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PubMed2004

Decision making for physical therapy service delivery in schools: a nationwide survey of pediatric physical therapists.

BACKGROUND AND PURPOSE: A nationwide survey was conducted to explore decision making among school-based physical therapists and to examine recommendations regarding the models, contexts, frequency, and intensity of physical therapy service delivery. Factors that the therapists considered important in making clinical decisions also were examined. SUBJECTS AND METHODS: A survey instrument using a clinical case format was sent to all members of the American Physical Therapy Association's Section on Pediatrics who identified themselves as school-based therapists (N=1,154); 626 respondents, from all 50 states, completed the survey. Four case descriptions were presented in the survey: 2 preschool girls with developmental delay (1 with and 1 without cognitive impairment) and a boy with cerebral palsy (at 6 and 12 years of age). RESULTS: Individual direct services were recommended by 52% to 55% of the respondents for both 4-year-old girls and for the boy at 12 years of age; 92% of the respondents recommended them for the boy at 6 years of age. The most prevalent choice (48%-73%) for the context of service delivery (location or environment) was a combination of integrated and isolated contexts. For those respondents who selected direct services (individual or group, or both), the mean recommended monthly frequency for the boy at 6 years of age (5.8) was more than twice that for the boy at 12 years of age (2.4). The mean suggested direct frequency for the girl with cognitive impairment (4.5) was greater than that for the girl without cognitive impairment (4). The students' functional levels were considered very to extremely important in decision making by 87% to 90% of the respondents. DISCUSSION AND CONCLUSION: Survey responses were relatively consistent with current literature regarding school practice and principles of motor learning. Recommendations varied for each case, regarding the models, contexts, frequency, and intensity of physical therapy service delivery.

Adult↗
PubMed2004

Consultant supported intermediate care--a model for remote and island hospitals.

INTRODUCTION: Providing local consultant-delivered hospital services in remote and island communities in the United Kingdom is increasingly problematic due to difficulties with recruitment and retention of staff, statutory restrictions to hours worked by health professionals and the expectation each clinician must manage an externally defined volume of cases to maintain clinical standards. This article describes a before-and-after evaluation of a novel method of providing consultant support for acute internal medicine to an island grouping off the Scottish coast. Under the scheme, local GPs provided acute medical care of inpatients. A consultant general physician was appointed in a district general hospital on the mainland, approximately 100 miles from the island group, to provide a lead clinician role for inpatient services at the island hospital, visiting the island on a twice-monthly basis, undertaking educational sessions and developing local guidelines and care pathways for the management of individual medical conditions. In addition, two junior doctors were appointed to the island hospital to support inpatient care. METHODS: A prospective recording system for case mix was established with agreed evidence-based protocols, developed as integrated care pathways (ICP), for indicator conditions. General case mix was determined during two 6-month periods, June-November 2001 and June-November 2002, before and after implementation of the new arrangements. Performance against an ICP for management of suspected cardiac chest pain was evaluated in detail, examining the process of management, clinical outcome and economics. Data from the clinical literature were used to estimate the potential health gains from observed changes in clinical practice. RESULTS: Total admissions rose by 25% in the second time period, with particular increases noted for cardiovascular, cerebrovascular disease, and cancer. Total air ambulance transfers between the islands and the mainland within these time periods increased by 31%, from 88 to 115 transfers. Recording specific details from the history and frequency of appropriate blood investigations increased and initial steps in management changed considerably after introduction of the ICP. The number of transfers to the mainland teaching hospital increased from 3/37 (8%) in 2001 to 15/56 (27%) in 2002. Based on an estimated 100 patients per year, of whom 15 would receive thrombolysis, total additional patient costs would be 64,000 pounds sterling. The annual cost of the additional resource input into the medical service was 148,000 pounds sterling. Approximately 16 adverse events would be avoided at a combined cost of 212,000 pounds sterling (148,000 pounds sterling direct costs of intervention + 64,000 pounds sterling additional treatment costs) or 13,250 pounds sterling per event avoided. This is a conservative estimate of benefit as all the direct costs of the intervention have been included. CONCLUSIONS: This study shows that appropriate standards of care can be delivered in the setting described. Costs of care increased, but the level of service provided increased concomitantly, and the health benefits were achieved at costs that compare favourably with other interventions recommended by health technology assessment groups. An estimate of notional costs involved in alternative models for the delivery of hospital medical services in a remote area suggests that costs would be similar for a three-consultant service, the present model, and a triage and transfer system. In the future, the models chosen by remote and island communities and healthcare providers are therefore likely to be determined by viability, sustainability and public acceptability rather than cost. Our study indicates that consultant supported intermediate care is a viable model.

