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PubMed2006

Linking case management and community development.

Case management, in various forms, is now institutionalized as a core part of policy and programs designed to deliver home- and community-based services to older adults. The case management role, in theory, requires attention to both client and system goals, although in practice the system goals that have received most attention have been gatekeeping and resource allocation. While case managers have been admonished to find and develop resources in the community, this has primarily taken the form of including informal services in individual client care plans. What has been missing is focused attention to the potential of the community as a nurturing environment with the capacity to support older adults and their caregivers. Sustainable care for older adults cannot be achieved by formal service and family support alone. This article proposes the creation of linkages between case managers, who build the service arrangements for older people, and community developers, who are responsible for building community capacity and social capital. It is argued that this linkage is essential for establishing the foundations of a caring community with the capacity to support older people.

Aged↗
PubMed2002

Insurance product design and its effects: trade-offs along the managed care continuum.

This paper uses 1996-97 Community Tracking Study data to analyze the effects of different insurance product designs on service use, access, and consumer assessments of care for nonelderly people with employer-sponsored insurance. Product types are defined by features including use of networks, gatekeeping, capitation, and group/staff model delivery systems. We found no evidence of differences across product types in unmet need or delayed care or use of hospitals, surgery, or emergency rooms. At the same time, different product designs present purchasers with a clear trade-off between paying more out of pocket and encountering more administrative barriers to care. In addition, an increasing proportion of consumers report dissatisfaction with choice of physicians and low trust in physicians as one moves along the managed care continuum from unmanaged to heavily managed products. Our findings have implications for efforts to regulate managed care. The existence of a trade-off between out-of-pocket costs and administrative barriers to care means that some forms of regulation run the risk of reducing choices available to consumers. This is particularly true of regulations that would change the nature of managed care products by prohibiting the use of specific care management tools. To the extent that the backlash against managed care targets restrictions on choice and administrative hassles among consumers who nonetheless choose more heavily managed products because of their lower cost, eliminating heavily managed products would leave those consumers worse off.

Adult↗
PubMed1999

Perceived role of primary care physicians in Nova Scotia's reformed health care system. Qualitative study.

OBJECTIVE: To determine primary care physicians' perceptions of their role in a reformed health system. DESIGN: Qualitative study using in-depth interviews. SETTING: Province of Nova Scotia. PARTICIPANTS: Purposefully selected sample of 14 practising primary care physicians. MAIN OUTCOME FINDINGS: Participants identified seven aspects of their role: primarily, diagnosis and treatment of patient's medical problems; then coordination, counseling, education, advocacy, disease prevention, and gatekeeping. The range of activities and degree of responsibility assumed by participants, however, varied. Factors affecting role perception fell into three categories: philosophical view of health and medicine, willingness to collaborate, and practical realities. Participants differed in their understanding of primary health care and their overall vision of the health system. Remuneration policies and concerns about sharing accountability were factors preventing an integrated, collaborative approach to care. Personal, patient, and structural realities also limited physicians' roles. CONCLUSIONS: This sample of primary care physicians had diverse perceptions of their role. Results of this study could provide information for identifying issues that need to be addressed to facilitate changes taking place in the health care system.

Attitude of Health Personnel↗
PubMed2000

Measuring the effects of managed care on physicians' perceptions of their personal financial incentives.

Using data from the 1997 Resurvey of Young Physicians (N = 1,549), this study examines whether several measures of physicians' contractual arrangements with health plans are associated with their perceptions of overall financial incentives to either decrease or increase the volume of services to patients. Results indicate the following factors were significantly associated with an increased likelihood of reporting an incentive to decrease services: a gatekeeper arrangement with a compensation incentive; the perception of a high risk of plan deselection for physicians with high costs; the perception that referrals received depended on the costs of care provided; communication prohibiting or discouraging the disclosure to patients of the physician's financial relationship with the health plan; receiving capitation payments from at least one plan; and employment in a health maintenance organization. Being compensated on a fee-for-service basis or receiving a salary with incentive or bonus provisions (compared to straight salary) were associated with an increased likelihood of reporting an incentive to increase services to patients. Physicians' overall methods of compensation had a relatively small impact on their perceived financial incentives compared to other statistically significant factors. Our findings suggest that physicians' self-reported, overall personal financial incentives within their practices are a valid summary measure of the heterogeneous mix of specific financial arrangements faced by most physicians.

