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The pilot study for this project was established in February 1993 under a Health Communications Network initiative to improve the treatment results for asthmatics in Campbelltown, New South Wales. A user specific, standardized information environment was implemented across the community and hospital sectors linking General Practitioners, Specialist Consultants, and hospital doctors and nurses. The pilot included 20 General Practitioners, four pediatricians and respiratory physicians, and the nurses and doctors of a district hospital. ¿A multi-disciplinary team implemented the pilot, consisting of men and women from Campbelltown Health Service, Ernst & Young Health Services Consulting, and a major systems vendor. The team used process modeling tools to document the required changes to the roles and responsibilities of the individual practitioners and the impact of these changes on the cost of providing services and patient flow. Significant cost savings were anticipated from moving care out of the hospital and into the community. In the re-engineered environment, the General Practitioner became the case manager, responsible for guiding and coordinating the management of the patient's asthma, in consultation with the appropriate specialist consultants. The hospital continued to provide acute/emergency care. The level of sophistication of the information systems solutions was determined by the level of technical awareness of the users. Fax based communications were chosen to support the flow of timely and relevant information between the practitioners. A VAX based system was used as a data repository for the information collected by hospital staff and General Practitioners. The data repository acted as a clinical record for asthmatics who participated in the pilot. The clinical history of an asthmatic could then be viewed when a patient sought treatment from Campbelltown's Emergency Department during periods when the General Practitioner was not available. If a patient did seek emergency treatment, a record of the patient's visit was faxed immediately to the General Practitioner upon discharge from the hospital. Specialist consultants are independent practitioners in Australia. They were provided with a custom built application for their own personal computers. A key feature of this application was the automatic generation of letters to the General Practitioner to assist them in the management of asthmatics. The Specialist Consultants also identified a sub-group of high risk patients for whom additional clinical information was stored in the data repository at Campbelltown Hospital. Analysis of the patient information formed a core component of the project. Clinical outcomes for individual patients were forwarded to the General Practitioners regularly to assist them in their case management duties. System implementation in this re-engineered environment yielded the following: Strategies for managing the responses of clinicians and patients to the use of technology and a standardized information sharing environment. A means of assessing the system's impact on both the clinician-patient relationship and the professionals' relationship with other clinicians; The evolution of clinical use of information regarding individual patient's health outcome for the management of asthma; The integration of the information systems with policy and planning cycles for the Area Health Service; and The establishment of effective links with vendors of health service applications.
In early 1988 a discharge assessment team surveyed the records of 421 extended-care patients at Washington's Western State Hospital to facilitate planning for patients who were able to move out of the hospital. The group as a whole manifested serious problem behaviors, both current and past. Less than 40 percent of the patients needed continued state hospital care, but most who could be discharged to the community would require intensive residential supervision and support. The authors review linkages between two kinds of residential treatment programming that exists for this population, a network of community residential treatment facilities operated by private providers and community mental health centers and a hospital-based transitional program called the Program for Adaptive Living Skills. Linkages between these programs have proved useful in the residential placement of extended-care patients.
BACKGROUND: The National Immunization Survey demonstrates that national immunization coverage in 2002 remained near the all-time highs achieved in 2000. However, that survey cannot detect whether coverage is uniformly high within relatively small areas or populations. The measles resurgence in the early 1990s revealed that coverage was low in some areas, particularly among inner-city children from racial and ethnic minority groups. Today, identifying areas with low childhood-vaccination coverage remains important, particularly if these areas are at risk for the introduction of disease. In 1995, the Centers for Disease Control and Prevention launched a congressionally mandated demonstrated project now called the Childhood Immunization Demonstration project of Community Health Networks. This mandate specified an assessment to determine whether a network of primary care providers affiliated with university teaching hospitals could assume a public health responsibility for raising immunization levels among preschoolers in medically underserved communities. Communities with federally designated health professional shortage areas were invited to submit proposals, and 4 were selected: Detroit, MI, New York, NY, San Diego, CA, and rural Colorado. OBJECTIVES: To measure immunization coverage among preschool children in the 4 selected medically underserved areas and determine predictors of coverage levels. DESIGN AND SETTING: Surveys in the 4 areas were based on stratified cluster probability sample designs in which clusters of dwelling units were selected and all households in selected clusters were screened for the presence of children aged 12 to 35 months. Immunization histories were obtained from parents and providers for these children. For each age-eligible child, the information collected on utilization of immunization health services included a listing of all clinics or offices ever used for the child's well-child care and/or for obtaining immunizations. