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Organisation of neoplastic haematopathology services: a UK perspective.

The diagnosis of haematological malignancies has begun to emerge as a distinct pathological discipline in the United Kingdom. This has been driven by the recommendation of the National Institute for Clinical Excellence that diagnosis of leukaemia and lymphoma should take place in a specialist laboratory and in most cases this should be organised on a regional basis. The reason for this guidance was the perception that there was a considerable level of diagnostic inaccuracy and that this could be improved by better integration of the currently available technologies. This is one of a number of major changes in the way that services to patients are being delivered, all of which are centred on the development of multidisciplinary teams responsible for the provision of local services. The introduction of the WHO classification of haematological malignancy provides a structure for the development of integrated haemtopathology laboratories, with its emphasis on definition of disease entities based on clinical, morphological, phenotypical and molecular features. This means that these diagnostic modalities can be used systematically and in parallel to provide effective cross validation of a diagnosis. One of the challenges raised by this approach is the selection of the most informative panels of investigations both at presentation and subsequent follow up from the wide range of options that are now available. The introduction of specialist haematopathology services in the United Kingdom has highlighted a number of scientific and organisational issues that in time may have a wider impact on diagnostic laboratories in general. These include the relationship between size and cost effectiveness and the future role of clinical scientists and medically trained pathologists. Integrated laboratories of the type being developed challenge the prevailing model for delivery of pathological services in the United Kingdom, which is based around the traditional pathology disciplines. These speciality boundaries will become less relevant as long established diagnostic techniques are replaced by the new generation of diagnostic technologies and it is important to establish frameworks of service delivery that can deploy these developments for the benefit of patients.

Flow Cytometry↗

Nurse entrepreneurs.

1. Supervised Environmental Living Facility (SELF) is a nurse-developed, non-profit, community-based, supervised apartment program for the chronically mentally ill. It provides comprehensive supportive and rehabilitative services to the chronically mentally ill, allowing them to re-establish themselves as part of the community. 2. SELF is based on the philosophy that a person needs assistance according to the extent that the illness affects the individual's ability to live safely and optimally. 3. Nurses can be entrepreneurs by seeking and creating innovative models for the delivery of services to specialized populations.

Chronic Disease↗

Collaborative consultation: a method for improving educational services for mainstreamed students who are hearing impaired.

As a result of well-known recent federal mandates for appropriate special education to all disabled students, the majority of children who are hearing impaired currently are educated in public school settings, along with hearing students. Consequently, teachers of students who are hearing impaired have expanded their role to include the provision of ongoing support to regular classroom teachers, speech-language pathologists, paraprofessionals and administrators. One model for delivery of these services is that of collaborative consultation. The purpose of this paper is to provide an overview of collaborative consultation, and to delineate some principles that merit consideration by regular and special educators who are involved in the education of students who are hearing impaired.

Correction of Hearing Impairment↗

Synergies between veterinarians and para-professionals in the public and private sectors: organisational and institutional relationships that facilitate the process of privatising animal health services in developing countries.

