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PubMed2002

An innovative model of health care delivery: the care management program of the University of Iowa.

The Indigent Patient Care Program (legislatively enacted in 1915) provides comprehensive health care to indigent Iowans without health insurance. The University of Iowa Hospitals and Clinics, a leading academic medical center, was designated as the health care provider for these medically and socially complex patients. The Care Management Program of the University of Iowa (CMPUI) is an innovative care delivery model responsible for total health management of patients enrolled in the indigent program. The CMPUI is a solution to preserve the tripartite missions of an academic medical center while ensuring the preservation of the historic Indigent Patient Care Program in Iowa.

Academic Medical Centers↗
PubMed1997

Translating ideas into actions: entrepreneurial leadership in state health care reforms.

States are often touted as "laboratories" for developing national solutions to social problems. In this article we examine the appropriateness of this metaphor for comprehensive health care reform and attempt to draw lessons about policy innovation from recent state actions. We present evidence from six states that enacted major pieces of health care legislation in the late 1980s or early 1990s: Massachusetts, Oregon, Florida, Minnesota, Vermont, and Washington State. The variation in design casts doubt on the proposition that states can invent plans and programs for other states and the federal government to adopt for themselves. Instead, we argue that it is more accurate to think of states as specialized political markets in which individuals and groups develop and promote innovative products. We examine the factors that might create receptive markets for comprehensive health care reforms and conclude that the critical factor these states shared in common was skilled and committed leadership from "policy entrepreneurs" who formulated the plans for system reform and prominent "investors" who contributed substantial political capital to the development of the reforms. We illustrate different strategies that leaders in these states used to carry out the entrepreneurial tasks of identifying a market opportunity, designing an innovation, attracting political investment, marketing the innovation, and monitoring its early production.

Diffusion of Innovation↗
PubMed1994

The Larimer County Children's Clinic. A public-private partnership to provide medical care to indigent children.

OBJECTIVE: To describe a unique collaboration between private and public entities to provide comprehensive health care to medically indigent children in rural Larimer County, Colo. SETTING: The Children's Clinic, Fort Collins, Colo. STUDY PARTICIPANTS: Uninsured children and those eligible for Medicaid, living in families with incomes below 150% of the federal poverty level. SELECTION PROCEDURES: Eligible patients have been enrolled in the Children's Clinic on a first-come, first-served basis. INTERVENTIONS: A community collaboration involving an interactive system with the Children's Clinic staff, the Larimer County Department of Health and Environment, private primary care and subspecialty physicians, ancillary health providers, and the family practice residency program at Poudre Valley Hospital, Fort Collins. Funding for this endeavor has been composed of city and county funds, public and private grants, community business support, and local fund-raising efforts, as well as Medicaid reimbursements. MEASUREMENTS/MAIN RESULTS: Since 1989, comprehensive pediatric care has been provided to a growing number of eligible children. At present, 3619 children, aged birth to 18 years, from 2230 families are being served. From this population, there were 8945 office visits to the Children's Clinic, 1392 patient contacts by the clinic social workers, 1287 visits to the Larimer County Department of Health and Environment for well-child care, 543 referrals to subspecialists and other community health care providers, and 615 after-hours visits to the Poudre Valley Hospital emergency department between July 1, 1992, and June 30, 1993. The clinic's professional staff consists of 2 1/4 full-time pediatric care providers, one nurse, one medical social worker, one receptionist, and one administrator, with an expenditure of $356,471. CONCLUSIONS: The Children's Clinic collaboration has provided comprehensive pediatric health care to a population that previously received only fragmented care. The next step is to assess the impact of this program on the frequency of emergency department visits for these patients.

Adolescent↗
PubMed1999

The scope of unmet maternal health needs in pediatric settings.

