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PubMed1995

Cardiac rehabilitation in the time of health-care reform.

Cardiac rehabilitation has evolved into a medically efficacious, cost-effective intervention for patients with ischemic heart disease. Most aspects of this therapy are well developed, and guidelines for programs exist. As the health-care delivery system undergoes scrutiny and evolution, it would be prudent for the practitioners of cardiac rehabilitation to evaluate the methods they use to deliver their services. Program administrators should reconsider traditional approaches that are largely based on reimbursement criteria. Goal-directed, patient-centered service delivery will allow individualization of care. A model for such an approach to cardiac rehabilitation is presented.

Cost-Benefit Analysis↗
PubMed2001

Organizational models for medical school-clinical enterprise relationships.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers-models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.

Delivery of Health Care↗
PubMed1997

Improving service delivery: provider perspectives on building community-based systems of care.

This article examines the views of service providers toward different public policy efforts to improve service delivery to elders requiring multiple services from an array of organizations. The authors examine the relationship between provider assessments of the adequacy of their community-based systems of care and community resource levels, coordination strategies, and client characteristics. Findings, based on responses from managers of programs serving older adults (n = 250) to a mailed survey, were that two-thirds (69.4%) evaluated their service delivery systems as adequate or better. A regression model used to explain system adequacy indicated that 22% of the variance was accounted for by community resource level, information and service availability, attention to specific need clients, and percentage of minority clients served by the respondents' programs. Findings suggest that community resource level appears to be an important factor in respondents' evaluation of system adequacy. While respondents indicated that improved coordination could enhance their efforts to deliver services, this strategy was not one they favored in improving their community-based system of care. Instead, they preferred strategies which expanded or improved the services that were available.

Aged↗
PubMed2004

What is important to continuity in home care?. Perspectives of key stakeholders.

In Canada, home care is growing rapidly. Each province takes a somewhat different approach to its delivery. Ontario uses a competitive bidding model to award contracts to community agencies that bid for service delivery rights. Contracts are to be awarded based on quality and price. However, the attributes thought to contribute to high quality, such as continuity of care, are not clearly defined and are not measured. We sought to identify factors that were important to experiencing continuity of care in home care. We interviewed home care clients and their caregivers, workers in the home care system (nursing and homemaking service providers, case managers) and physicians whose patients use home care. During in-depth interviews with these key stakeholders, they described the conditions that led to continuity of care in home care. Service providers and case managers were also asked about the types of clients who need a high level of care continuity. Care that is experienced as running smoothly, that responds to clients' needs and requires no special effort for clients to maintain, was seen as having continuity. The attributes of care experienced as facilitating continuity could be grouped under two dimensions of care-managing care (care planning, monitoring and review; and care coordination) and direct service provision (uninterrupted service delivery; consistent, appropriate knowledge and skills; ongoing accurate observation; trusting relationship between service provider and client/caregiver; rapport among team members; and consistent timing). Different stakeholders emphasized different attributes of care as most important to continuity. Clients included consistency of timing of service delivery while rarely mentioning care management issues. They emphasized the importance of consistent knowledge and skills in the workers and trusting relationships as important to experiencing care continuity. The description of attributes of continuity of home care that emerged from this study is compared to definitions found in the nursing, mental health and primary care literature.

Case Management↗
PubMed1996

The dawn of a revolution in mental health.

Issues surrounding the debate regarding psychologists' evolution as prescribers are discussed in a balanced format. Arguments against prescribing are challenged, such as the change in focus of psychological work and the potential harm to public welfare. Disruption of the process of psychotherapy, through employment of external prescribers, is also discussed, especially given the psychological meaning imbued to medicine by patients. It is concluded that psychologists have the opportunity and responsibility to improve the present models for the delivery of mental health services by obtaining the requisite training and legislative mandate to prescribe.

Delivery of Health Care↗
PubMed1999

The application of the continuum of care model in the re-configuration of nutrition and dietetics services.