The delivery of veterinary services in most developing countries was, until recently, considered to be the responsibility of the public sector. However, over the past four decades, economic constraints and the imposition of structural adjustment policies (SAPs) have led to a gradual decline in public sector investment in real terms and thus a reduction in the quality and quantity of services available to livestock keepers. Many governments acknowledged that they were no longer able to provide services that were essentially of a 'private good' nature and introduced radical policy changes which sought to introduce the concepts of a market orientated approach towards agriculture and livestock production in particular. The role of government, in the future, would be to provide a reduced range of essential 'public good' services and to create a favourable environment in which the private sector could become established as a provider of 'private good' services and at the same time act as a partner in carrying out certain public functions under contract or 'sanitary mandates'. In almost all developing countries, however, these policy changes were not accompanied by appropriate development strategies. The reasons for this are complex. Firstly, SAPs may be considered to have been foisted upon governments by donors and are thus perceived by many policy-makers as the cause of financial problems, rather than a solution to them. Secondly, most animal health senior policy-makers in the public sector have been trained as veterinarians and lack the required management skills to plan change effectively. Furthermore, as regards clinical veterinary service delivery, especially in rural or more remote areas, the solution fostered by donor investment, which involves deregulation and the deployment of privately operating para-professionals, is often perceived as a threat to the veterinary profession and might result in limiting access to international markets for the trade of livestock and livestock products. An informal delivery system has gained a foothold in many developing countries in the absence of a well-planned strategy for the privatisation of animal health services. Most governments would now acknowledge that this presents a greater risk than the deployment of well-regulated and effectively supervised para-professionals. This paper explores some of the principal challenges facing policy-makers in their efforts to bridge the transition from full state provision of animal health services to the formation of a partnership with the private sector. Governments and donors need to take active steps to facilitate the process of privatisation of animal health services, especially those targeting the poorer rural subsistence and pastoralist farming systems. This would entail an initial investment in developing the necessary management skills at all levels in the delivery system. Thereafter, further investment would be required to allow the changes to be managed using tools such as the strategic planning cycle. Should sufficient resources be made available to allow the full participation of all stakeholders in the delivery of animal health services, appropriate institutions and effective organisational relationships addressing all the more important issues will have to be identified. The paper then proceeds to describe how different livestock production systems determine the level of demand for animal health services. If these services are to be provided on a financially sustainable basis, they must be tailored to meet actual rather than perceived demand. Identifying an appropriate model for animal health service delivery thus requires careful analysis of the production system to be targeted. Governments and donors can play a useful role in providing resources for this type of study as well as for appropriate market studies, business planning, training and access to soft loans. Finally, as regards regulation, as the law stands today, many activities currently practised by para-professionals are classified as 'acts of veterinary medicine or surgery' and may only legally be performed by qualified and registered veterinarians. The concept of 'principal' and 'subsidiary' legislation provides the necessary flexibility in the regulation of the delivery of animal health services to accommodate the rapid changes taking place in this environment today. Deregulation involves the delegation of responsibility for the performance of a defined range of veterinary interventions to para-professionals under the 'supervision' or 'direction' of a registered veterinarian. The author illustrates how the experiences of a number of projects in Tanzania were used to propose a definition of 'supervision' in law. The definition offers an opportunity to overcome the fear of compromising standards of delivery of animal health services through the deployment of para-professionals. In addition, such functioning provides employment opportunities for private veterinarians in rural areas where access to formal primary animal health services would otherwise be denied and may contribute to the process of quality assurance of national veterinary services in developing countries.

Animal Technicians↗

Nurse managed occupational health services without on-site clinical care delivery: a case example.

1. In this program management/community network model of occupational health services, the occupational health nurse is responsible for managing program development and implementation, with vendors providing the clinical services. 2. Occupational health nurses' primary areas of responsibility are occupational health, disability case management, ergonomics, and health promotion. 3. Successful management of program outcomes requires the occupational health nurse to continually assess employee/business needs, maintain communication with employees and management, and partner with the environmental, health, and safety team, other functional work groups, and vendors. 4. Effective management of contracts becomes critical to the process beginning with clear service requirements through the delivery of quality services.

Ambulatory Care Facilities↗

Case management in public health screening programs: the experience of the national breast and cervical cancer early detection program.

This article describes a large public health screening program's early experience in adding case management as a formal program component. The results demonstrate that state and tribal programs participating in the National Breast and Cervical Cancer Early Detection Program have implemented a variety of organizational models for case management of women with abnormal screening results. Programs have different approaches to staffing and reimbursement of case management services, yet most programs have implemented a "patient navigator" or "medical" model of case management service delivery. Although a number of challenges were identified, a clear and positive finding is that case managers are playing an integral role in the transition between a cancer diagnosis through the program and enrollment in Medicaid for treatment services through the National Breast and Cervical Cancer Prevention and Treatment Act of 2000.

Breast Neoplasms↗

Does the chronic care model serve also as a template for improving prevention?

