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PubMed2005

Psychosocial problems among patients in neighborhood health centers: perspectives from health care providers.

Little is known about how health care professionals perceive and understand the psychosocial problems of individuals receiving services in neighborhood health centers (NHCs). We conducted interviews with health care professionals in NHCs in New York City. The respondents identified seven problems, including a lack of financial resources, unsafe housing, and emotional distress/depression as affecting large portions of their patient populations. Respondents reported that they are presently meeting many of the psychosocial needs of their clients, but they were pessimistic about their ability to continue to do so due to a lack of funding streams to support their provision of comprehensive health care that includes psychosocial services. The findings suggest that while NHCs may be "holding their own" in providing quality services to their clients, this will be harder to sustain in the future if the numbers of the uninsured served continues to increase, and the revenues generated continue to decrease.

Adult↗
PubMed2002

Promoting identification of HIV-infected youths: borrowing concepts from the media to reduce the HIV epidemic?

The HIV/AIDS epidemic is dramatically affecting adolescents. Although it is estimated that 50% of new HIV infections in the United States is among people under 25 years of age, adolescents seek HIV counseling and testing services at a much lower rate than adults. Furthermore, many HIV-infected adolescents remain unaware of their status and do not seek health care. As HIV identification remains the most important gap in the efforts to control the spread of the HIV epidemic among youths, there is an increasing need to implement creative strategies to attract youths to HIV screening services. This article describes the implementation of an innovative HIV/AIDS social marketing campaign designed to attract at-risk urban adolescents to youth-friendly HIV counseling and testing services and link them to comprehensive health care. In addition, the article describes the key elements of the social marketing initiative: 1) designing a meaningful message, 2) attaining audience credibility, and 3) mobilizing the community.

AIDS Serodiagnosis↗
PubMed2006

Office counseling for the adolescent.

Physicians can and do influence adolescents' health-related behaviors. A recent study of low-income adolescents found that most adolescents report they are not receiving sufficient counseling about risk and risky behaviors from their physicians [8]. The results of this study and the author's personal experience (teaching physicians how to counsel and interview adolescents) support the need for physicians to learn more about office-based counseling with adolescents. Physicians who care for teens should learn how to meet the unique needs of individuals at varying stages of development and be prepared to offer counseling services tailored to the special needs of this population. Awareness of counseling techniques and knowledge of how to use those techniques effectively should help family medicine physicians to provide effective comprehensive health care to adolescent patients.

Adolescent↗
PubMed1985

Financing nutrition services in a competitive market.

Budget deficits and inflationary medical care costs threaten nutrition services, which until recently have been funded largely by federal, state, and local revenues. Nutritionists and dietitians responding to demands in the marketplace should develop innovative programs and pursue new sources for financing through the private sector, third-party payers, business/industry health promotion, and consumer fees for their services, as well as targeted federal, state, and locally funded food assistance, nutrition education, and health care programs. Trail-blazing dietitians are successfully offering their services in health maintenance organizations (HMOs), hospital or industry fitness programs, private practice, voluntary health agencies, and official agency programs. With the new federalism, nutritionists must articulate their role in comprehensive health care and market their services at the state and local levels in addition to the federal level. Nutrition services are defined to include assessment, planning, counseling, education, and referral to supportive agencies. Data management, managerial, and marketing skills must be developed for dietitians to compete effectively. Basic educational preparation and continuing education for practicing professionals must develop these competencies.

Costs and Cost Analysis↗
PubMedDate not supplied

Service models in community-based health: some findings from a literature review.

The findings from a review of the literature on community-based health services in Canada in 1991 indicate that two systems of health care exist side by side: the clinical care of the sick and the supportive care of those seeking to keep well. Organizational models of clinical care have not altered much since the introduction of health insurance. The medical profession has been resistant to changing traditional forms of practice organization from fee-for-service businesses treating individuals in isolation to components of an integrated comprehensive health care system. Traditional public health departments offering supportive and preventive care have been more ready to adapt to change. They are now working closely with provincial continuing-care organizers to provide home care for those who might otherwise need institutional care; however they are not closely linked with the clinical care services. More recently, public health departments have engaged in the health promotion movement to give citizens increased control over the conditions affecting their health. Yet we perceived a conflict between the rhetoric and the reality of their work.

Canada↗
PubMedDate not supplied

[Use of international databases for improvement of comprehensive care of patients with head and neck cancer].

The aim of this paper was to examine the usefulness of CancerNet in the improvement of knowledge of general practitioners on specific types of cancer and the procedures for patient management, thus indirectly producing an impact on quality improvement in comprehensive health care of patients with the head and neck cancer. Data on 58 patients with the head and neck cancer were collected from medical records in 28 general practices of the "Novi Zagreb" Health Center and from GPs' information. The GPs' knowledge on cancer of the larynx and hypopharynx was examined before and after they had studied the information provided by CancerNet. The mechanism of transferring information from the clinical and public health levels towards GPs was examined on GPs having in their care patients with the head and neck cancer. The following methodological characteristics were determined to have had an impact on patient care: within the structure of health care, a possible contribution of this procedure was identified in completing patient medical documentation as well as GPs' specific knowledge; within the health care process, a possible impact of this procedure on the quality of monitoring of a population health status, on more regular referrals to specialist consultations, as well as on pain and anxiety management, and a higher quality education on elimination of risk factors in patients' lifestyles. In average, the usefulness was scored by GPs with 4.0 for improving the communication with patients, and with 4.3 for expanding the GPs' knowledge. Three fifths of GPs involved in the study considered the contact range provided by CancerNet sufficient. All GPs assessed such information as useful for GPs in Croatia.

Databases as Topic↗
PubMed1993

Pregnancy complications and perinatal outcomes among women with diabetes--North Carolina, 1989-1990.

Women with diabetes have a higher risk for complications of pregnancy than do women without diabetes; in addition, infants born to women with diabetes are at increased risk for adverse birth outcomes. Preconception counseling for women with established diabetes and early and continual prenatal care for women with established or gestational diabetes can reduce maternal and infant morbidity and mortality. Although the rate of pregnancy complicated by diabetes and the use of prenatal care varies by race of the mother, it is unknown whether the effect of diabetes on maternal and infant outcomes differs by race. Race reflects differing distributions of several risk factors for pregnancy outcomes (e.g., socioeconomic status and access to comprehensive health care) and is useful for identifying groups at greatest risk for adverse outcomes. To determine the prevalence of diabetes during pregnancy among women residing in North Carolina and to characterize differences in prenatal care and the risk for maternal complications and adverse pregnancy outcomes by race among mothers with diabetes, the North Carolina State Center for Health and Environmental Statistics examined birth certificates of infants of women who gave birth in the state during 1989-1990. This report summarizes the findings of the study.

Adult↗
PubMed1993

Cost of care for patients with human immunodeficiency virus infection. Patterns of utilization and charges in a public health care system.

BACKGROUND: The increasing impact of human immunodeficiency virus (HIV) infection on the health care delivery system requires surveillance of current patterns of HIV-related health care utilization to adequately plan for future needs. Most studies to date have concentrated on inpatient care for patients with the acquired immunodeficiency syndrome (AIDS). Outpatient utilization has been less well studied and there are few data regarding HIV-infected patients without a diagnosis of AIDS. METHODS: Denver Health and Hospitals is a public system delivering comprehensive health care to mostly indigent residents of the city and county of Denver. Patients with HIV infection in this system were identified through multiple surveillance sources, and billing system records for these patients were analyzed. RESULTS: During 1990, 812 patients with HIV infection of 13 years or more were accessed in the Denver Health and Hospitals. During that year, the total HIV-related health care charges were $7,858,690, of which 57% were for inpatient care and 43% for ambulatory care. Patients with AIDS (34% of patients) accounted for 62% of all charges, and patients with HIV infection but without a diagnosis of AIDS (66% of patients) for 38% of charges. Compared with national predictions, patients with AIDS in our system had lower inpatient and higher outpatient utilization. CONCLUSIONS: These results are consistent with a shift from inpatient to outpatient health care services in patients with AIDS. A significant proportion of HIV-related health care costs are incurred by patients who have not yet developed AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed2004

Anti-aging medicine--the good, the bad, and the ugly.