Journal Article↗
PubMed2006

Untangling the web: the need to clarify care co-ordinating models for people with chronic and complex conditions.

OBJECTIVE: In order to clarify the expanding care co-ordinating field and stimulate debate, a descriptive typology is developed suitable for a range of stakeholders and purposes. METHODS: The strategy for development of the typology involved a literature review of the most commonly used care coordinating models and the utilisation of select government publications that verified diverse ways of classifying care co-ordinating needs. A descriptive typology is proposed to better communicate similarities and differences. RESULTS: The typology delineates similarities and differences among care co-ordinating models that stakeholders can use as a step towards determining the most effective model to meet the varied needs of individuals and populations. CONCLUSIONS AND IMPLICATIONS: Stakeholders can more informatively communicate about care co-ordinating models and their place in the service delivery system. The typology may be used in comparing the effectiveness of the models. A clearer understanding of the field is both timely and warranted.

Chronic Disease↗
PubMed2004

The informationist in Australia: a feasibility study.

OBJECTIVES: A clinical informationist could provide the best available published evidence in response to clinicians' questions identified during the process of care. This study sought to assess the feasibility of an informationist service and to propose a model for its delivery in an Australian teaching hospital. Whilst similar services are increasing in the UK, with a long history in the USA, this is the first Australian study in an acute public hospital. METHODS: The views of 40/49 (82%) medical staff at the Daw Park Repatriation General Hospital, South Australia were canvassed using a questionnaire designed to address key issues relating to a proposed service. RESULTS: Doctors were receptive to its potential benefits, perceived it as relevant and likely to be used, and were interested in a pilot. They typically indicated a required response time of 24 h. They expressed limited concerns other than a likely high workload for such a service, and reported currently searching infrequently for evidence in response to clinical questions, citing time issues and unavailability of computers as current key barriers to pursuing clinical questions. CONCLUSIONS: An informationist service is feasible. Results suggest that a pilot could be run in an area of acute medicine where questions about therapy and diagnosis are likely to proliferate, and the informationist should attend consultant ward rounds and clinical meetings, aiming to provide a response within 24 h.

Attitude of Health Personnel↗
PubMed1995

Integrated case management: the AID Atlanta Model.

This article describes the integrated case management model being developed by AID Atlanta, Inc., a community-based AIDS service organization. The case management system features centralized supervision and coordination with decentralized delivery of case management services that avoid duplication of services. The model establishes a system that links clients to appropriate levels of service. The integrated model seeks to address the client's physical, psychological, emotional, and spiritual needs across a continuum of care delivery. The cornerstone of the system is the development of standards of service, systematic documentation, and outcome evaluation criteria.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Models of integrated cancer care: a critique of the literature.

A number of models that integrate care across the hospital-community interface have been developed. Consumers and health care providers who are considering adopting this approach to service delivery need to consider which model is most suitable for implementation in their setting. A comprehensive review of the literature was conducted to identify and describe integrated care delivery models. This article defines five integrated models of care, provides a critical analysis of each model, and evaluates the extent to which claims about the models are supported by clinical reports and empirical findings. Finally, recommendations are made regarding implementation.

Continuity of Patient Care↗
PubMed2005

Fund allocation within Australian dental care: an innovative approach to output based funding.