Practical models of ways to enhance service delivery are sorely needed to help close the gap between research and practice. An evidenced-based model of chronic-illness management is shown to apply equally to preventive interventions. Successful examples of prevention programs in cancer screening and counseling for health behavior change illustrate the utility of the model for prevention and across different types of health care organizations. Although there are some important differences between interventions required for chronic disease management and prevention, there are a greater number of common factors. They share the need to alter reactive acute-care-oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required for both prevention and chronic care.

Chronic Disease↗

Empirically and clinically useful decision making in psychotherapy: differential predictions with treatment response models.

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Adult↗

Four systems develop regionally organized HMO.

Plans to establish HealthPlus HMO, Inc.--a joint venture of the Sisters of St. Francis Health Services, Ancilla Systems, Daughters of Charity Health Systems-East Central, and Holy Cross Health System--began in 1984 with a feasibility study to assess the potential for an HMO in Indiana. Goals set by the four systems included protecting and expanding hospitals' market share and physicians' patient bases; establishing local HMO ownership; and providing health education, preventive care, and comprehensive treatment at affordable costs. During the organizational phase, participants created a 12-member board of directors with three representatives from each system, selected the name HealthPlus, and contracted with a management company to direct the HMO's planning and development phases. HealthPlus adopted a regional organizational structure, which allows financial risk to be shared among three regions, and a primary care physician model for the delivery of services. As of January 1987, the joint venture had 16 participating hospitals, 345 primary care physicians, more than 1,000 consulting specialists, and a membership of 13,100. HealthPlus now offers a triple-option product in partnership with a preferred provider organization and an insurance carrier and has developed non-health-related products with the insurance carrier as well.

Catholicism↗

Service delivery for patients with HIV in a rural state: the Vermont model.

The incidence of human immunodeficiency virus (HIV) infection is increasing rapidly in rural areas of the United States. Barriers to health-care delivery for this patient population include the complexity of this rapidly changing field, inexperienced rural physicians, long travel distances to receive expert care, lack of psychosocial support systems, and concerns about confidentiality. Models of HIV care for rural areas have not been developed that remove these barriers. We present the philosophy, structure, implementation, and services of a model of care in Vermont that is designed to remove many of these barriers and bring HIV expertise into the rural areas of the state. Three HIV specialty clinics have been developed in regional hospitals throughout the state. The clinic team includes an HIV-trained nurse practitioner and social worker from the hospital, a client consultant from the regional AIDS service organization, and an infectious disease specialist who travels to each of the clinics monthly. Patient care will be centralized in these regionally located clinics. The dispersion of HIV care among numerous and inexperienced rural providers will be obviated. Confidentiality will be emphasized within the hospital environment. The model has the potential to provide a complete continuum of medical care and psychosocial case management, integrate patient care and regional provider education, and increase community awareness. Patients will be able to receive their care in their own community, avoiding long travel distances. This may encourage patients to seek care earlier in their illness. The model may be adaptable to other rural areas of the United States.

Case Management↗

Payment policy, quality of care and decision making with inadequate information.

The health care system in the United States is in chaos. The conflict is between containing costs on an aggregate level while, at the same time, not reducing services to the individual if the services are essential for quality care. There is little information on which to base decisions about the value of services. Health care organizations and delivery models must be restructured because current models are out of date. To accomplish this restructuring, better information is needed on why hospitals and doctors do what they do. Success in developing information and decision models that result in patients receiving only medically necessary services will contribute greatly to promoting high quality, cost-conscious care.

Cost Control↗

Evaluation of the transprofessional model of home health care for HIV/AIDS.

