Standards of care in geriatric practice

We propose a set of standards to aid the physician in the care of older patients. These standards are based on the practical experiences of our own group and of others with years of clinical practice in geriatric medicine. The standards also reflect the guidelines, position papers, and deliberations of various organizations concerned with the care of older people. This article does not discuss specific illnesses or the common geriatric syndromes. The proposed standards cover comprehensive care and assessment, especially of vulnerable elders and prevention of disease and disability. We also propose standards for facilitation of care across the health service continuum, care of the nursing home resident, and palliative and hospice care.

A framework for gauging the comprehensiveness of governmental HIV prevention programs

This article presents a brief, logical framework that can be used in conducting a review of the comprehensiveness of any governmental human immunodeficiency virus (HIV) prevention program at the local, state, or national level. The framework, presented as a checklist of questions, could be used by external evaluators of an HIV prevention program, used internally for continuous quality improvement, or a combination of the two. The checklist can be used to select components of HIV prevention programs in need of particular, critical improvements.

An evaluation of the evidence base related to critical care outreach teams--2 years on from Comprehensive Critical Care

It is now 2 years since the publication of Department of Health [Comprehensive Critical Care: A Review of Adult Critical Care Services (2000a)] document 'Comprehensive Critical Care'. One of its' main recommendations was the introduction of critical care outreach services. Many hospitals have since established such services and are providing education for ward nurses and house officers, and follow-up for patients discharged from intensive care when they return to a general ward. Early Warning Scoring (EWS) systems have also been introduced onto the wards to improve the identification of patients deteriorating into critical illness. However, as yet there appears to be little evidence that this investment has been worthwhile in terms of improving patient outcomes, such as reduction in cardiac arrests on the wards, reduction in unplanned admissions to critical care or earlier referrals to critical care. With many outreach teams hoping to expand their services in the future there is a pressing need to demonstrate an impact. We must remember however that some outreach teams have only been in post for 12 months and so it may therefore be far too early to reliably demonstrate any effect.

The practice of nurse-midwifery in the era of managed care: reports from the field

OBJECTIVE

The purpose of this paper is to describe the reports of certified nurse-midwives (CNMs) about how changes in the financing and organization of health care in the late 1990s influenced their ability to serve vulnerable populations and provide a woman-centered, prevention-oriented midwifery model of care.

METHODS

A 13-page survey was mailed to all CNMs ever certified by the American College of Nurse-Midwives (N = 6365) in July 1998. The survey included closed- and open-ended questions. A total of 2405 CNMs responded: of these, 2089 were in clinical practice during the study period (1997-98) and 82% of the 2089 (N = 1704) wrote responses to the open-ended questions and were included in the qualitative database. We present responses to the closed-ended questions about seven domains of practice and elaborate on three major themes identified through content analysis of the qualitative data.

RESULTS

The majority (57%) reported that the changes in the larger health care environment had influenced their practices during 1997-98. The effects most frequently reported were 1) increased client loads (31%); 2) altered style of practice (30%): 3) inability to serve the same populations; (20%); 4) decreased client loads (20%); and 5) increased administrative duties (17%). Three major themes were identified and elaborated upon in the qualitative data: 1) challenges to the style of midwifery practice related to the managed care environment; 2) the loss of socially and economically at-risk women from CNMs' client base; and 3) barriers to high quality and comprehensive services for women.

CONCLUSIONS

During the late 1990s as managed care was expanding and health systems were merging, a significant number of CNMs in the field described threats to their ability to sustain economically viable practices and a style of care consistent with the woman-centered, prevention-oriented midwifery model.

