PubMed · 8772372
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L BeSaw. 1996. HMO vs case management.. https://pubmed.ncbi.nlm.nih.gov/8772372/
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In Canada, home care is growing rapidly. Each province takes a somewhat different approach to its delivery. Ontario uses a competitive bidding model to award contracts to community agencies that bid for service delivery rights. Contracts are to be awarded based on quality and price. However, the attributes thought to contribute to high quality, such as continuity of care, are not clearly defined and are not measured. We sought to identify factors that were important to experiencing continuity of care in home care. We interviewed home care clients and their caregivers, workers in the home care system (nursing and homemaking service providers, case managers) and physicians whose patients use home care. During in-depth interviews with these key stakeholders, they described the conditions that led to continuity of care in home care. Service providers and case managers were also asked about the types of clients who need a high level of care continuity. Care that is experienced as running smoothly, that responds to clients' needs and requires no special effort for clients to maintain, was seen as having continuity. The attributes of care experienced as facilitating continuity could be grouped under two dimensions of care-managing care (care planning, monitoring and review; and care coordination) and direct service provision (uninterrupted service delivery; consistent, appropriate knowledge and skills; ongoing accurate observation; trusting relationship between service provider and client/caregiver; rapport among team members; and consistent timing). Different stakeholders emphasized different attributes of care as most important to continuity. Clients included consistency of timing of service delivery while rarely mentioning care management issues. They emphasized the importance of consistent knowledge and skills in the workers and trusting relationships as important to experiencing care continuity. The description of attributes of continuity of home care that emerged from this study is compared to definitions found in the nursing, mental health and primary care literature.
Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.
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