OBJECTIVE: Previous work has focused attention on the prevalence of specific maternal health problems known to affect children, such as smoking or depression. However, the cumulative health burden experienced by mothers and the potential for a practical pediatric health services response have not been examined. The aims of this study were to characterize: 1) the prevalence and cumulative burden of maternal health behaviors and conditions, 2) maternal access to a source of comprehensive adult primary care, and 3) maternal perceptions of a pediatric role in screening and referral. METHODS: We surveyed 559 consecutive women bringing a child 18 months of age or less to one of four pediatric primary care sites between July 1996 and May 1997. The pediatric sites included one outpatient program in an academic hospital, one in a community health center, and two in-staff model practices of a managed care organization (these last two were combined for analysis). The self-administered questionnaire contained previously validated questions to assess health behaviors and conditions (smoking, alcohol abuse, depression, violence, risk for unintended pregnancy, serious illness, self-reported health) and access to care (regular source, regular provider, health insurance, care delayed or not received). Maternal attitudes toward a pediatric role in screening and referral were also elicited. RESULTS: In the three settings, response rates ranged from 75% to 84%. The average age of the women ranged from 25.1 to 32. 1 years and the average age of the children ranged from 6.5 to 8.0 months. Across the settings, the percentage of women reporting at least one health condition (66%-74%) was similarly high, despite significant demographic differences among sites. Many women reported more than one condition (31%-37%); among all women who smoked, 33% also screened positive for alcohol abuse, 31% for emotional or physical abuse, and 48% for depression. Access to comprehensive adult primary care was variable with 23% to 58% of women reporting one or more barriers depending on the site. Across all sites, >85% of mothers reported they would "not mind" or "would welcome" a pediatric role in screening and referral. CONCLUSIONS: Two-thirds of women bringing their children for pediatric care had health problems regardless of the site of care. Many women also reported substantial barriers to comprehensive health care. Most women reported acceptance of a pediatric role in screening and referral. Given the range and depth of maternal health needs, strategies to connect or reconnect mothers to comprehensive adult primary care from a variety of pediatric settings should be explored.

Adult↗
PubMed1987

The U.S. health care economy: from guild to market in ten years.

The U.S. health care economy is changing with remarkable speed from the non-competitive guild system of the past 50 years to a competitive market stem. A more efficient industry, more responsive to consumer preferences, is emerging. National health care expenditures grew from 5.3 percent of GNP in 1950 to 10.7 percent in 1983. Three factors that were especially important contributors to this are now being changed. The first is the fee-for-service method of payment of providers. The second is the principle of 'free choice of provider', a medical-economic concept designed to assure that the payor has no bargaining power and that there will be no economic competition among doctors. The third is that most government subsidies were open-ended subsidies of marginal costs. Important changes took place in the early 1980s, and additional changes appear inevitable, that will bring the open-ended era to an end. These changes are setting in motion an accelerating process that seems sure to change the whole system of health care finance from fees for individual items of service reimbursed after the fact, to prospective payments for global units of care, with providers at risk for their use of resources, and from cost-unconscious 'free choice' of provider to cost-conscious choice among limited groups of selected providers contracting in advance. The likely outcome of the process appears to be consolidation of the medical care system into comprehensive health care financing and delivery organizations serving, perhaps, several hundred thousand to several million people each.(ABSTRACT TRUNCATED AT 250 WORDS)

Economic Competition↗
PubMed1975

The health and medical system in Japan.

This has been a brief sketch of the health and medical system in Japan. While many health indices have improved since the end of World War II, the health system still has many problems to be solved. The shortage of professional personnel remains a glaring one. And especially detrimental to the effective functioning of a good system is the fragmentation of various institutions, schemes and functions. It is necessary to integrate all of these things into a comprehensive health care system, and to establish a comprehensive plan for health and medical services.

Community Participation↗
PubMed2006

Effectiveness of a training programme for primary care physicians directed at the enhancement of their psychiatric knowledge in Saudi Arabia.