OBJECTIVE: To determine if a Transprofessional care-management approach (experimental group) produces savings in service delivery dollars when compared to a Traditional treatment approach (control group). The care-management approach utilizes an interdisciplinary mix of allied health professionals who adhere to a service delivery protocol based on active, medical, surgical treatment (curative services) as well as on pain, symptoms, and emotional care (palliative services). DATA SOURCES AND STUDY SETTING: Data were collected from 549 AIDS patients admitted for medical/surgical home-care services to the Visiting Nurse Association of Los Angeles (VNA-LA). Demographic and disease-specific data were collected from admitting records; service-utilization data were collected from the VNA-LA's computerized data system. STUDY DESIGN: Upon admission for home-care services, patients were randomly assigned to an experimental (Transprofessional) or control (Traditional) treatment group. Service levels were comparable. PRINCIPLE FINDINGS: Post-test measures indicate an 8 percent reduction in labor delivery costs for an average experimental patient's entire episode of home-care versus for an average control patient's. CONCLUSIONS: An integrated model of service delivery, which is based on interdiscriplinary, care-management and blended modalities of service, provides a cost-effective method in the provision of home-care services for terminally ill AIDS patients.

Adult↗

Speech-language interventions in Alzheimer's disease. A functional communication approach.

Alzheimer's disease is a progressive degenerative neurogenic disease that is more prevalent among the old than the young. The primary symptoms are forgetfulness, repetitiousness, losing one's way, and the loss of ability to perform complex tasks on the job. Diagnostic confirmation of Alzheimer's disease is determined by autopsy. As of this writing, there is no specific drug that can stop or reverse the disease. Medical management is focused on treating behavioral symptoms and managing the individual's general well-being. The communication needs of the Alzheimer's client depend on the individual's level of cognition, degree of independence, circumstance, and communicative abilities. Due to their poor rehabilitation potential, the majority of persons with Alzheimer's disease are not suitable candidates for traditional therapy programs. An alternative to traditional therapies is the Tri-Model system. The Tri-Model philosophy of rehabilitation and service delivery systems (Glickstein and Neustadt, 1992) lends itself readily to the needs of the dementia client because the model is designed to maintain the continuum of rehabilitation care for individuals with "red flag" diagnoses such as dementia. Establishing a treatment protocol based on the Tri-Model philosophy of rehabilitation not only assures the individual treatment based on his or her level of functional ability and rehabilitation need, it provides a framework for the rehabilitation specialist to use as reference for the various stages of disability and change during rehabilitation. The Tri-Model System is a decision tree which allows movement in any direction according to the client's needs (Figure 1). Clients, staff, and families are encouraged to set realistic goals at the outset of the rehabilitation program. By delineating three overlapping phases in the recovery process a base is established which allows the rehabilitation professional to appropriately follow the client after discharge and maintain the continuum of care. Since each restorative phase in the system requires the design of restorative programs which address that particular phase of the rehabilitation process and cooperation of an interdisciplinary team, addressing all three phases of rehabilitation at the time of the initial evaluation maintains the continuity of the client's treatment protocol throughout the course of the disease. Inclusion of Restorative III (functional maintenance) assures the continuum of care. The strength of the Tri-Model philosophy and system of rehabilitation is the inclusion of the definition and delineation of functional maintenance, the most neglected and for many clients the most important part of a complete rehabilitation program. When an incomplete definition of rehabilitation is used, questions regarding the efficacy of treatment is common.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗

Coping with disasters: estimation of additional capacity of the mental health sector to meet extended service demands.