Adult↗
PubMed2000

Management matters: technology succeeds when management innovates.

It is widely believed that better technology means better business: now that consumers and patients have direct access to computers and information services, the cost of care should decrease and services improve. Yet even with the advent of computer technology and the phenomenal growth of the Internet, costs have increased and quality problems have persisted. Far more important than the technology, then, is how business is conducted and systems are organized. Despite overwhelming evidence that computer services can significantly reduce the costs of care, healthcare organizations have not adopted the changes, or have tried and failed. This article explores what it will take to succeed. We propose a list of necessary nontechnical changes. Patient expectations will change the nature of care; clinicians' roles and training, the gatekeeper profession, healthcare financing and bundling of services, and capital costs will all change. In the end, management innovations make the difference between the success and failure of new technology. Technology is important, but it is not enough. Without new practices, we can buy the technology but will fail to effectively use it. Unless management modifies the very nature of its business, technology's promise to the healthcare industry will go unfulfilled.

Capital Expenditures↗
PubMed2001

Admissibility of neuropsychological testimony after Daubert and Kumho.

Neuropsychological testing has been used in court cases all over the United States, as testimony to provide evidence of whether or not a person has a traumatic brain injury. It has, however, been scrutinized for its admissibility in court, but recognized for objectivity in successfully documenting and proving deficits in people with traumatic brain injuries. The trial court is used as a gatekeeper, and may chose to perform assessments of the tests themselves, for validity of sensitivity, specificity, reliability and validity in determining whether a neuropsychological test may be used as testimony in a court case.

Brain Concussion↗
PubMed2002

Impact of a simple intervention to increase primary care provider recognition of patient referral concerns.

OBJECTIVE: To determine whether a brief previsit questionnaire about referral concerns can improve primary care provider (PCP) recognition of patient concerns and satisfaction with care. DESIGN: Sequential prospective study in the internal medicine clinic of an academic medical center providing primary care to patients enrolled in a gatekeeper-model managed care plan. PARTICIPANTS AND METHODS: Twelve faculty internists serving as PCPs for 1495 consecutive patient visits. Patients were given a previsit questionnaire asking about referral need and rationale and a postvisit questionnaire asking about discussion of referral concern and visit satisfaction. Providers were given a postvisit questionnaire asking whether a referral was discussed and made and about visit satisfaction. In the control phase, patient previsit questionnaires remained confidential, whereas in the intervention phase PCPs were shown the previsit questionnaires at the time of encounter. RESULTS: The intervention significantly increased PCP referral recognition from 61% to 81% (P < .001) and was associated with increased visit satisfaction (P = .05). Satisfaction of PCPs with the referral discussion, overall rate of referral, and visit duration were not affected by the intervention. CONCLUSIONS: Using a brief previsit questionnaire about patient referral concerns increases PCP recognition of such concerns. The intervention does not adversely affect PCP satisfaction with the referral discussion or the overall referral rate and may enhance patient visit satisfaction.

Academic Medical Centers↗
PubMed2003

The development of family health nurses and family nurse practitioners in remote and rural Australia.

BACKGROUND: The World Health Organisation HEALTH21 strategy has firmly placed families and family oriented services at the core of health care delivery. OBJECTIVE: In this article we argue that a fundamental reorganisation of primary health care practices in remote and rural Australia needs to be undertaken. DISCUSSION: Nurses have been shown to be equally effective and less costly than general practitioners. Family nurse practitioners should be a first point of contact, and family health nurses should be responsible for responding to problems of multiple deprivation and social exclusion in remote and rural areas. These practitioners would, in their respective areas of responsibility, identify, diagnose, refer or treat individuals, families and communities. In effect they would act as gatekeepers to health and social care services. Family health nurses would also aim to support the community in developing and sustaining the capacity to take responsibility for its own health and social care. The main obstacles to these initiatives are concerns of general practitioners and nurses, the inertia of large organisations when faced with the need to undertake radical change and the highly unionised and rule bound nature of Australian nursing.

