Acute care and long term care partner to provide better services for seniors

Many seniors have the same common problem, they have experienced the frustration of having to go to several different facilities, making more than one trip, to access appropriate medical, rehabilitation, behavioral, and/or long term health care services. The seemingly simple task of obtaining a medical evaluation can often require not only a physical examination, but also a visit to a laboratory to have blood drawn, vision and/or hearing testing, a physical or rehabilitation therapy assessment and more. This series of events can be particularly difficult for seniors. Seniors may require assistance of a friend or family member and can be compounded when mental health issues are involved as well.

Physician outcome measurement: review and proposed model

As health care moves from a free-for-service environment to a capitated arena, outcome measurements must change. ABC Children's Medical Center is challenged with developing comprehensive outcome measures for an employed physician group. An extensive literature review validates that physician outcomes must move beyond revenue production and measure all aspects of care delivery. The proposed measurement model for this physician group is a trilogy model. It includes measures of cost, quality, and service. While these measures can be examined separately, it is imperative to understand their integration in determining an organization's competitive advantage. The recommended measurements for the physician group must be consistent with the overall organizational goals. The long-term impact will be better utilization of resources. This will result in the most cost effective, quality care for the health care consumer.

Conceptualizing and measuring integration: findings from the health systems integration study

Given the pressures for health care reform, interest in the concept of integrated or organized delivery systems as a means to offer more coordinated cost-effective care is growing. This article has two primary objectives: (1) to clarify the different types of integration associated with the notion of an organized delivery system, and (2) to share the results from an ongoing study of 12 organized delivery systems. The findings indicate a moderate level of integration overall, particularly in the areas of culture, financial planning, and strategic planning. The study found that corporate staff respondents perceive their systems to be more integrated and effective than do operating unit managers, and that some functional integration areas are positively associated with both physician-system and clinical integration that, in turn, are positively related to each other. Overall, perceived integration was found to be positively associated with perceived effectiveness.

Creating organized delivery systems: the barriers and facilitators

An organized delivery system is a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and the health status of the population served. As such, organized delivery systems are at the center of efforts to implement health care reform. Based on analysis of 12 such systems, this article identifies key characteristics that influence what organized delivery systems are able to do, outlines the major obstacles or challenges to achieving greater levels of integration, and then discusses a number of approaches for effectively dealing with these obstacles.

Measuring and evaluating the performance of vertically integrated rural health networks

The growing interest in health care networks is extraordinary given the lack of a common understanding of what networks are and what they can accomplish. The purpose of this article is to develop a conceptual approach to the study of vertically integrated rural health networks. This article provides a network typology, a framework for assessing network performance, and examples of measurable performance indicators. It concludes with a description of the salient research questions that need to be addressed concerning the relationships between the environment, structure, and performance of vertically integrated rural health networks.

Coordinated system of care cuts costs, maintains quality for persons with AIDS

Coordinated HMO care reduces costs for patients with AIDS. Although HMOs get a bad rap, a surprising study from Boston University found that a comprehensive system of managed care can do a better job of avoiding hospitalization and reducing health care costs than traditional fee-for-service plans--without negatively impacting patient satisfaction, health status, or level of function.

Effect of comprehensive care on pregnancy outcomes

The purpose of the study was to compare pregnancy outcomes of low socioeconomic pregnant women receiving prenatal care at a prototype, comprehensive, multidisciplinary tertiary clinic with outcomes of a matched sample who received prenatal care from a variety of area public health clinics. Multidisciplinary clinic subjects were matched by age, race, and parity to 175 control subjects selected from labor and delivery logs of the general hospital that services the entire community. There were significant differences between groups on the measures of gestational age (t[174] = 2.50, p < .01), maternal risk factors (t[174] = 11.12, p < .0), and infant complications (t[174] = 5.86, p < .01). Infant birthweight and APGAR scores were not significantly different between the multidisciplinary clinic subjects and the matched sample. This study showed the importance of comprehensive prenatal care for low socioeconomic women at high risk for obstetrical and medical complications.

Comprehensive home care in the Czech Republic

In the Czech Republic comprehensive home care encompasses many services. The overall focus is on providing a mosaic of care to help maintain each patient's quality of life.

The Norwegian Polio Study 1994: a nation-wide survey of problems in long-standing poliomyelitis

'The Norwegian Polio Study 1994' was performed to make a nation-wide survey of the medical and social situation, and of the needs of anterior poliomyelitis (polio). A questionnaire, consisting of 133 questions with sub-questions, was sent to a total of 2392 polio victims, most of them registered in 'The National Society of Polio Victims' in Norway. 1449 persons (61%) answered. Sixty-six per cent were between 45 and 64 years of age, 25% were above 64 years and 9% were under 45 years. When specifying new health problems, 85% stated that they had experienced increased weakness in muscles affected by polio, while 58% had experienced increased weakness in previous non-affected muscles. Other health problems related to polio were fatigue during exercise (80%), general fatigue (57%), joint pain (58%), muscular pain (58%) and cold intolerance (62%). The participants indicated an increasing need of aids, but 80% were still independent of help from others and 57% were still employed, fully or part time. Only 17% were satisfied with the public health services for polio survivors, while 67% of those who had undergone comprehensive examination at some central hospital were satisfied. This study indicates an obvious need of building up expertise in multidisciplinary evaluation and treatment of post polio problems in countries where acute polio has been eliminated.

Breaking the barriers for improved glycaemic control: primary care and secondary care interface

The prevalence of diabetes is predicted to increase dramatically over the next 30 years, mostly as a result of Type 2 diabetes. To manage this increased burden, the following measures must be implemented: diabetes care must be delivered in the most suitable locations; people with diabetes must remain in contact with the appropriate healthcare professionals; and health professionals must use the most effective methods to treat their patients. The structure for diabetes care suggested by the World Health Organization uses terminology that is familiar universally. The reality, in terms of what can be delivered at primary- and secondary-care level will, however, differ greatly according to the extent of service development and the resources available. The optimum forum for diabetes care should have the advantages of the primary-care setting and, when required, the main advantages of the secondary-care setting, i.e. specialized knowledge and more sophisticated facilities. In most healthcare systems, particularly those without financial disincentives to the patient to be followed up in hospital, the tendency remains for secondary care to 'capture' and retain patients for longer than is required clinically. The end results are the overloading of hospital services, inappropriate use of resources and the tendency for patients to default from care because of the relative inaccessibility and remoteness of the hospital service. Issues with special reference to different models of diabetes care, use of patient registers and clinical guidelines, and the perceptions of patients regarding the successful use of services are presented.

The economics of managing healthcare delivery systems by service lines

In their continuing quest for greater efficiency and lower costs without compromising quality of care (and preferably while improving quality), some health system leaders have adopted what is called the "service line" or "product line" approach to healthcare delivery.

Measuring comprehensive case management interventions. Development of a tool

As case management programs seek to demonstrate effectiveness data are needed on the interventions used by case managers. This research was done to quantify the interventions used by case managers for low-income prenatal clients. Using the Client Intervention Form, case managers from two local health departments, whose caseload included pregnant Medicaid recipients, recorded the use of 7 types of interventions in 10-minute increments. The Client Intervention Form is easy to use and is based on an existing valid typology of nursing interventions. Intervention types include: assessment, monitoring, education, clinical acts, coordination, support, and coaching. The amount of time spent doing each of the seven types of interventions varied between agencies and across types of interventions, suggesting that the Client Intervention Form can quantify interventions used. Recommendations for practice and research are identified.

A comprehensive model of cooperation between caregivers related to quality of care

BACKGROUND

The system and delivery of health care tend to suffer from fragmentation, resulting in discontinuous and costly care. Local cooperation between caregivers is essential to achieve appropriate, timely, continuous and efficient care. The article develops a general comprehensive patient-centered model of quality of care related to local cooperation between caregivers. The model can be used in quality improvement and research.

THE PROPOSED MODEL

Within the framework of Donabedian's triad (structure-->process-->outcome), cooperation between caregivers is divided into two parts. Firstly, client related cooperation (multiple caregivers to one patient) is a part of the process of health care and relevant for important quality aspects: appropriateness, timeliness, continuity of care, effectiveness and efficiency. Secondly, local cooperation between caregivers, which is not restricted to one patient, is called non client related cooperation. Such non client related cooperation creates conditions for optimal patient care. Non client related cooperation has different degrees, dependent on the existence of agreements between the caregivers (such as protocols) and evaluation of these agreements. The highest degree of non client related cooperation is continuous quality improvement. To achieve a certain degree of non client related cooperation, conditions must be fulfilled in several fields (organization, information, financing and participants).