BACKGROUND: Over the last 15 years in Australia the process of funding government health care has changed significantly. The development of dental funding models that transparently meet both the service delivery needs for data at the treatment level and policy makers' need for health condition data is critical to the continued integration of dentistry into the wider health system. METHODS: This paper presents a model of fund allocation that provides a communication construct that addresses the needs of both policy makers and service providers. RESULTS: In this model, dental treatments (dental item numbers) have been grouped into eight broad dental health conditions. Within each dental health condition, a weighted average price is determined using the Department of Veterans Affairs' (DVA) fee schedule as the benchmark, adjusted for the mix of care. The model also adjusts for the efficiency differences between sectors providing government funded dental care. In summary, the price to be applied to a dental health condition category is determined by the weighted average DVA price adjusted by the sector efficiency. CONCLUSIONS: This model allows governments and dental service providers to develop funding agreements that both quantify and justify the treatment to be provided. Such a process facilitates the continued integration of dental care into the wider health system.

Australia↗
PubMedDate not supplied

The occupational therapist on a geriatric rehabilitation team.

This article describes a rehabilitation services team at a skilled nursing facility. The objectives were to explore what occupational therapy can offer nursing home residents and to provide a model in the delivery of rehabilitation services to the institutionalized elderly. Emphasis is placed upon program structure and rationale, staff interrelationships, and the role of the occupational therapist on the team.

Aged↗
PubMed1997

HRSA's strategies to combat family violence.

This paper discusses the efforts of the Health Resources and Services Administration (HRSA) to work with a broad constituency to combat and ultimately prevent family violence. In partnership with states and communities, HRSA implements programs to strengthen health care infrastructure, support direct community-based service delivery, and educate health care providers. Soliciting and incorporating community input are critical steps in designing innovative training approaches to deal with pressing health concerns, such as the efforts of family violence in a community. This type of collaboration is evident in HRSA's programs such as the Area Health Education Centers, the Geriatric Education Centers, and the AIDS Education and Training Centers. Health care delivery systems and special health interventions must respond to the far-reaching effects of family violence. HRSA is devising a comprehensive strategy to guide program development in violence intervention. This strategy would build on successful models of education, prevention, and service delivery, as well as identification of critical areas for collaboration between community activists, researchers, epidemiologists, health care providers, policymakers, academicians, survivors, philanthropists, representatives from state and local government, and the faith community.

Domestic Violence↗
PubMed1982

Pharmacy in the health care center: a model for health care delivery.

Health care consumers use a plethora of services which are accessible on an ambulatory basis. These include the services of pharmacists, optometrists, nurses, dentists, audiologists, orthotics, and so forth. Since many of these services are provided in physically and financially separate facilities and often are not located in close proximity to one another, consumers may spend a large amount of time traveling between locations. Economic inefficiencies due to the size and dispersion of separate and independent facilities may produce an increase in the cost of ambulatory health care services. Thus, the concept of a health care center, an ambulatory health care analog to the multispecialty shopping center, is proposed as a potential alternative and improvement in the delivery of these services. Space, location, personnel, and initial capital requirements for a model health care center are projected based on existing data for the establishment of each separate auxiliary health care facility. Projections are made to determine the appropriate and necessary site for the health care center's trade area. Potential revenues are calculated by examining some pharmacy operations which are beginning to pioneer these areas and utilizing revenue figures for the various individual services. The results indicate that the pharmacy, as a frequently visited health care facility, may be an excellent choice around which to develop the health care center concept in metropolitan areas.

Ambulatory Care Facilities↗
PubMed2006

Role function and job satisfaction of school psychologists practicing in an expanded role model.