Australia↗
PubMed2005

General commentary on access to cardiovascular care in Canada: universal access, but when? Treating the right patient at the right time.

In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary is the first in the series and lays out issues regarding timely access to care that are common to all cardiovascular services and procedures. The commentary briefly describes the 'right' to timely access, wait lists as a health care system management tool, and the role of the physician as patient advocate and gatekeeper. It also provides advice to funders, administrators and providers who must monitor and manage wait times to improve access to cardiovascular care in Canada and restore the confidence of Canadians in their publicly funded health care system.

Canada↗
PubMed2005

Sexual health promotion: the barriers school nurses face.

This paper reports on the findings of a study which aimed to determine the contribution of school nurses to promoting sexual health within schools and whether occupational and professional boundaries impinged on the school nurses' ability to undertake this aspect of their role. The research was carried out across three Primary Care Trusts (PCTs). Data were collected using semi-structured interviews, a total of 30 school nurses (n=30) from across the three PCTs were included in the study. Analysis of the data indicated that barriers in the form of gate-keepers were present and they could impede the school nurse in fulfilling her role as a health educator. This gate-keeping existed across three 'tiers': the school governors, the school (as a collective organisation) and teachers. Nurses employed a variety of strategies to negotiate their way through these gatekeepers in order to access the classroom setting, key among them was their willingness to collaborate and co-operate, by 'slotting in' with the school, the curriculum and its timetable and 'fitting in' with the teachers, as their needs dictated.

Adolescent↗
PubMed2006

Expanding disaster mental health response: a conceptual training framework for public health professionals.

The available research literature suggests that in disasters, individuals presenting acutely with psychologically-related complaints tend to outnumber those presenting with physical symptoms directly stemming from the injury-causing agent or event. This acute "mental health surge" can rapidly overwhelm existing community mental health resources, especially in the context of terrorism. Training professionals from outside the traditional mental health workforce in basic psychological crisis intervention may promote more efficient use of mental health services through a gatekeeper process of early intervention and appropriate referrals to mental health specialists. With their experience in patient and client services at the community level, public health professionals represent a cohort well-suited for training in and delivery of acute mental health services in disasters. In this paper, we outline a conceptual model and rationale for training public health professionals in basic crisis-oriented mental health functions (psychological first aid) in order to augment community-based mental health services for affected populations in a disaster.

Clinical Competence↗
PubMedDate not supplied

[Prior authorisation to visit the neurologist from primary care may not be necessary: the findings of a prospective, controlled study].

INTRODUCTION: The system by which approval must be given by the primary care physician before a patient can visit a specialist is known as gatekeeping and is aimed at preventing the mistaken or simple referral of patients to the next stage of health care services. We present a study that compares the final diagnoses of 400 patients who used a direct access model of referral (DAM) with those of 400 patients referred by a primary care physician in a prior authorisation model (PAM). PATIENTS AND METHODS: We conducted a prospective analysis of two cohorts of patients who visited the same neurologist in a PAM system versus a DAM system. The 800 patients were evaluated following similar diagnostic criteria. The primary objective of the study was to compare the patients who were referred with a final diagnosis of 'non-neurological pathology' in the PAM and the DAM systems. Secondary aims consisted in conducting an analysis of the diagnoses by different pathologies between the two models. RESULTS: No significant differences were found between the referrals that were considered to be non-neurological in the PAM and the DAM systems (27.0% versus 26.3%; p = 0.48). A logistic regression model was performed with 'non-neurological pathology' as the dependent variable and age, sex and type of model (PAM or DAM) as the independent variables, similar results being obtained in both cases. CONCLUSIONS: Our data suggest that the role played by the primary care physician is not effective when it comes to preventing mistaken referrals to the neurologist in our area. A populational study would be needed to evaluate the rate at which resources are used and the spending on health care in the two models.

Female↗
PubMed1996

Dermatologists in Kaiser Permanente-northern California. Satisfaction, perceived constrains, and policy options.