BACKGROUND: The September 11th disaster in New York City resulted in an increase in mental health service delivery as a vast network of providers responded to the urgent needs of those impacted by the tragedy. Estimates of current capacity, potential additional capacity to deliver services and of potential shortfall within the mental health sector are needed pieces of information for planning the responses to future disasters. AIMS OF THE STUDY: Using New York State data, to determine the distribution of clinical service delivery rates among programs and to examine an explanatory model of observed variation; to estimate potential additional capacity in the mental health sector; and to estimate shortfall based on this capacity and data from studies on the need and use of services post September 11th METHODS: Empirical distributions of weekly clinical service delivery rates in programs likely to be used by persons with post disaster mental health problems were obtained from available data. Three regression models were fit to explain rate variation in terms of unmodifiable program characteristics likely to impact the rates. We argue that rates could not be easily increased if any of the models had good explanatory power, and could be increased if it did not. All models had poor fit. We then assumed that the median and 75th percentile of the clinical service delivery rates were candidates for the minimum production capability of a clinician. The service rates of those clinicians whose rates fell below these quartiles were increased to the quartile value to yield estimates of potential additional capacity. These were used along with data on clinical need to estimate shortfall. RESULTS: There is substantial variation in clinical service delivery rates within impact regions and among programs serving different age populations. The estimate of the percent increase in services overall based on the median is 12% and based on the 75th percentile is 27%. Using an estimate of need of.03 suggested by available data, and a range of services (1-10) that might be required in a six month period, shortfall estimates based on the median ranged between 22-92% and for the 75th percentile from no shortfall to 86%. A less conservative estimate of need of.05 produces median shortfall ranging between 59-96% and for the 75th percentile between 10-91%. LIMITATIONS: While the program descriptor variables used in the explanatory model of rates were those most likely to impact rates, explanatory power of the model might have increased if other characteristics that are not modifiable had been included. In this case, the assumption that service production can be increased is called into question. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: In the first six months post September 11th, in New York State (NYS) 250,000 persons received crisis counseling through Project Liberty. In 1999, NYS served approximately that same number in mental health clinic programs during the entire year. The estimates of this study suggest that additional funding and personnel are needed to provide mental health services in the event of a major disaster. IMPLICATIONS FOR HEALTH POLICIES: A disaster plan is needed to coordinate the use of current and additional personnel including mental health resources from other sources and sectors.

Adult↗

School health: a national policy issue in the Soviet Union.

In the Soviet Union school health services are provided as an integral part of the health care delivery system, which is under the Ministry of Health. This paper presents an overview of the Soviet health care delivery system, the model for the delivery of school health services, the role and training of school personnel involved in school health services and implications the Soviet model may have for other countries.

Health Policy↗

Empowering primary care health professionals in medical genetics: how soon? How fast? How far?

Applications of genetics to the practices of medicine and public health are important today and will only become more compelling as our understanding of the human genome evolves. Because of a perceived lack of medical genetics professionals, it is generally believed that primary health care providers (PCPs) will need to assume prominent roles in delivering clinical genetics services. However, a number of studies indicate that most PCPs are neither well enough educated in genetics nor interested enough in becoming so to effectively contribute. Those who advocate empowering PCPs must be aware of potential problems with any approach thus far suggested for achieving this goal. Moreover, any analysis of this model must consider the potential ramifications for medical genetics professionals, patients, and families. In this article, we explore some of the unique features of the culture of medical genetics services and service providers. We discuss how important this culture is to clinical outcomes and the likelihood that its positive attributes would be preserved in a PCP model of medical genetics service delivery.

Delivery of Health Care↗

How we live: participatory research with six people with learning difficulties.

Drawing from the Social Model of disability, six people with learning difficulties participated over 18 months in researching their own lived experiences. The method involved weekly group discussions supplemented by participant observation. The study's value stems from in-depth inquiry, which included the participants in the data collection, analysis, dissemination and consequences that they found meaningful. The participants lived in nurse managed community homes. They described how they had faced social and economic exclusion, for example, concerning marriage, child rearing and decently paid employment. With the assistance of nursing staff, the participants had overcome many other social barriers and were enjoying a wide range of activities and choices. Consequently, the participants lived varied lives which they described as interesting and worthwhile. Contemporary models of nursing had successfully directed nursing staff to support 'ordinary living'. However, some disabling assumptions were evident within contemporary nursing. Hence, models of nursing and service delivery were helping both to create lifestyles that the participants valued, whilst simultaneously contributing to their disempowerment.

Adult↗

Assertive Community Treatment for patients with chronic and severe mental illness who abuse drugs.

The Assertive Community Treatment model of mental health service delivery has been extensively studied and has undergone various modifications over the past twenty years. This article describes a modified ACT Team approach to the treatment of individuals who suffer from severe comorbid mental illness and substance abuse. Demographics of patients who are chosen to receive these intensive services, service utilization patterns, and elements of team treatment are discussed. Comparisons with less severely ill dual diagnosis patients who receive more traditional case management services are reviewed.

Adult↗