OBJECTIVE: A substantial number of patients with psychiatric disorders consult primary care physicians for comprehensive health care; however, the diagnosis and effective treatment of psychiatric disorders are deficient in primary health care. The aim of this intervention study is to assess the pre- and post-psychiatric training knowledge of primary care physicians. METHOD: The setting of this study was Buraidah Mental Health Hospital. The research design consisted of a pre- and post-test comparison of physicians' responses (n = 70) with a control group (n = 40). The instrument includes a Knowledge Test comprised of 50 questions on primary care psychiatry. RESULTS: There were no significant differences between the intervention and control groups with regard to several confounding sociodemographic variables, but physicians' age and duration of medical practice were significantly higher in the control group. There were significant differences between knowledge of intervention and controls prior to psychiatric training and this difference was further highly significant post-psychiatric training. The gain in knowledge of intervention group post-psychiatric training was highly significant as compared to pre-test knowledge but there was no difference in the knowledge of the control group. CONCLUSION: Psychiatric training courses can enhance physicians' knowledge in clinical psychiatry with possible psychiatric implications, including early diagnosis and better treatment of primary care patients with psychiatric problems.

Adult↗
PubMed2004

[Management of hospitals in the prospective payment system].

Since last year a prospective payment system, the so-called "diagnosis procedure combination" system has been implemented at 82 hospitals, and this fiscal year national universities and national hospitals became independent agencies. Furthermore, a new postgraduate training and education system started this year. Now it is time for hospitals to transform into institutions that are opted for by health professionals, patients, and medical students. Every hospital has to transform into a hospital that provides safe health care with a minimal number of medical errors and delivers care with a degree of information, transparency and logicality that will fully satisfy patients. That care must also be distinguished by efficiency giving proper consideration to costs. For this purpose, all hospital staff including physicians, nurses, technicians, pharmacists, dietitians, and clerical staff have to pursue health care as a team. In a comprehensive health care system, practice of team-based care is imperative. As we think that the implementation of critical paths (or clinical paths) will be a strong impetus for team-centered care and, especially important, for a change in the mindset of the physicians, we have addressed this subject.

Critical Pathways↗
PubMed1993

The Comprehensive Health Organization--a practical solution for an integrated health care system.

This brief report takes a look at the structure and functions of a new type of health care delivery system, the comprehensive health organization (CHO). The development of such a system, however, requires a new mindset or shift of focus: none of the activities of a CHO has been part of the training or experience of providers in the Canadian health care system. The range of services a CHO would offer, whether they would be provided by the CHO or by an outside contractor, the possible risks involved, and who the potential participants would be are also discussed.

Comprehensive Health Care↗
PubMed1994

Forming and reforming the market for third-party purchasing of health care: a German perspective.

Germany is known for its comprehensive health care coverage by sickness funds and private health insurers and its successful cost containment policy. The stabilization of health care expenditures as a percentage of GNP was enforced by five cost containment laws since 1977. The last one became effective in 1993 and the next ones are planned for 1996 and 2000. The 1993 law has initiated drastic changes of the system. Office based physicians will be paid by a mixture of capitation, fee-for-service and fees for combined service packages. The hospital financing will be transformed from the current per diem remuneration to a payment system where per diems are combined with payments based on diagnostic related groups and patient management categories. Up till now many restrictions exist for insurees to switch sickness funds. These limitations were removed by the 1993 law. To allow unbiased competition between sickness funds, a risk compensation pool, some kind of statutory reinsurance, will transfer financial resources from sickness funds with good risk structure to those with many bad risks. In many respects health policy has imposed what health economists have recommended for a long time. However, there is some doubt whether increased competition will really increase efficiency of providing medical care because it takes place in a highly regulated market.

Cost Control↗
PubMed1997

The psychiatric-primary care nurse practitioner: a futuristic model for advanced practice psychiatric-mental health nursing.

A new paradigm for delivering comprehensive mental and general health services has been born out of the necessity to integrate all aspects of health care. Because of issues of cost-effectiveness and capitation, fragmentation of services is no longer viable. Graduate programs in nursing will need to: (1) effectively prepare its practitioners to manage the complexity of both medical and psychiatric problems of clients, (2) promote health and prevent disease, and (3) counsel and refer clients. The psychiatric nurse practitioner is uniquely suited to provide comprehensive health care to both clients in psychiatric settings as well as primary care environments. An overview of the Psychiatric-Primary Care Nurse Practitioner program at the University of Pittsburgh is described.

Clinical Competence↗