BACKGROUND AND DESIGN: A survey was conducted in a large closed-panel health maintainance organization to identify and understand influences on dermatologists' job satisfaction and preferences for policies affecting management of routine dermatologic care. Of the population of 98 dermatologists, 91 (93%) responded. The main variables of interest were current and ideal practice characteristics (time allocations and case mix) and (dis) agreement with 4 statements: (1) I am satisfied with my job; (2) I favour a direct access model over a gatekeeper model for patients seeking dermatologic care; (3) I favour training primary care physicians to evaluate and treat routine dermatologic problems; and (4) I welcome incorporating nurse practitioners and physician extenders into my practice. RESULTS: The dermatologists currently spend 86% of their work time providing patient care. On average, 70% of their caseload involves routine problems; 56% would ideally increase the complexity mix of their patients. The survey reveals gender differences in perceptions of time constraints and opportunities for professional development. Most dermatologists (88%) report they are satisfied with their jobs. Satisfaction correlates strongly with their perceived ability to deliver excellent care, use their skills, and develop new skills (correlations, 0.53-0.59). Although 78% favor retaining direct patient access, at least 60% endorse more cooperative work with primary care physicians and nurse practitioners. These views are related to their satisfaction, interest in challenging cases, development and use of new skills, and perceived relationships with colleagues and support staff. CONCLUSIONS: Understanding the factors that affect physician preferences can help to identify policies that potentially improve efficiency without compromising quality of care or physician satisfaction. If routine problems can be effectively managed in cooperation with other health care providers, this may also lead to the more complex case mix these dermatologists ideally want. Further study might focus on the scheduling and referral processes that influence both cost-effectiveness and continuity in coverage for dermatologic problems.

California↗
PubMed2000

Sporadic trichoepithelioma demonstrates deletions at 9q22.3.

BACKGROUND: Trichoepithelioma (TE) is a benign cutaneous tumor that originates from hair follicles and occurs either in multiple or solitary lesions. Multiple TE is transmitted as an autosomal dominant trait, and a region at 9p21 is thought to be involved in the tumorigenesis. Solitary TE occurs more commonly than multiple TE and is not inherited. Histologically, TE tumors contain horn cysts and abortive hair papillae. A basal cell carcinoma appearance in some or all regions of a TE tumor can happen. In sporadic basal cell carcinoma, frequent deletions at 9q22.3 (Drosophila patched gene) have occurred. The objective of this study is to test whether loss of heterozygosity (LOH) on either 9p21 or on chromosome 9q22.3 could be detected in archival sporadic TE. OBSERVATIONS: We studied 29 randomly selected cases of sporadic TE by microdissection and polymerase chain reaction using paraffin-embedded, formalin-fixed tissue specimens on glass slides. Analysis was performed with the polymorphic markers IFNA and D9S171 (9p21) as well as D9S15, D9S303, D9S287, and D9S252 (9q22.3). RESULTS: The LOH at 9q22.3 was identified in 14 (48%) of 29 cases with at least 1 marker, while LOH could not be demonstrated using the markers IFNA and D9S171 (9p21). CONCLUSIONS: The results show that the Drosophila patched gene LOH can be frequently identified in paraffin-embedded sporadic TE after routine processing and indicates a common gatekeeper mechanism for both TE and basal cell carcinoma.

Chromosomes, Human, Pair 9↗
PubMed2007

Effect of health care delivery models on melanoma thickness and stage in a university-based referral center: an observational pilot study.