Haemophilia care in the developing world: benchmarking for excellence

Seventy-five percent of patients with haemophilia receive no or inadequate treatment, and often do not survive to adulthood. With efficient organization, the disorder is treatable and becomes part of normal life. In developing countries there is a large discrepancy in haemophilia care. Some have zero treatment levels, while others already have comprehensive care centres. This paper attempts to assess and standardize the levels of haemophilia care for developing countries, setting up benchmarks or guidelines for future development. Four major areas are emphasized: clinical care, laboratory, blood products and patient organization. For each country or community, development work begins after the assessment of competency level in each area. The next step is then to plan, organize, improve and move up to the next level. To become successful, a sound and realistic strategy should be employed, starting from the identification of key leaders and the recruitment of an expert team. To obtain recognition and support from health authorities, the haemophilia care programme should not limit itself to haemophilia care but should also include medical care for all bleeding disorders, including the improvement of blood banks, blood products, coagulation laboratories and other medical facilities. This would directly improve the overall medical care standard of the whole hospital. It is also important to emphasize the need for selfreliance, employing simple yet effective methodology, equipment and mechanical facilities. The effective coordination of World Federation of Hemophilia assistance and the host country's committed action will ensure success in the emerging trend of better haemophilia care in developing countries.

Current health care system policy for vulnerability reduction in the United States of America: a personal perspective

AIM

To raise questions about how the United States of America, which spends 1.3 trillion dollars on health care, conducts cutting-edge biomedical research, has the most advanced medical technology, and trains a cadre of highly competent health professionals cares for the most vulnerable members of its population.

METHODS

Relevant statistical data were extrapolated from the most current statistical sources and research reports, and assessed in terms of existing practices and policies.

RESULTS

The data clearly demonstrated that particular population cohorts -- the elderly, the poor, new immigrants, the homeless, the HIV-positive, and substance abusers -- were especially vulnerable to illness and its consequences.

CONCLUSION

Since American medicine, despite all of its science, technology, and clinical competence, operates in a non-system, there is currently no efficacious approach to vulnerability reduction. To turn health care in the U.S. into a high quality, comprehensive, and cost-effective system, government officials, health care planners, and medical practitioners must address a series of fundamental social, economic, and political issues. What other countries, like those in South Eastern Europe, can learn from this is not to duplicate these mistakes.

Health care consumption among elderly patients in california: a comprehensive 10-year evaluation of trends in hospitalization rates and charges

PURPOSE

This report examines health care rates, charges, and patterns of consumption from a comprehensive California hospitalization data set covering 1986-1995. An improved understanding of current trends in health care consumption would facilitate the development of future resource allocation models.

DESIGN AND METHODS

We obtained discharge and charge data from all licensed nonfederal hospitals in California between 1986 and 1995 relating to inpatient discharges of individuals aged 55 years and older. We used the direct method of standardization to adjust discharge statistics for differing age and gender case mixes, and we adjusted all charges to 1990 dollars for cost comparisons.

RESULTS

Standardized to the 1990 population, annual discharge rates declined between 1986 and 1992, then leveled off to about 227 per 1,000 between 1993 and 1995. Rates of both discharges and charges for men consistently exceeded those for women, there being about a 5-year lag between female and male rates of discharge. The insurance payer mix shifted between 1986 and 1995, with dramatic declines in private insurance mirrored by increases in managed care.

IMPLICATIONS

Hospital care consumption among the elderly people in California demonstrates a trend of increasing adjusted total charges despite declining hospitalization rates. Overall, individuals aged 55 years and older comprise 18% of the California population and incur 52% of discounted total charges. Private insurance has virtually disappeared, replaced by HMO/PHP/PPO organizations; still, charges to governmental sources (primarily Medicare and Medi-Cal) account for about 78% of total billings. Absolute numbers of Californians aged 55 and older are projected to increase 54% by 2010 and 226% by 2025 compared with 1995, engendering a dramatic increase in the financial burden of health care to this segment of the population.

Long-term increase in quality of nursing documentation: effects of a comprehensive intervention

This study aimed to evaluate the longitudinal effects of a nursing-documentation intervention on the quantity and quality of the nursing documentation in a sample of patient records at a university hospital in Stockholm, Sweden. In this quasi-experimental longitudinal study, two hospital wards participated in a 2-year intervention and a third ward was used for comparison. The intervention consisted of organizational changes and education regarding nursing documentation in accordance with the VIPS model, a model designed to structure nursing documentation. To evaluate the effect, patient records were audited at three different time points: before the intervention, directly after the intervention and 3 years after the intervention. A total of 269 patient records were used. The findings showed a significant score increase in quantity as well as in quality of the nursing documentation, in the intervention wards directly after the intervention, as compared with those from the comparison ward. The results suggests that a comprehensive intervention based on the VIPS model and including organizational support for registered nurses (RN) may improve nursing documentation in an acute care hospital setting.