Complementary and alternative medicine has flourished since the beginning of time because of a human need to postpone the aging process and to reverse disease. Complementary and alternative medicine sells, because in some cases it works as well or better than mainstream medicine. In addition, many practitioners of complementary medicine understand Hippocrates' aphorism: "It is more important to know the person that has the disease than the disease the person has." It is important to recognize that spending time with the patient is often as therapeutic as drugs. CAM offers patients the time, touch, attention, and level of personal interaction that are increasingly uncommon in contemporary medical care. There is a major need for large and appropriately designed studies to test the effectiveness of complementary techniques. As in other areas of health care, studies in the elderly are consistently lacking. With the growing interest in CAM, it is important for medical providers to keep an open mind--to both the potential benefits and potential harms of alternative treatments. When treatments are shown to be dangerous or ineffective, we must educate the public and work to remove these therapies from the market place. When treatments are proven effective, Western and Eastern medical providers must work together with patients to provide the most appropriate and comprehensive health care.

Adolescent↗
PubMed1998

Approach to assessing adolescents on serious or sensitive issues.

For some young people, adolescence is a time of experimentation with high-risk behaviors that can lead to significant morbidity and mortality. Providers of adolescent health care need to become comfortable screening their patients for involvement with sexual activity, drug and alcohol use, violence, and mental health issues. This includes taking into consideration not only the patient's age and development status, but their rights to confidentiality and comprehensive health care. Several tools such as HEADSS interview and the CAGE questionnaire can easily be used to screen for high-risk behaviors. By taking the time to get to know adolescent patients, it is possible to identify problems early and intervene while the adolescent is amenable to treatment.

Adolescent Medicine↗
PubMed1991

Methodological issues for adolescent pregnancy research.

Nurses have long been in the forefront of health care delivery for adolescents and are becoming more involved in adolescent pregnancy research. This article focuses on six methodological issues for adolescent pregnancy research: formulating the research question, selecting appropriate measures, recruiting subjects, obtaining informed consent, categorizing socioeconomic status, and balancing the clinician-researcher relationship. As we prepare for the 21st Century, we must develop new and creative approaches to adolescent pregnancy research, and we must bridge the gap between research and practice. Ultimately, knowledge derived from research and clinical practice should generate comprehensive health care and social policies for dealing with adolescent pregnancy.

Adolescent↗
PubMed1984

Pediatrics in the Marshall Islands.

The delivery of health care to children living on isolated island communities presents unique challenges to health professionals. An evolved method of providing longitudinal services to infants and children residing on islands of the Marshall Island chain--a central Pacific portion of the Micronesian archipelago--is presented. The difficulties associated with provision of comprehensive health care in a vast ocean area are discussed.

Adolescent↗
PubMed1997

Identification of needs of and utilization of resources by rural and urban elders after hospital discharge to the home.

The recent reductions in lengths of hospital stays may particularly affect the elderly in rural communities where resources may be scarce. The purpose of this descriptive, comparative study was to assess and evaluate the match of formal and informal resources with individual functional, behavioral, knowledge, and skilled care needs of rural and urban elderly during a 21-day transition period following hospital discharge to the home. Eighty-one elderly patients discharged to one urban and two frontier rural counties were selected. There were no significant differences in demographic variables between rural and urban participants. The Comprehensive Health Care Needs Assessment (CHCNA) questionnaire was used to assess needs and utilization of resources at 3 days and 3 weeks after discharge. Using repeated measure analyses of variance, there were significantly fewer needs identified at 3 weeks than at 3 days after discharge. Rural dwellers identified significantly more skilled care needs than their urban counterparts; however, none were highly technical in nature. Unexpectedly, at 3 weeks after discharge, considerably more functional needs were met by families in the urban setting than in the rural setting. Although only a small number of participants reported unmet needs in multiple domains, the complexity of the unmet needs requires further exploration.