The continuum of health care model can be used to improve service delivery. Within a hospital setting, finite resources are available. Service gaps must be identified, priorities established and resources re-distributed to meet these gaps. Using Continuous Quality Improvement (CQI) tools, barriers to change were identified and a plan for improvement was formulated. Areas receiving disproportionate resources were identified and a more even resource allocation adopted. In an illustration of the success of strategic change, core services were not only maintained but also showed improved efficiency. The Department of Nutrition and Dietetics at Wollongong and Port Kembla Hospitals achieved an increase in dietetic services through a reorientation of current resources.

Continuity of Patient Care↗
PubMed1999

Physician utilization by Hispanic elderly persons: national perspective.

BACKGROUND: The number of elderly Hispanic Americans is projected to more than double by 2010 and account for 16% of all elders by 2050. The complex health needs and diversity of that growing population poses challenges for planning and delivery of health services. OBJECTIVES: The behavioral model of health services utilization was used to examine predisposing, enabling, and need factors associated with physician use by Hispanic elders and to assess whether Mexican American, Cuban American, and Puerto Rican elders differ in their likelihood of use. RESEARCH DESIGN: Data are from the 1988 National Survey of Hispanic Elderly People, which is a nationally representative sample of Hispanic elders living within telephone exchanges with at least 30% concentration of Hispanics. SUBJECTS: There were 2,299 completed interviews. Analyses are based on a subsample of 773 Mexican Americans, 714 Cuban Americans, and 368 Puerto Ricans. MEASURES: The dependent variable, physician utilization, was self-reported number of visits in the previous year. It was dichotomized because of skewness. Independent variables include predisposing, enabling, and need factors. RESULTS: Using hierarchical logistic regression, all three sets of factors contributed to the likelihood of a visit. Enabling factors, especially insurance coverage and adult children, had the greatest impact. Cuban Americans and Puerto Ricans were 2.3 and 2.6 times more likely, respectively, to have seen a physician than were Mexican Americans. CONCLUSIONS: In seeking to improve access and use of physician services, health care providers and policy makers should consider the role of social and economic factors and national origin group.

Adult↗
PubMed1976

Rationalizing the delivery of eye care--part I.

The often proclaimed health care crisis has led to a variety of efforts to reorganize and rationalize the existing health care system. One such effort has been to develop a conceptual model for the delivery of personal health services in which the region is the fundamental planning unit and levels of care form its organizational framework. Three levels of care are defined--primary, secondary, and tertiary--each level being based on a combination of the frequency with which a service is needed and its professional and technical sophistication. The regionalization of health services would serve to "achieve a balance between the public's request for decentralized resources and the centralization required so that they may be used efficiently."

Delivery of Health Care↗
PubMed2005

The PICNIC Story.

This chapter describes how the Professionals and Citizens Network for Integrated Care (PICNIC) project was conducted in order to meet its objectives in preparing the regional healthcare providers to implement the next generation, comprehensive, user-friendly, secure healthcare network for patient centred care, and through it contribute to the de-fragmentation of the European market for health telematics. It describes the methodology followed in order to reach certain project results, starting from the selection of common documentation tools and methods, to the delivery of a new model for providing services, assessment plans, and a number of open source software components running on a number of diverse pilots throughout Europe in line with the overall PICNIC architecture.

Documentation↗
PubMed2006

Racial and ethnic disparities in cancers of the uterine corpus.

Survival after diagnosis of cancer of the uterine corpus is significantly worse in black women as compared with white women. The etiology of the racial and ethnic disparities that exist in endometrial cancer incidence and outcome is multifactorial and complex. Potential explanations include cancer biology, differences in access to care, sociodemographic characteristics, response to treatment and comorbid factors. In this article, a review was performed to assess the magnitude and reasons for the observed disparity in endometrial cancer mortality. Strategies and recommendations to reduce or eliminate differences in endometrial cancer outcome are explored. These include advocacy for more research to clarify the underlying causes of cancer disparities at all levels, including the molecular basis of disparate outcomes, improving access to quality healthcare services, establishing culturally competent models of healthcare delivery, and developing novel cost-effective screening and early prevention methods.

Black or African American↗
PubMed1991

Pharmacist salaries and hiring practices in teaching hospitals.

