M1, Canada; Children’s Health Research Institute, London, Ontario, N6C 2V5, Canada; ICES, Toronto, Ontario, M4N 3M5, Canada.

James Im, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.

Melissa Huestis, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.

Tasbeen Akhtar Sheekha, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, S7N 2Z4, Canada.

Cynthia H Seow, Departments of Medicine & Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada.

Gilaad G Kaplan, Departments of Medicine & Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada.

Geoffrey C Nguyen, ICES, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, M5T 3M6, Canada; Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, M5G 1X5, Canada.

Eric I Benchimol, SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, M5G 1X8, Canada; Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada; ICES, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, M5T 3M6, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, M5G 1X8, Canada.

Author contributions

N.R. contributed to the design of the work, co-generated the scoping review protocol, screened references, extracted data, assisted with article conflict resolution, analyzed data, interpreted results, and co-drafted the manuscript, and approved the final manuscript version to be published. M.E.K. contributed to the conception and design of the work, co-generated the scoping review protocol, screened references, extracted data, assisted with article conflict resolution, analyzed data, interpreted results, co-drafted the manuscript including data presentation, and approved the final manuscript version to be published. J.I. screened references, extracted data, critically reviewed and edited the manuscript for important intellectual content, and approved the final manuscript version to be published. M.H. extracted data, analyzed data, interpreted results, critically reviewed and edited the manuscript for important intellectual content, and approved the final manuscript version to be published. T.A.S. screened references, extracted data, analyzed data, interpreted results, critically reviewed and edited the manuscript for important intellectual content, and approved the final manuscript version to be published. C.H.S., G.G.K., and G.C.N. critically reviewed and edited the manuscript for important intellectual content and approved the final manuscript version to be published. E.I.B. contributed to the conception of the work, assisted with article conflict resolution, critically reviewed and edited the manuscript for important intellectual content, and approved the final manuscript version to be published.

Supplementary material

Supplementary material is available at Journal of the Canadian Association of Gastroenterology online.

Funding

No funding has been provided for this scoping review.

Conflicts of interest

Conflict of interest disclosure forms (ICMJE) have been collected for all co-authors and can be accessed as supplementary material.

Data availability

The data underlying this article are available in the article and in its online supplementary material.

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Associated Data

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Supplementary Materials

gwaf031_Supplementary_Data

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Data Availability Statement

The data underlying this article are available in the article and in its online supplementary material.

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PERMALINK

Models of outpatient care delivery in inflammatory bowel disease: a scoping review

Noelle Rohatinsky, PhD

M Ellen Kuenzig, PhD

James Im, MPH

Melissa Huestis, MSc, MPH

Tasbeen Akhtar Sheekha, MPH

Cynthia H Seow, MBBS (Hons), MSc

Gilaad G Kaplan, MD, MPH

Geoffrey C Nguyen, MD, PhD

Eric I Benchimol, MD, PhD

Abstract

Background

Methods

Results

Conclusions

Graphical abstract

Graphical Abstract.

Introduction

Methods

Eligibility criteria

Search strategy

Study selection

Data extraction

Analysis and presentation of results

Results

Figure 1.

Figure 2.

Models of outpatient care delivery

Figure 3.

Approaches to model of care delivery

Table 1.

Transition care

Surgical care

Preconception, perinatal, and postpartum care

Outcomes of models of care

Table 2.

Components of models of care

Figure 4.

Rapid access clinics and advice lines

Table 3.

Open access clinics

Remote monitoring systems

Remote healthcare

Roles of HCPs

Figure 5.

Nurses

Table 4.

Pharmacists

Primary care physicians

Advanced practice providers

Mental health professionals

Dietitians

Barriers to models of care

Facilitators of models of care

Discussion

Limitations

Implications for practice and future research

Conclusions

Supplementary Material

Contributor Information

Author contributions

Supplementary material

Funding

Conflicts of interest

Data availability

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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