Delivering HIV services to vulnerable populations: a review of CARE Act-funded research

This article summarizes key findings from evaluation and research studies that have received financial support from the HIV/AIDS Bureau of the Health Resources and Services Administration or from Ryan White Comprehensive AIDS Resources Emergency (CARE) Act grantees. These studies suggest that the CARE Act has improved but not equalized service accessibility, quality, and outcomes for different populations living with HIV disease. Evaluations of access to highly active antiretroviral therapy (HAART) found that uninsured patients, women, people of color, and injection drug users waited much longer than others to receive the new therapies. These disparities were not uniform across study sites, suggesting that clinic characteristics and geographic location have a major influence on prescribing patterns. Once patients gained access to HAART, health insurance status made little difference in clinical outcomes.

An evaluation of a Medicaid managed maternity program: the impact of comprehensive care coordination on utilization and pregnancy outcome

The purpose of this study is to evaluate the effectiveness of the implementation of a Medicaid managed maternity care program in a public health department service population, analyzing race-specific models of WIC participation and risk of small-for-gestational age of term. There were 13,095 singleton deliveries during the period 1987-1990 to women with prenatal care in this managed maternity care program. The research design entailed comparison of the intervention group (those receiving regular prenatal care plus comprehensive care coordination in 1989-90) with an historical comparison group of women who received only regular prenatal care in the two years (1987-88).

"Transcend": initial outcomes from a posttraumatic stress disorder/substance abuse treatment program

This paper describes the development of a comprehensive treatment program for combat veterans diagnosed with posttraumatic stress disorder (PTSD) and substance abuse (SA). Outcome data are presented on 46 male patients who completed treatment between 1996 and 1998. The treatment approach, defined by a detailed manual, integrates elements of cognitive-behavioral skills training, constructivist theory approaches, SA relapse prevention strategies, and peer social support into a group-focused program. The Clinician-Administered PTSD Scale (CAPS) and the Addiction Severity Index (ASI) were used to assess treatment effectiveness at discharge and 6- and 12-month follow-up. Significant symptom changes revealed on CAPS and ASI scores at discharge and follow-up are analyzed. Discussion focuses on hypotheses regarding treatment effectiveness, study limitations, and suggestions for further research.

Changing systems in health and social care for older people in Japan: observations and implications for interprofessional working

The impact of a rapidly ageing population on the development of insurance policies and health and social care services of older people is a major concern in Japan. The discussion in this paper draws on information gained from recent visits to leaders of these services in Japan. The paper briefly reviews the policy and demographic background to recent legislative changes in the long-term care insurance system, models of care management and assessment and outstanding challenges for health and social care professionals. Some key issues have emerged with implications for interprofessional working, such as the lack of integrated care systems, contradictions within the scope and responsibilities of care management, and the absence of quality and ethical frameworks to safeguard the interests of the service user and carer.

Survey of pediatrician practices in retrieving statewide authorized newborn screening results

OBJECTIVE

Mandated state newborn screening programs for the approximately 4 million infants born each year in the United States involves the following 5 components: 1) initial screening, 2) immediate follow-up testing of the screen-positive newborn, 3) diagnosis confirmation (true positive versus false positive), 4) immediate and long-term care, and 5) evaluation of all of the components of the system, including process and outcomes measures. Smooth functioning of this system requires pretest education of the parents as well as education and involvement of all health care providers who interact with the newborn screening system. Although extensive literature is available concerning public health aspects, technical standards/protocols, and discussion of the interfaces among the 5 components of the system, little information is available regarding physician awareness, involvement, and interactions with the system. The objective of this study was to determine, through a survey, primary care pediatricians' satisfaction with their state's newborn screening program. This was reflected in survey questions that asked how pediatricians were notified of the results of newborn screening tests that were performed on infants in their practice.