A survey of selected teaching hospitals was conducted in early 1990 to determine salary ranges for pharmacist positions, salaries at which pharmacists were typically hired for these positions, differences in salary between clinical practitioner and managerial positions, and geographic differences in these salaries. Surveys were mailed to 50 members of the University Hospital Consortium (UHC) and 50 other university-affiliated and non-university-affiliated hospitals believed to be comparable to the investigators' hospital. Hospital capacity and census data, numbers of pharmacist and support staff positions, qualifications preferred and required for those positions, and salary information were requested. Data from 22 UHC hospitals and 23 non-UHC hospitals were evaluated. Relative to average daily census, UHC hospitals indicated higher pharmacist staffing levels and non-UHC hospitals reported higher support staff levels. More non-UHC hospitals than UHC hospitals (69.2% versus 43.5%) used an integrated model for delivery of clinical and distributive services. Nationally, the reported annual salaries were as follows: staff pharmacist, $34,881 to $47,906; clinical pharmacist, $37,768 to $51,564; clinical specialist, $38,905 to $55,282; supervisor, $39,905 to $54,416; assistant director, $43,554 to $58,758. Overall, typical hire rates (THRs) exceeded mean minimum salaries by about 10%. The percentages by which THRs exceeded mean minimum salaries were greatest in the West for staff pharmacist, clinical pharmacist, and clinical specialist positions and greatest in the Midwest for supervisor and assistant director positions. THRs for supervisors and assistant directors exceeded those for clinical specialists. Respondents' preferences varied regarding advanced education and training, and their actual requirements did not match their stated preferences.(ABSTRACT TRUNCATED AT 250 WORDS)

Data Collection↗
PubMed1983

[Training needs for health and nutrition personnel in developing nations].

This paper examines some of the factors related to the training of health and nutrition personnel in developing countries in general and in Latin America in particular. It addresses both professional and technical level staff responsible for the formulation of plans and programs, and auxiliary personnel responsible for the delivery of services. Using the systems analysis model, the need for training human resources in research techniques and decision-making on a scientific basis is taken as an example for a discussion of aspects of the diagnosis, planning, execution and evaluation of health and nutrition programs. Various ways are indicated of giving training in research techniques, using the personnel available and employing simple instructions and methods, currently under-used, such as gathering anthropometric data. The authors stress that if an effort were to be made in the countries, the risk factors influencing health and nutrition, particularly among the maternal-child group, might well be identified quickly and without great cost. The case of the height census in Costa Rica is reviewed as a practical example of programs that have originated in developing countries and that make maximum use of auxiliary personnel in obtaining reliable, valid information for decision-making purposes. This census included children in the first grade of the primary cycle at the national level. The contents of the tutorial training program of the Institute of Nutrition of Central America and Panama (INCAP) are also described.

Child↗
PubMed1991

Outpatient psychogeriatric nursing services: an integrative model.

The complex needs of psychogeriatric patients and their families require specialized outpatient psychogeriatric services. The interaction of physical and mental health and the need for coordinated care places important responsibilities on nursing because it contributes to integrated, multidisciplinary care delivery to these patients and their families. This article presents a model of outpatient psychogeriatric nursing services focused on the community integration of patients and families. Experiences in the development of the Geriatric Neuropsychiatry Clinic at the University of Virginia, Charlottesville, are used as the point of departure from which to describe a model of outpatient psychogeriatric nursing care delivery that is multidisciplinary, clinically innovative, and epidemiologically justified.

Aged↗
PubMed2006

The Calman-Hine report: a personal retrospective on the UK's first comprehensive policy on cancer services.

Calman-Hine was the first comprehensive cancer report to be produced in the UK, and set out principles for cancer care and the clinical organisation for service delivery. It advocated a change from a generalist model (eg, care given by general surgeons and physicians) that was supported by specialists to a fully specialist service. The process of policy development was innovative and the report was accepted widely throughout the UK. However, implementation, which began at a time of organisational change across the UK National Health Service (NHS), was not addressed sufficiently in the years immediately after publication. Consequently, change was more variable both geographically and within a single location and took longer than necessary. Evidence from research, routine data, and external assessments suggest that the policy was eventually successful and a worthwhile change. Well thought out and sustained mechanisms for policy implementation are as crucial as well-designed policies, and government health reforms can conflict with specific policies for quality improvement.

