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PubMed1996

The Practice Environment Project. A process for outcome evaluation.

OBJECTIVE: Evaluating the practice environment is essential to determine if the practice environment is conducive to the delivery of quality patient care. The Practice Environment Project (PEP) was created to provide a framework for current and ongoing evaluation of the practice environment. BACKGROUND: Major changes in the delivery of patient care services have focused attention on the evaluation of the effectiveness of these changes. The extent and type of change may vary throughout an institution. The identification of core variables to assess the effectiveness of these changes sets the framework for ongoing evaluation of new unit-based models for delivery of services. METHODS: In part 1, quantitative data were collected from nursing staff members (job satisfaction, collaboration with physicians, autonomy), physicians (quality of nursing care, collaboration with nurses), and patients (satisfaction with nursing care). In part 2, focus groups were held with nursing personnel to discuss factors that affected the provision of services. Unit-based action plans were developed to manage barriers to the delivery of services. RESULTS: Patients and physicians reported a high degree of satisfaction with patient care. Physicians reported a higher level of collaboration with nurses than that reported by nurses. Nurses reported a high degree of autonomy in practice, however, in other areas of job satisfaction (development and recognition), they suggested areas for improvement. CONCLUSIONS: The PEP created a mechanism to evaluate the current state-of-the-practice environment by identifying core elements for evaluation of work redesign. It also provided a framework for managing barriers that disrupted the delivery of patient care services.

Focus Groups↗
PubMed1991

Purdue stepped approach model: application to pharmacy practice.

The Purdue Stepped Approach Model (PSAM) of service delivery is applied to pharmacy practice. The PSAM offers a method to organize interventions in a systematic and sequential manner according to the amount and type of resources required to achieve optimal patient health status. The model also provides an approach to integrating the expertise of other healthcare professionals into the provision of pharmacy services (e.g., health educators, psychologists, nurse practitioners, exercise physiologists), addresses economic costs and differential modes of reimbursement, and provides suggestions for future research. Examples are included to facilitate application of the PSAM in pharmacy and implications for holistic healthcare or health promotion in pharmacy practice are discussed.

Humans↗
PubMed2006

Improving access to evidence-based acute stroke services: development and evaluation of a health systems model to address equity of access issues.

Level 1 evidence for management of patients with stroke in a dedicated Stroke Care Unit (SCU) demonstrates improved outcomes by about 20%. It has been estimated that 21% of Australian hospitals provide an SCU and that these SCUs are mainly located in either metropolitan sites and/or in hospitals with more than 300 beds. To address equity issues related to access to SCUs, the National Stroke Foundation and the Australian Government undertook the National Stroke Units Program. One program outcome was the development of a conceptual model of acute stroke service delivery. The development process and initial evaluation of the model are described. Use of the model to increase capacity within the health care system to treat stroke is discussed.

Acute Disease↗
PubMed1999

The gatekeeper model is inefficient for the delivery of dermatologic services.

BACKGROUND: Gatekeeper-paradigm managed care systems may discourage the use of dermatologists in the management of skin conditions by limiting direct access. This may limit the quality of care patients with skin disorders receive and may be an inefficient use of medical resources. OBJECTIVE: The purpose of this study was to determine the likelihood that patients with dermatologic conditions who see a primary care provider will be referred to a dermatologist. METHODS: Data on the disposition of outpatient visits to primary care physicians for one and only one dermatologic diagnosis were obtained from the 1990-1994 National Ambulatory Medical Care Survey. These data were used in an econometric model to estimate the likelihood of referral to a dermatologist for an episode of care. RESULTS: Of all visits for a single dermatologic diagnosis, 39% were to primary care physicians. The disposition of referral was more common for these dermatology-related visits than for all office visits to primary care physicians (5.8% vs 4.5%, P < .001). The most frequent diagnoses associated with referral were common dermatologic problems, not rare disorders. The number of visits per episode of care was highly dependent on the assumptions of the analysis, resulting in estimate ranges for referral rates per episode between 6.8% and 18.5% for pediatricians, 8.2% and 23% for family and general practitioners, and 16.6% and 46.5% for internists. CONCLUSION: The relative difficulty for primary care providers of managing skin problems is reflected by their frequent need to refer patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical conditions. The high rates of referral per episode of care supports the cost-effectiveness of direct access to dermatologists.

Costs and Cost Analysis↗
PubMed1999

Outcome of case management and comprehensive support services following policy changes in mental health care delivery.