School psychologists are typically itinerant among multiple schools and often spend up to two-thirds of their time on assessment activities related to students with disabilities and special education programs. School psychologists in delivery of an expanded role service model are assigned to a single school and provide more consultation and intervention services. 97 school psychologists assigned to an expanded role in a single southeastern urban school district were surveyed on their job roles and job satisfaction. The majority were satisfied or very satisfied with their jobs, particularly with engaging in activities that were of service to others and staying involved in a variety of job activities. School psychologists wanted to spend less time in assessment, multidisciplinary team meetings, and administrative duties. The discrepancy between the desired and actual amount of time spent in multidisciplinary meetings was negatively related to job satisfaction. Psychologists wanted to spend more time in direct and indirect intervention, professional development, and networking.

Adult↗
PubMed1996

Evolution of services for the chronically mentally ill in a managed care setting: a case study.

Managed care plans have expanded to serve individuals with severe and chronic mental illness over the past 25 years. During that time, the evolution of several key clinical phases has been witnessed: the creation of a diverse spectrum of services; the development of treatment algorithms; and the implementation of treatment outcomes measures as a way to gauge program success and develop future strategies. At the same time, a number of additional factors have had a significant impact upon the development of clinical programs targeted toward the chronically mentally ill: dollars allocated to mental health services; the influence of different models of delivery; and the incentives inherent in various methods of payment.

Algorithms↗
PubMed1999

Genetic cancer risk assessment. Putting it all together.

Dramatic advances in our understanding of the genetic basis for cancer have led to the development of new technologies and tools for genetic cancer risk assessment. Yet, cancer is a complex disorder, and risk assessment, counseling, and management strategies need to consider several important domains: state of cancer genetics knowledge, state of mind (previous cancer experience within the family), state of technology, and state of the art in terms of management. There are several barriers to the efficient identification and counseling of patients and families at high risk for cancer because of inherited susceptibility mutations. Chief among these concerns is the lack of access to competent counseling and education services that are equipped to handle the complex and rapidly evolving medical, technological, and ethical issues. Cancer risk assessment is developing into a distinct discipline in which established empiric risk models are recast along with rapidly evolving genetic technologies for estimation of individual cancer risk. Cancer genetics consultants are an important resource for primary care physicians, gynecologists, surgeons, and oncologists. However, no formal qualification criteria exist for either physicians or allied health care professionals who subspecialize in this new field. This article covers the unique domains of cancer genetics in health care and surveys models for delivery of cancer genetics services and tools for risk assessment. Coupled with innovative cancer diagnostic and preventive services and research, we have the potential to make great strides in cancer prevention and control.

Education, Medical, Continuing↗
PubMed2001

The pharmaceutical care of patients with hypertension: an examination of service models in primary care in the US.

BACKGROUND: In the UK, the delivery of health care in cardiovascular disease is guided by national service frameworks', which are a source of standards of practice and evidence that help to define and aid the implementation of service models capable of responding to public health goals. The revised British Hypertension Society guidelines reflect a lower target blood pressure consistent with those recommended in the US and by the WHO. The lowering of the target for the control of blood pressure has increased the estimated proportion of treated patients with inadequate control in the UK from 37% to 72%. OBJECTIVE: To identify the requirements for the provision of a pharmacy service that supports hypertension monitoring, and to gain insights into how such a service might be delivered as part of a wider provision of pharmaceutical care in the UK. METHOD: Two pharmacists followed a structured programme of observation involving three centres in the United States (Minnesota, Colorado and Iowa). Twelve clinical settings were observed, and the pharmacists who provided the services were also the subjects of documented interviews. The settings offered different models of pharmaceutical care from which issues relevant to the international development of such services were identified. FINDINGS: Differences noted between the service models observed included; physical environment of the community pharmacy, the use and type of documentation, methods of blood pressure measurement, extent of monitoring and follow-up, inter-professional communication and service orientation in terms of the provision of comprehensive pharmaceutical care to patients or specific disease management. CONCLUSION: If clearly defined operational models of pharmaceutical care practice in the primary care setting are to form part of a national public health strategy in the UK, they must also be capable of responding to local opportunities and patients' needs. Future development of models and services must be patient-centred and more widely informed by the range of practice experience gained elsewhere.

Blood Pressure Monitoring, Ambulatory↗