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Health planning such as consolidation and closure of facilities and services to contain costs often contradicts rural populations' needs for increased access to better or even basic services/Model programs to meet these needs are discussed.
We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVES: To explore the views and opinions of patients with a family history of colorectal cancer, and of primary and secondary care health professionals, on how to improve current services for individuals with a family history of colorectal cancer. DESIGN: Focus group and interview study. SETTING: Primary and secondary care centres in south east London, UK. PARTICIPANTS: A total of 53 people participated in this qualitative study: 18 individuals with a family history of colorectal cancer were interviewed in three focus groups and 35 health professionals were interviewed either in focus groups or individually. Visual qualitative analysis of transcribed interviews was used to identify the key themes which emerged. MAIN OUTCOME MEASURES: Interviewees' needs, views and opinions of current services and ways to improve them. RESULTS: Several areas of concern were identified. The role of primary care needs to be clarified. Education and information about services should be provided for patients and caregivers and better support is required for those undergoing screening and surveillance. Methods to ensure effective and meaningful risk communication are inadequate and require further exploration. Standardisation of care is required to ensure consistency of advice and treatment. CONCLUSION: These interviews revealed substantial shortfalls in the provision of services for patients at increased genetic risk of colorectal cancer. Current systems for the assessment of risk, delivery of advice, and for surveillance are inconsistent and sometimes maybe inadequate. The role of primary care physicians in service delivery requires clarification. Significant opportunities exist for the development of new, more appropriate models of service to provide better standards of care.
The aim of this study was to develop a best practice model of professional assessment to ensure efficient and effective delivery of home-based services to frail and disabled elders. In 2000, an innovative model of professional assessment was introduced by one of Australia's largest providers of home-based care in order to reduce multiple assessments and to reduce the utilisation of assessment as a gatekeeping tool for limiting access to services. Data was analysed from a random sample of 1500 clients drawn from a population of 5000 as well as through the use of a survey tool administered to the Organisation's assessment staff and other key stakeholders. Results revealed that, contrary to popular belief, carer advocacy plays a significant role in the professional assessment process to the point that clients with carers received significantly more services and service time that clients without such support. However, if not monitored, assessment can also be used as a gate-keeping tool as opposed to one that can provide significant benefits to the consumers through comprehensive need articulation. We argue that the "professional" approach does not preclude empowerment and that assessment should not be used as a gate-keeping tool.
This paper critically discusses the conceptualization and structure of the therapeutic community employed for the treatment of substance misuse in America. The predominant American model, the concept-house model, is criticized on the grounds that the therapeutic milieu of these treatment agencies is contaminated by their subordinance to the influences of the larger American society. These influences include: the predominance of the medical model, the agency as an agent of service delivery, capitalism and inequity, implicit views of human nature, and stratification of social structure. The thesis of this paper is that treatment personnel in therapeutic communities must develop increased sensitivity to the larger cultural factors which influence the construction of the therapeutic community. It is argued that problems within the American culture play a significant role in the etiology of substance misuse. Therefore, treatment personnel must be careful to avoid constructing therapeutic communities which too closely mirror the larger culture. This cultural influence in therapeutic communities functions to maintain long-term substance misuse problems within the individual and the nation.
This is an overview of the home care sector's evolution in Canada, including current models and delivery structures, funding, eligibility criteria, and services provided. Cost escalations of the traditional healthcare system and a reduction in federal funding has driven health reform in Canada. This has been accompanied by a major but sporadic expansion of the home care sector across the country. For the home care sector to develop in a more rational, cost-effective and client-focused manner, the development of common standards, a common database and programme evaluation will be required. This will also be necessary for political, planning, and administrative officials to understand and justify the reallocation of resources from institutional to community health sectors. Addressing issues such as the impact of health reform, the role of the private sector, realignment of system incentives, and developing effective partnerships with hospitals is critical if home care is to be recognized as an essential, cost-effective component in Canada's healthcare system.
This paper examines an alternative model for a long-term care facility for the mentally ill. Termed the "family model," it is based upon the assumption that the primary function of a psychiatric environment is the delivery of services in loco familias. The difficulties in integrating the family model and the traditional medical model are examined.
For over three decades, chronic-care services have been described as fragmented, complex, difficult to access, overlapping, and duplicative in function. Although a number of remedies have been implemented to improve service delivery, little has been written about the potential of integrated information systems (IIS) to serve as a remedy to fragmentation. We begin to address this gap by comparing and contrasting three unique models of chronic-care IIS developed in California to improve service delivery. To analyze the current status of each IIS, we apply six design criteria: (1) the information on programs and services is comprehensive, (2) the system has the capacity to serve the needs of diverse users, (3) the system integrates multiple layers and levels of information, (4) information from multiple sources is standardized and uniform, (5) information can be accessed in a timely manner, and (6) provisions are adequate to meet all requirements for privacy and confidentiality. Although much work remains to be done, there is reason to be optimistic that innovative IIS can contribute to the development of more effective chronic-care delivery systems.