Health Policy↗
PubMed2000

Medical and psychosocial services in drug abuse treatment: do stronger linkages promote client utilization?

OBJECTIVE: To examine the extent to which linkage mechanisms (on-site delivery, external arrangements, case management, and transportation assistance) are associated with increased utilization of medical and psychosocial services in outpatient drug abuse treatment units. DATA SOURCES: Survey of administrative directors and clinical supervisors from a nationally representative sample of 597 outpatient drug abuse treatment units in 1995. STUDY DESIGN: We generated separate two-stage multivariate generalized linear models to evaluate the correlation of on-site service delivery, formal external arrangements (joint program/venture or contract), referral agreements, case management, and transportation with the percentage of clients reported to have utilized eight services: physical examinations, routine medical care, tuberculosis screening, HIV treatment, mental health care, employment counseling, housing assistance, and financial counseling services. PRINCIPAL FINDINGS: On-site service delivery and transportation assistance were significantly associated with higher levels of client utilization of ancillary services. Referral agreements and formal external arrangements had no detectable relationship to most service utilization. On-site case management was related to increased clients' use of routine medical care, financial counseling, and housing assistance, but off-site case management was not correlated with utilization of most services. CONCLUSIONS: On-site service delivery appears to be the most reliable mechanism to link drug abuse treatment clients to ancillary services, while referral agreements and formal external mechanisms offer little detectable advantage over ad hoc referral. On-site case management might facilitate utilization of some services, but transportation seems a more important linkage mechanism overall. These findings imply that initiatives and policies to promote linkage of such clients to medical and psychosocial services should emphasize on-site service delivery, transportation and, for some services, on-site case management.

Ambulatory Care Facilities↗
PubMed2001

Patient care staffing patterns and roles in community-based family practices.

OBJECTIVES: Our study describes patient care staff patterns and roles in community-based family practices. STUDY DESIGN: We used a multimethod comparative case study design that included detailed descriptive field notes of the office environment of 18 family practices and of 1637 clinical encounters, as well as in-depth interviews of practice staff and physicians. Systematic analysis of these data provided detailed descriptions of patient care staff patterns and functions. POPULATION: We included physicians and staff in 18 community-based Nebraska family practices. RESULTS: Practices are staffed with a range of clinical personnel, including registered nurses, licensed practical nurses, certified medical assistants, radiology technicians, and trained and untrained medical assistants. Each of these has specific educational preparation that potentially qualifies them for different patient care roles; however, staff roles were determined primarily by local needs and physician expectations rather than by education, training, or licensure. Staffing patterns varied greatly; the majority of practices employed at least one registered nurse (10 of 18), one licensed practical nurse (5), or both (4). Still, the overall majority of practices used non-nursing personnel as the predominate patient care staff. Patient care staff-to-clinician ratios ranged from a low of 0.5 to a high of 3.3. CONCLUSIONS: Many recent recommendations about collaborative models of clinical care seem problematic when put into a context of the findings of current staffing patterns and use of personnel in family practices. Staff members often fulfill roles independent of training. Staff leadership is also potentially important for designing effective collaborative care models; however, we found leadership only occurred with the approval of clinic authorities. These practical issues are rarely addressed in normative recommendations about system change and intervention. Our findings indicate that there are considerable opportunities for better use of the nursing and other patient care staff in the delivery of clinical services. Developing a collaborative practice model should include formalizing expectations of staff to reflect training and experience, and explicitly configuring staff to meet the needs, values, and goals of a practice.

Community Health Services↗
PubMedDate not supplied

Considerations for the use of a conceptual model in home health nursing.

The goal of home health nursing is to promote self-care capabilities in the client's home. A conceptual model for home health care would incorporate the nursing practice performed in the home on an intermittent skilled nursing visit. An appropriate model for home health care would include concepts of health service delivery, standards of care on which to focus practice, and guide the development of nursing interventions that are efficient and effective in our cost-conscious society. The model would also include the ability to measure the quality of services delivered in the home.

Home Care Services↗