Aged↗
PubMedDate not supplied

Comprehension of written health care information in an affluent geriatric retirement community: use of the Test of Functional Health Literacy.

BACKGROUND: The comprehension of written health care information, e.g. prescription bottle labels or an informed consent form, impacts on communication with patients and their ability to understand medical procedures, as well as goals of therapy. OBJECTIVE: To determine if the problem of literacy was present in a population of affluent Albuquerque retirement community dwellers. METHODS: We administered the Test of Functional Health Literacy in Adults (TOFHL) to 93 residents (71 women and 22 men), using a one-on-one directed examination conducted by one of the authors (J.G.B.). RESULTS: The group studied had a mean age of >70 years, were not acutely ill, had no known loss of mental function, were better educated and had a high standard of living compared to national standards. However, 30% (95% confidence level) of our group were unable to adequately comprehend written information as measured by the TOFHL. The subgroup with poor comprehension (21 women and 7 men) had a mean age of 85 years (versus 82 years in the group with good comprehension) and a mean of 13 years (versus 15 years in the group with good comprehension) of formal education. Multivariate analysis was consistent with a negative effect of age (p = 0.04), a positive effect of years of formal education (p = 0.0005) and no effect of gender on the TOFHL score. CONCLUSION: Two recent studies, one in an emergency room setting and the other among Medicare enrollees, demonstrated similar results to ours. The high prevalence of poor comprehension in these groups should alert providers to the need to develop additional or different communication skills that can address the problem of poor reading comprehension across at least three diverse groups of people, with particular attention to those over the age of 65.

Aged↗
PubMed2002

Quality and outcomes of heart failure care in older adults: role of multidisciplinary disease-management programs.