After the dissolution of Soviet Union in 1991, haemophilia care in the Republic of Georgia was negatively affected because of the expense of treatment products, lack of clinical and diagnostic facilities, and the need for trained personnel throughout the country. In 2001, the Georgian Government, working through the Ministry of Health, in collaboration with Georgian Association of Haemophilia and Donors, the Institute of Haematology and Transfusion, and the World Federation of Haemophilia, initiated a National Haemophilia Programme. As part of this programme the first Georgian Haemophilia Treatment Centre (HTC) was established. In this paper, we will describe (i) our outreach efforts to identify patients with haemophilia (PWH), (ii) the diagnostic and clinical services provided to patients by the HTC, and (iii) the results of a patient survey designed to assess patient satisfaction with the care provided. Total of 216 PWH were diagnosed, mean age was 25 years (range 4 months to 75 years); 43% had severe, 33% had moderate and 24% had mild haemophilia A or B. Overall, 183 (85%) had haemophilia A and 33 (15%) had haemophilia B, giving a ratio of 5.6. During the 2-year period, 77% of the expected number of PWH was identified by our outreach programme. Vast majority had comprehensive evaluation including joint assessment and over 60% were tested for blood-borne infections within a year and half period. Our findings showed that haemophilia care was considerably improved since the beginning of the National Haemophilia Programme and the survey of PWH showed a high degree of satisfaction with services provided in the HTC. In conclusion, close collaboration of the government, non-government entities and medical professionals in a Georgian national haemophilia care model; resulted in the successful delivery of the much needed services and care to the people living in Georgia with haemophilia.
INTRODUCTION: Collegiate-based emergency medical systems (CBEMS) are a unique model for the delivery of prehospital care. The National Collegiate Emergency Medical Services Foundation (NCEMSF) was founded to serve as a resource for CBEMS groups. The purpose of this investigation is to describe the current state of CBEMS organizations. METHODS: The NCEMSF maintains a Web-based, data collection system to gather data on CBEMS organizations. Collegiate-based emergency medical services are defined as emergency medical services in a university or college campus setting. The abstracted data from the NCEMSF registry were analyzed using descriptive statistics. RESULTS: The NCEMSF registry contained data on 175 groups, and 145 groups were identified as providing CBEMS. The levels of service provided by the groups were: (1) first responder, 8.3%; (2) basic life support (BLS) 66.2%; (3) intermediate life support (ILS) 4.8%; (4) advanced life support (ALS), 9.7%; and (5) combination BLS/ALS, 8.3%. Transport capabilities were provided by 31.7% of the CBEMS. The average response time was estimated at 2.6 minutes (95% confidence interval (CI), 2.35-2.91 minutes). Early defibrillation using a automated external defibrillator (AED) or ALS was available by 75.9% (95% CI, 68.8-83.0) of CBEMS. Service to the community beyond the campus was provided by 21.3% of CBEMS groups. Forty-eight percent of the services operate 24 hours/day, seven days/week. The average call volume per year was 568 responses (95% CI, 315-820), and the groups averaged 29 (95% CI, 25-34) members. During the past five years, an average of 4.3 new CBEMS groups were formed per year. Eleven of the CBEMS are based at international schools.
Alcoholism treatment services in the United States continue to be characterized by a lack of evidence-based care. Problems establishing effective research-practice knowledge transfer stem, in part, from the strong allegiance of scientists and practitioners to contrasting treatment models. Four underlying assumptions of the Minnesota model that continue to guide the delivery of alcohol services in the United States are identified and related research is reviewed. Findings indicate little support for these assumptions. However, support for superiority of alternative science-based treatments to replace current practices varies. To facilitate effective technology transfer, research practitioner collaboration must be promoted. Research paradigms are needed that possess high salience to practitioners while preserving scientific rigor. Two examples of studies involving research-practitioner collaboration are described.
To address the local health care needs of both patients and primary care providers in Montana, an integrated primary care and behavioral health family practice clinic was developed. In this paper we describe our experience with integrating mental health and substance abuse services into a primary care setting (a community health center) while simultaneously teaching family practice physicians to take the lead in providing these services. The Deering Community Health Center in Billings, Montana, is a Federally Qualified Health Center serving a largely low-income patient population. The medical care at the clinic is provided primarily by the faculty and residents of the Montana Family Medicine Residency. The teaching model was founded on the belief that improved care will result when physicians have increased comfort with, and are able to enjoy the challenges of, patients with mental illnesses. The enhanced longitudinal curriculum incorporates mental health across the 3 years of the family practice residency. Unique characteristics of this model include staffing and the concurrent delivery of a high volume mental health service while teaching family practice resident physicians and the faculty to integrate this competency into their primary care practices.