APPLICATION OF THE MODEL

A "how to use the model in eight steps" is given and possible operationalizations of key concepts in the model are outlined. Finally, the use of the model is illustrated by two examples.

Comprehensive management of epilepsy in persons with mental retardation

Epilepsy is a common occurrence in persons with mental retardation. The application of recent advances in epilepsy research to patients with mental retardation has shown that well-accepted principles of management are as relevant for multiply handicapped people as for those with epilepsy alone. Quality enhancement is emphasized as the overarching concept that determines the quality of care provided to patients with epilepsy and mental retardation. This article reviews the comprehensive management of epilepsy, discusses what is known at present, and indicates what is not known and needs further research.

A partnership of care: an approach to the management of adults with cystic fibrosis

Several factors occurring more or less simultaneously have led to a major change in the management of adults with cystic fibrosis at The Prince Charles Hospital, Brisbane. Less than 50 years ago, 80 per cent of infants born with cystic fibrosis did not survive the first two years of life. In Australia today, the median survival is around 30 years of age, with many surviving into their fourth decade (Landau & Ryan 1991, p 4). Recent developments in the management and treatment of cystic fibrosis provide an exciting and promising foundation for further development and a changing focus in cystic fibrosis management. Increased longevity has significant implications for the management of adults with cystic fibrosis. Until recently, most people with cystic fibrosis were managed within the paediatric setting, with the expectation that life expectancy would not exceed adolescence. In reality, there has been a dramatic increase in the number transferring from children's hospitals to adult facilities, and a subsequent need to provide optimal care to a group of patients coming to terms with their own perceptions of being adolescents with a life-shortening condition. From an organisational perspective, the increased demand for resources has generated the need to consider alternative methods of providing care. Such options include home intravenous therapy, day admission, alternative accommodation and education of staff in remote health centres. Home intravenous therapy has proven to be a popular alternative to hospital treatment and has significant implications for reducing lengths of stay and occupied bed-days. Within the current focus on best practice, developing strategies for providing optimal health care in the hospital setting are paramount. A multidisciplinary team focus based on a 'partnership of care' philosophy underpinned by best practice principles describes the approach adopted by the cystic fibrosis team at The Prince Charles Hospital that has led to successful outcomes in meeting challenges inherent in the care of young adults with cystic fibrosis.

Total partnership for primary health care provision: a proposed model: Part I

Presents the first of a two part paper, based on a study which examined the dynamics of primary health care provision. The study examined 49 general practices in the Kirklees area, UK, through a detailed questionnaire mode. The response was 67 per cent covering the views of 106 doctors. To capture further input for the study, an in-depth seminar with nine doctors from a range of practices was conducted. Examines internal factors for managing general practices and the levels of competence in addressing financial, strategic, quality issues and whether general practices get involved in any external activities for new learning and benchmarking. Comprehensively covers common areas of concern and areas where expertise may be inadequate or lacking.

Optometric record keeping in a comprehensive health care environment

Optometric records which have evolved in private practice must be reconsidered when included in a comprehensive care environment. These hospital, health maintenance organization (HMO), preferred provider organization, and similarly linked systems require a higher degree of communication among specialties than do self-standing practices. Furthermore, the administrative requirements of such a system require more standardization, cost sensitivity, medicolegal compliance, and other elements pecular to a comprehensive facility. The expended scope of care provided by optometrists within a hospital requires familiarity with a new range of procedures, languages, and reports. Information from laboratories, radiology, and other areas must be incorporated into the optometric record. Continuity of care is more complex. Opportunities for strong interprofessional synergies within the organization arise directly from proactivity in optometric record keeping. New legal hot spots arise from questions of records ownership, access, and privacy. Billing procedures are becoming extremely important, with significant effects on quality assurance audits, coding, doctor "profiling" against fraud, and abuse; these priorities can interfere with clinical priorities. Driven primarily by the concerns and resources of large third-party payers, technology is making rapid changes in the form of optometric record keeping in comprehensive systems. Electronic data management will change the face of medical records, although administrative data will be digitized much more quickly than clinical notes. Comprehensive care environments will be the "test beds" for these technologies. Optometry is in a good position to show its contribution to the health care team through leadership in the implementation of new record keeping models.