UNLABELLED: An assessment of policy toward the care of seriously mentally ill (SMI) persons residing in a suburban Chicago community was undertaken. Results indicated the SMI population was classically "underserved." Few alternatives to a state inpatient hospital were being utilized. A policy change in SMI care was instituted by the local community mental health board which included implementation of the Unified Services Program (USP). The features of the USP were: centralized case management and outreach; and an expansion of service philosophy into a comprehensive, multidisciplinary service model of mental health delivery. METHODS: This study examined SMI service utilization, quality of life, and satisfaction with care outcomes following 12 months of USP exposure. Fifty percent of USP caseloads were randomly sampled for study participation. USP study results were compared to a large SMI population with similar exposures in another state. RESULTS: 100% of USP SMI reported to be satisfied or very satisfied with their place of residence compared to the state hospital; and 100% were satisfied or very satisfied with the USP overall. Eighty two to 100% of the study participants rated their status as better than before enrolling in USP. SMI utilized USP services, and service combinations which they find useful (88 to 100%); and felt they could not access their services without USP case managers or outreach. Compared to New York State SMI, study SMI reported similar scores, but superior ratings on "services/facilities." CONCLUSION: The study supports use of the USP for SMI living in the community, and also identified areas for programmatic improvement.

Adult↗
PubMed1979

Into the breach: emergency psychiatry in the general hospital.

In its position at the interface between the community and the general hospital, the emergency ward (EW) serves to reconcile the complex needs of the local population with the traditional organizational structure of the hospital. In recent years, the EW has been faced with the dilemma of managing increasing numbers of psychotic patients with chronic illness and psychosocial problems. In response to this impressive growth in the utilization of psychiatric emergency services, a variety of general hospitals have developed model programs of service delivery and methods for the evaluation of their effectiveness. This paper is an overview of utilization patterns, organization of services, and assessment of the evaluation and referral model. This issues facing general hospitals in the development of emergency care are clarified. The need for further research, program development, and clinical implementation is discussed.

Crisis Intervention↗
PubMed1985

Distributive effects of dental programs for old-age pensioners in Norway.

The purpose of the present paper was to study the distributive effects of different delivery models of dental services to old-age pensioners in the county of Troms in Northern Norway. The empirical basis was formed by a baseline survey at the start of a 50% demand subsidy in 1975/76, and from a delivery experiment along a "market-need" dimension which was started in 1978 and lasted for 1 yr in three research areas (Municipalities). In the control area there was no intervention beyond the 50% demand subsidy, while the two experimental areas differed with regard to improvements of the market mechanism in terms of increasing degree of collective decisions as to which treatment needs should come to treatment. The aggregate consumption of dental services was relatively unaffected by a reduction in the price of dental treatment. The improvements of the market contributed to a net gain in use rate from 16% to 23%, while moving towards the "need" end of the "market-need" dimension. By minimizing the market mechanism, the use of dental services expanded and the cost of the programs increased, but whether the inequalities diminished could not be decided empirically.

Aged↗
PubMed1986

Health care delivery models: emerging trends in the delivery of health services.

Rising costs, a higher proportion of elderly in the population, proliferation of high technology and increased knowledge about efficient and effective service provision have all led to increased cost-consciousness in the health system. Historically, regulatory approaches have provided equity of access and funding, but for controlling costs they have now become inappropriate because they leave the mix of services untouched. In the future, regulatory approaches may make more use of guidelines and algorithms for care (the "soft" regulatory route), or they may directly control the supply of providers and other resources in the health system (the "hard" regulatory route). An alternative is the competition approach which allows choices by consumers on where to obtain health care based on the efficiency with which those services are provided. The danger in this approach is the potential for equity to be compromised; this may be addressed by combining the regulatory and competitive approaches.

Canada↗
PubMed2002

Linking mental health and addiction services: a continuity-of-care team model.

Reorganization of mental health care delivery services at a Department of Veterans Affairs medical center addressed problems with the coordination of addiction treatment and mental health programming for patients with significant psychiatric and addiction comorbidity. Clinical services were organized into interdisciplinary continuity-of-care teams that follow patients across different levels of care. The teams provide addiction treatment through "universally available" resources such as a partial hospital addiction rehabilitation module. Continuity of care remains within the team structure as clinicians follow patients throughout their rehabilitation course. Patient and staff satisfaction focus on improved accessibility of addiction services and continuity of care providers across time and levels of care. Overall inpatient utilization and recidivism decreased after model implementation.

Continuity of Patient Care↗
PubMed2002

Factors related to client satisfaction with community-based respite services.