BACKGROUND: Laboratory services delivery face criticisms on daily basis by the patients (the beneficiary), the clinicians (the user), and the hospital management (the policy maker). The service provider (the laboratory) is faced with the task of trying to explain her problems. OBJECTIVE OF THE STUDY: Was to critically do a policy analysis of the problems of laboratory service delivery, with the aim of identifying the causes of these problems and making recommendations to the policy makers. SETTING: The University of Benin Teaching Hospital, a foremost tertiary institution in Nigeria. METHOD: George Kent's normative policy analysis model was used to analyse the laboratory guidelines and procedures of sample collection, transportation, analysis and eventual generation of laboratory results. All the steps in the guidelines are analysed using the fifteen steps in Kent's normative model of policy analysis. RESULTS: The policy analysis shows that problems of laboratory services delivery are triangular with the patient at the center of the triangle. The most important finding of this analysis is that there is no formal laboratory service policy to guide all the actors i.e. the hospital management, laboratory staff and the clinicians. Problems arising from the laboratory are solved through the use of circular letters, likened to administrative incremental model of decision-making. CONCLUSION: There is a need to have a formal policy. A formal policy on laboratory service delivery will guide the provider, the user and the policy makers in solving the problems that originate from the laboratory service on a permanent basis. It will also establish a regular method of evaluating the services that are provided by the laboratory.
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A screening and intervention program, soon to be implemented by the U.S. Air Force, will screen personnel for cardiovascular risk and treat those at highest risk. Design alternatives were analyzed relating to the organization and method of delivery of this health service program. A simulation model was devised to aid the analysis. It includes the effect of turnover of personnel, the effect of treatment on the therapy group, and the effect of aging on blood pressure and cholesterol level. The model determines how the overall incidence of cardiovascular disease in the U.S. Air Force may be expected to change each year through a 20-year period under each of several design policies. Results are given to justify the choice of several design options, and the scope of future improvements in the simulation are outlined. It appears possible to achieve a reduction of one-third in the calculated risk of cardiovascular disease, and this more than justifies the risk reduction program, based on a cost-effectiveness study performed earlier. All design decisions have not been made but will await the result of a demonstration implementation. The demonstration will produce more accurate data on initial distribution of risk factors and effect of therapy, which in turn will permit a sharpening of the analyses presented here.
A critical and often overlooked component of the use and transfer of research in the health care system is the local health and social service delivery agency. There is also very little understanding of the extent to which local community-based agencies conduct research internally to improve their operational capacity. More than ever, these local service organizations require research to guide activity in a rapidly changing health care environment which is characterized by diminishing health and social service budgets, de-institutionalization and concomitant increases and metamorphoses in service demands. This study interviewed 25 executive directors and held a focus group with a group of other directors to examine the use and transfer of research in these organizations. A number of central issues were identified by the directors that affect the contribution of research to the delivery of their programs and services. A conceptual model for developing 'locally-based research transfer' was subsequently outlined that could serve as the basis for enhanced research use and research transfer in other local area contexts.
Recent epidemiologic surveys indicate that anxiety disorders in older adults are more common than previously believed. Despite this, knowledge regarding the clinical characteristics of anxiety disorders in elderly patients is emerging slowly. In addition, detection of anxiety symptoms in elders is complicated by several factors, including a confounding of symptom picture by high medical comorbidity, frequent use of multiple prescribed and over-the-counter medications, difficulty of differentiating anxiety from depression, and a tendency of some older adults to resist psychiatric evaluation. Nonetheless, a comprehensive evaluation that includes a clinical interview, self-report measures, and laboratory results, can improve detection and accurate assessment of anxiety in elderly patients. Empirically validated knowledge regarding appropriate pharmacologic interventions in elderly patients is still sparse, and inferences from data in young and middle-aged populations typically form the basis of clinical practice in elderly patients. SSRIs and SNRIs are considered first-line interventions because of their efficacy and relative tolerability in elderly patients. Psychotherapy, particularly cognitive-behavioral therapy, also has been found to be efficacious for older adults with anxiety disorders. Collaborative care models that address physician, patient, and healthcare service delivery barriers, also hold promise for adequately treating anxiety disorders experienced by older adults.
As the epidemic of HIV disease continues to grow among drug users and their sexual partners, new ways must be adopted to do prevention work, outreach, and service delivery to this population. The Harm Reduction Model offers methods of working with drug users, which are in contrast to traditional methods based on confrontation and that require abstinence before change can occur. This position paper examines the Harm Reduction Model and outlines areas in which the Association of Nurses in AIDS Care can play a role in the expansion of harm-reduction-based intervention and policies.