METHODS

Two thousand questionnaires were sent to primary care pediatricians in all 50 states and the District of Columbia regarding their practices in retrieving statewide newborn screening results. Of the 2000 surveys, 574 (29%) responses from primary care pediatricians who care for at least 1 to 5 newborns each week form the basis of this report. Also reported are the commentaries of the physicians concerning their specific practices, overall assessment of the system, and ideas for improvement.

RESULTS

Physicians reported their general satisfaction with the newborn screening system's ability to retrieve screen-positive infants for follow-up testing. However, communication and partnership with the primary care pediatrician regarding accessibility and timely retrieval of newborn screening test results was deemed less than optimal. Thirty-one percent of respondents indicated that notification for screen-positive test results was greater than 10 days, whereas 26% indicated that they do not receive the results of screen-negative tests and need to develop office procedures (contact birth hospital or state laboratory) to obtain results. Twenty-eight percent indicated that they do not actively seek results of newborn screening for their patients and presume that "no news is good news." Barriers to retrieving test results included that infants were born at hospitals where the physician does not have privileges, there were new transfers to the practice, infants were born in other states, personnel time was needed to track results, and there was a lack of a cohesive communication/reporting system that includes the primary care physician as an integral partner in the newborn screening communication process. Ninety-two percent of physicians would welcome an enhanced state system with direct communication to the primary care pediatrician as well as the birth hospital.

CONCLUSION

Pediatricians recognize and endorse the benefits of newborn screening and believe that they play an important role in the efficient functioning of the system. An enhanced physician partnership with the newborn screening program will enable the timely follow-up of the screen-positive newborn for confirmatory testing. All test results need to be communicated to the pediatrician in a timely and efficient manner: 7 days for screen-positive results and 10 to 14 days for all results. Newborn screening test results of new patients who enter the practice should be available at the time of the first well-infant visit, ideally by 2 weeks of age. The majority of primary care pediatricians acknowledge the need to establish office protocols for the retrieval of newborn screening test results and would welcome an enhanced direct communication system with the state newborn screening program.

The prenatal visit

In their role as advocates for children and families, pediatricians are in an excellent position to support and guide parents during the prenatal period. Prenatal visits allow the pediatrician to gather basic information from parents, provide information and advice to them, and identify high-risk situations in which parents may need to be referred to appropriate resources for help. In addition, prenatal visits are the first step in establishing a relationship between the pediatrician and parents and help parents develop parenting skills. The prenatal visit may take several possible forms depending on the experience and preferences of the parents, competence and availability of the pediatrician, and provisions of the health care plan.

Personal doctoring. Its impact on continuity of care as measured by the comprehensiveness of care score

OBJECTIVE

To determine the impact of personal provider continuity on continuity of care as measured by the comprehensiveness of care score.

DESIGN

Retrospective cross sectional analysis of medical records.

SETTING

The setting was a four doctor practice on the New South Wales Central Coast of Australia.

METHOD

The subjects were 131 male and 123 female patients with a mean age of 42.7 years (SD 25.9) median age of 42 years and an age range of 1-95 years. The main outcome measures were a comprehensiveness score for each patient in the personal provider continuity and discontinuity of care group over a two year period.

RESULTS

The overall comprehensiveness scores in the personal provider continuity group was 7.38 (95% CI: 7.04-7.71) compared to 6.03 (95% CI: 5.7-6.35) for those in the discontinuity group (p < 0.000). A linear regression model revealed that 15.8% of the total variance of the comprehensiveness score is explained by the two independent variables 'modified continuity index' (13.6%) and 'age' (2.2%). Nonrelated independent variables are gender, number of visits and number of years attending the practice.

CONCLUSION

Personal doctoring significantly improves continuity of care as measured by the comprehensiveness of care score, and this observation is essentially age independent. These findings clearly suggest that patients should be encouraged to find and stay with one doctor, and that practices should develop systems to enable patients access to their usual provider. Both strategies, combined with the awareness of potential gaps in our service provision, will increase the likelihood of achieving increased continuity of care.