The goal of this study was to identify factors related to client satisfaction with respite services. Data were analyzed from interviews with 1183 family caregivers participating in the AoA Demonstration Grants to States program. Two groups of potential explanatory variables were examined: (1) characteristics of client families, and (2) caregivers' perceptions of service delivery. Separate regression models were estimated for users of in-home respite and adult day care. Factors related to satisfaction with in-home respite included elder's ADL, ethnicity, caregivers' expectations for what the respite worker would and would not do, access to services, and the amount of red tape. Factors related to satisfaction with adult day care included the caregiver's age and health, ethnicity, caregivers' expectations for what the respite worker would and would not do, access to services, and the amount of red tape. Differences be- tween the models are discussed in the context of how providers can improve client satisfaction with respite services.

Activities of Daily Living↗
PubMed1994

Megatrends in rehabilitation: a Canadian perspective.

In this article, based on a presentation to the New Zealand Rehabilitation Association, the author identifies and discusses seven 'megatrends' which are expected to shape the future of rehabilitation services and the quality of life enjoyed by people with disabilities. They include changes in the demography of disability, the empowerment of disabled people, the policy of integration and the rising cost of health and social-services. Also considered are changes in models of rehabilitation service delivery, the role of assistive technology and the shift from empiricism to applied rehabilitation science.

Canada↗
PubMedDate not supplied

Cluster analysis of psychogeriatric characteristics and service use among rural elders.

In developing models of psychiatric service delivery, nurses must be able to target groups on the basis of their health status and service needs. This investigation attempted to develop profiles of rural elderly, a significant risk population, by subjecting data on the psychogeriatric nursing status and health services utilization of 125 subjects to cluster-analytic methods. The cluster analysis yielded a three-cluster model: Cluster 1 (n = 39) predominantly comprised unmarried women in moderate health, but with a high degree of health service utilization; Cluster 2 (n = 53) had rural elders with moderate physical impairments, self-perceptions of poor health, and moderate health service utilization; and Cluster 3 (n = 33) comprised elders with severe cognitive and physical impairments and high health service utilization. Cluster 2 subjects were judged to be mild users of services because they were younger and married without a regular source of health care. Because subjects in Cluster 1 tended to be unmarried women who lived alone, with mild to moderate physical impairments and a regular source of health care, these subjects were assessed as moderate users of services. Cluster 3, which comprised the oldest and most impaired, both physically and cognitively, were judged to be intensive users of services.

Activities of Daily Living↗
PubMed1980

Migrant health revisited: a model for statewide health planning and services.

Since the migrant farmworker family is a marginal issue among competing priorities for public health services, the logical strategy ought to be the pooling of limited resources at the state and local level to provide maximum benefit for the dollar and the client. A program planning model in inter-agency migrant health services delivery has been developed in Colorado. The model includes tangible evidence of cooperation by front-line service agencies. A task force approach for joint agency programming was initiated at state and local levels, and a structure for accountability was established which was carried out with performance contracts.

Agriculture↗
PubMed2003

Primary care continuity and location of death for those with cancer.

BACKGROUND: Continuity of primary care is known to be associated with both improved processes and outcomes of care. Despite continuity being a desired attribute of end-of-life care and despite the desire by most patients with cancer to die at home, there has been no health services research examining this relationship. AIM: To examine the association between family physician continuity of care and the location of death for patients with cancer. DESIGN OF STUDY: A retrospective population-based study involving secondary data analysis of four linked administrative health databases spanning 6 years of information (1992-1997). SETTING: Nova Scotia, Canada Participants: All those who died of cancer from 1992 to 1997 and had made at least three ambulatory visits to a family physician. METHODS: The relationship of provider continuity of care and an out-of-hospital death was examined using logistic regression. RESULTS: Out-of-hospital deaths accounted for 31.6% of the 9714 deaths in the study population. The mean provider continuity of care was 0.78 (standard deviation [SD] 0.22). Those who died out-of-hospital had a greater odds of having received high provider continuity (adjusted odds ratio [OR] = 1.54, 95% confidence interval [CI] = 1.22, 1.93) when compared to those who died in-hospital. There appears to be a modification of this effect by gender with a significant association found for males and not for females. The trends in the point estimates are, however, similar for both sexes. CONCLUSIONS: This study demonstrates an association between family physician continuity of care and the location of death for those with advanced cancer. Such continuity should be fostered in the development of models of integrated service delivery for end-of-life care.

Adolescent↗