PURPOSE: To determine whether the management of heart failure by specialized multidisciplinary heart failure disease-management programs was associated with improved outcomes. BACKGROUND: The advent of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone has revolutionized the management of heart failure. Randomized double-blind studies have demonstrated survival benefits of these drugs in heart failure patients. Nevertheless, in spite of these advances, heart failure continues to be a syndrome of poor outcomes.1-4 There is also evidence that a significant portion of heart failure patients does not receive this evidence-based therapy that reduces morbidity and mortality.5-7 Various disease-management programs have been proposed and tested to improve the quality of heart failure care. Most of these programs are specialized multidisciplinary heart failure clinics lead by cardiologists or heart failure specialists and conducted by nurses or nurse practitioners. Similar to the Department of Veterans Affairs (VA) multidisciplinary geriatric assessment clinics, these clinics also use many other services, including pharmacists, dietitians, physical therapists, and social workers. Some of these programs also have an affiliated home health service. Several observation studies, using mostly pre- and postcomparison designs, have demonstrated the effectiveness of these programs in the process of care, resource use, healthcare costs, and clinical outcomes in patients with heart failure.8 Risk of hospitalization was reduced by 50% to 85% in six of the studies.8 Subsequently, several randomized trials were conducted to determine the effectiveness of these programs. The purpose of this systematic review was to determine the effectiveness of these programs on mortality and hospitalization rates of heart failure patients. METHODS: Published articles on human randomized trials involving specialized heart failure disease-management programs in all languages were searched using Medline from 1966 to 1999 and other online databases using the following terms and Medical Subject Headings: case management (exp); comprehensive health care (exp); disease management (exp); health services research (exp); home care services (exp); clinical protocols (exp); patient care planning (exp); quality of health care (exp); nurse led clinics; special clinics; and heart failure, congestive (exp). In addition, a manual search of the bibliographies of searched articles was performed to identify articles otherwise missed in the above search. Personal communications were made with three authors to obtain further data on their studies. Using a data abstraction tool, two of the investigators separately abstracted data from the selected articles. Data from the selected studies were combined using the DerSimonian and Laird random effects model and the Mantel-Haenszel-Peto fixed effects model. Meta-Analyst 0.998 software (J. Lau, New England Medical Center, Boston, MA) was used to determine risk ratios (RRs) with 95% confidence intervals (CIs) of mortality and hospitalization for patients receiving care through these specialized programs compared with those receiving usual care. The Cochran Q test was used to test heterogeneity among the studies, and sensitivity analyses were performed to examine the effect of various covariates, such as duration of intervention, and other characteristics of the disease-management programs. RESULTS: The original search resulted in 416 published articles, of which 35 met preliminary selection criteria. Of these, 11 were randomized trials and were selected for the meta-analysis. Studies that were not randomized trials, did not involve heart failure patients or disease-management programs, or had missing outcomes were excluded. Of the 11 studies selected, nine involved specialized follow-up using multidisciplinary teams and the remaining two involved follow-up by primary care physicians and telephone. These studies involved 1,937 heart failure patients with a mean age of 74. The follow-up period ranged from no follorom no follow-up (one study) to 1 year (one study). Patients receiving care from specialized heart failure disease-management programs had a 13% lower risk of hospitalization than those receiving usual care (summary RR = 0.87; 95% CI = 0.79 -0.96), but the Cochran Q test demonstrated significant heterogeneity among the studies (P =.003). Subgroup analysis of the nine studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77, 95% CI = 0.68-0.86; test of heterogeneity, P>.50). Seven of the nine studies did not show any significant association between intervention and reduced hospitalization, but the two studies that used follow up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94, 95% CI = 0.75-1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26, 95% CI = 1.04-1.52). Of the 11 studies, only six reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15, 95% CI = 0.96-1.37; test of heterogeneity, P>.15). Five of the studies used quality of life or functional status as outcomes, and, of them, only one demonstrated significant positive association. The results of the sensitivity analyses were negative for any significant association with duration of intervention or follow-up or year of study. Eight studies performed cost analyses and seven demonstrated cost-effectiveness of the intervention. CONCLUSIONS: The authors concluded that specialized disease-management programs were cost-effective, and heart failure patients cared for by these programs were more likely to undergo fewer hospitalizations, but the study did not provide any conclusive association between these programs and quality of care or mortality. The authors recommend that disease-management programs involve patient education and specialized follow-up by a multidisciplinary team including home health care.

Comment↗
PubMedDate not supplied

Patterns of care given migrant workers in Utah by private physicians and clinics.

This comparison of the care given migrant workers in Utah by private physicians with that provided by clinics demonstrates that clinics can provide more services and meet more of their needs. For a population group in need of an organization that can function specifically for them, the clinic offers many advantages. The clinic's role can also be expanded to become a focal point in the community for a comprehensive health care program for the disadvantaged. Although the cost of such a program may exceed the cost of traditional curative care from individual private physicians, the potential gains make it worth attempting. If long-term health is valued above short-term palliation, then the clinic would appear to be the best method of achieving this goal.

Adolescent↗
PubMed1977

Primary care education trends in U.S. medical schools and teaching hospitals.

In 1973 Schroeder and colleagues conducted a survey of U.S. Medical schools in order to ascertain the nature of change in primary care education which had occurred by that date. In 1976 the authors of the present paper utilized the same survey instrument to document trend data over the three-year period. While conclusions from the 1973 survey pictured primary care education in a transitional state, the 1976 data suggest movement toward a general consolidation of efforts. The 1976 data indicate a continued emphasis on education in the ambulatory care area with no well-defined locus for coordinating institutionwide primary care training efforts, a leveling off of interest in health maintenance organizations (HMO) affiliations, no significant change in the number of affiliated programs for training nurse practitioners or physician's assistants, and a marked increase in the number of schools with affiliated generalist residency programs in internal medicine and pediatrics.

Ambulatory Care↗