Maintaining quality of care in a comprehensive dual diagnosis treatment program

This paper describes how a large, multifaceted dual diagnosis treatment program has attempted to preserve its mission through termination of or changes in the nature of resident research projects. Research reports, because of their focus on specific treatment components, often fail to capture the essence of the larger treatment contexts from which they emanate. Although host programs derive benefits from research projects, enhancements are often temporary and difficult to sustain. Programs are thus challenged to respond to resource losses creatively. The author discusses adaptations to losses in the areas of case management, behavioral skills training, an incentive system, money management, and continuity of care.

Comprehensive versus holistic care. Case studies of chronic disease

Persons with chronic disease often experience an involvement of multiple body systems. A comprehensive care approach to patient care is often used with the belief that a health care team will ensure that a patient's needs will be covered. Instead, this approach is reductionist in practice and leads to fragmentation of care, and the difficult patients often slip through the cracks of the health care system. However, a holistic theory-based approach puts a patient's perceived needs first and offers care not only for the body but also for the human spirit. Two case studies of patients with chronic disease are reviewed, both of whom began in a comprehensive care model and ended up with holistic care. Suggestions for assisting in the movement of a comprehensive care model toward a holistic model are offered for the practicing nurse.

New opportunities, new approaches: serving children with special health care needs under SCHIP

OBJECTIVE

To identify models for caring for children with special health care needs (CSHCN) under the State Children's Health insurance Program (SCHIP) and to analyze the strengths and weaknesses of each.

DATA SOURCE

Site visits in five study States conducted in late 1999.

STUDY DESIGN

Approximately 12 to 15 interviews were conducted in each site with state and local-level policymakers, program administrators, providers, and families.

DATA COLLECTION

Standard protocols were used across sites to explore a range of key policy variables including eligibility, enrollment , identification, and referral of CSHCN; benefits; service delivery systems; payment mechanisms; and quality assurance and monitoring strategies. PRINCIPAL FINDINGS. Each of the study States' approaches to serving CSHCN represents one of four models: a mainstream approach , a wrap-around model, a service carve out , or a specialized system of care. Special provisions designed to enhance the coverage and accessibility of services beyond those extended to children generally can help to ensure that CSHCN enrolled in SCHIP receive comprehensive, coordinated care.

CONCLUSIONS

The mainstream approach , wh ile aimed at providing comprehensive care for all children , could not identify CSHCN or monitor their care. Wrap-around models, while offering rich benefits to CSHCN, rely on providers to identify eligible children , with few referrals reported to date. Service carve outs preserve long-standing specialty systems of care for CSH CN but create challenges for care coordination . Specialized systems of care present challenges for capitation but appear to offer the most promise for comprehensive, coordinated care to CSHCN.

Good practice in continence services

The Department of Health, England, issued new guidance on continence services earlier this year. Sue Thomas examines the guidelines with a view to the future of continence care.

Using structured implicit review to assess quality of care in the Program of All-Inclusive Care for the Elderly (PACE)

OBJECTIVE

To develop a quality assessment tool for care rendered to enrollees in the Program for All-inclusive Care of the Elderly (PACE) that can discriminate care quality ratings across PACE sites.

DESIGN

Structured implicit review (SIR) of medical records by trained geriatricians and geriatric nurse practitioners.

SETTING

Eight PACE sites.

PARTICIPANTS

Older adults enrolled in a PACE program for at least 6 months (n = 313).

MEASUREMENTS

Process and outcome measures for both overall care and 14 specific conditions (tracers) managed up to 1 year.

RESULTS

Overall care quality was judged to be above a community standard in 56% and below standard in 8% of cases. Process of care was rated as very good or good in 70% of the cases. Outcomes depended on how questions were phrased: only 19% of cases improved, whereas 28% were judged to have fared better than expected given their condition at baseline. The SIR method produced ratings demonstrating considerable variability across the sites; three of the sites consistently showed poorer quality ratings than the other five.

CONCLUSIONS

PACE care was generally assessed to be of good quality, but with room for improvement. Despite significant limitations of poor interrater reliability for process of care measures, excessive time involved for the reviews, and lack of a control group, the SIR method was able to consistently discriminate quality ratings among PACE sites. A modified version of the assessment instrument could prove useful in a quality improvement program for PACE care.