OBJECTIVE: To compare the effect of differing health care delivery models, specifically, gatekeeper (GK) vs direct access (DA) routes, on melanoma outcome as measured by tumor thickness and cancer stage at diagnosis. DESIGN: Retrospective medical record review of patients previously diagnosed as having cutaneous melanoma who were referred to a university-based clinic from January 1, 1996, through December 31, 2000. SETTING: Stanford Pigmented Lesion and Cutaneous Melanoma Clinic, Stanford, Calif. Patients Two hundred thirty-four patients with primary melanoma stratified according to health care access route (GK or DA). MAIN OUTCOME MEASURES: Differences in Breslow thickness, American Joint Committee on Cancer stage, histologic features, patient delay in seeking medical attention, and physician delay in diagnosis (time between initial physician visit and diagnostic biopsy procedure). RESULTS: Of 234 patients, 168 (72%) were referred through the DA route and 66 (28%) through the GK route. A significant association was found between physician delay and access route; patients in the DA group underwent biopsy sooner (< or =3 months vs >3 months) than those in the GK group (P<.001). No significant difference was observed in stage at diagnosis (predominantly stage IA), proportion of nodular melanoma (DA 4% vs GK 2%), patient delay, or median tumor thickness between DA and GK routes (0.42 mm vs 0.50 mm, respectively). A trend toward a greater proportion of histologically ulcerated melanoma was observed in the DA group compared with the GK group (12% vs 5%, respectively; P = .06). CONCLUSIONS: This pilot study demonstrated no difference in outcome between GK and DA routes as measured by melanoma thickness and stage, although patients in the DA group underwent diagnostic biopsy sooner than those in the GK group. The potential effect of health care models on melanoma outcomes merits further study.

Adult↗
PubMedDate not supplied

Alzheimer disease. Report of the Council on Scientific Affairs.

Alzheimer disease (AD) takes a heavy economic, social, physical, and psychological toll on patients, families, and society. Because of the increasing life expectancy in the United States, AD is expected to afflict approximately 14 million people within the next few decades. There is currently no cure, only interventions that can temporarily ameliorate the profound cognitive losses and behavioral manifestations of the disorder. Community services are fragmented and underutilized. Physicians, in their traditional role as gatekeepers, can encourage more families to use supportive services. This article reviews the guidelines on the diagnosis and treatment of AD of the Agency for Health Care Policy and Research, the American Academy of Neurology, the Veterans Health Administration, and the American Psychiatric Association. Although these guidelines contain valuable information, they do not adequately address the role of the family physician and the need for continuity of care. Recommendations regarding AD from the Council on Scientific Affairs, which were adopted as American Medical Association policy in December 1997, are included in this article.

Algorithms↗
PubMed1990

Implementing preventive services. Success and failure in an outpatient trial.

Physicians endorse prevention but provide only low levels of screening, health counseling, and immunization. Between 1981 and 1986, a randomized controlled trial was conducted at the Seattle (Wash) Veterans Affairs Medical Center to assess the effectiveness of the following three methods of delivery of preventive services: (1) a physician-oriented model that includes education and motivation, a chart flowsheet listing recommended activities, and periodic feedback about performance; (2) a patient education model in which patients were mailed an informative brochure advising them to ask physicians for preventive services as depicted in a patient-held pocket guide; and (3) a health promotion clinic that patients were invited to attend. A control group received their usual care. A total of 1224 male outpatients were enrolled in the trial. Baseline prevention rates for 12 age-specific prevention activities were below 25%. Neither the control group rates during the 5-year trial nor the rates for the two educational models, either singly or as a combined intervention, changed. Only the health promotion clinic model was effective, tripling prevention rates in its first year and sustaining these levels for all 5 years. It is difficult to change the clinic roles of experienced physicians and their long-term patients in a specialized multiclinic setting. Providing a separate health promotion clinic option is popular with patients, bypasses gatekeeper barriers, is reasonable in cost, and warrants wider application.

Adult↗
PubMedDate not supplied

Mild traumatic brain injury: toward understanding manifestations and treatment.

Mild traumatic brain injury is misleading as a diagnostic term, as it may include a spectrum of manifestations ranging from transient mild symptoms to ongoing disabling problems. It is a source of significant economic burden to society in terms of days lost from work and costs related to medical treatment. Symptomatic individuals will frequently present to primary care general medical practitioners days, weeks, or even months after the trauma. General medical practitioners are thus put in the position of being the "gatekeepers" of medical care for such patients and become responsible for appropriate determination and authorization of medical tests, specialized referrals, and treatment. The purpose of this article, which is based on a review of the literature to 1997, is to provide physicians with an understanding of mild traumatic brain injury, including manifestations and treatment, as it occurs commonly and can significantly impact the quality of life of those affected.

Brain Concussion↗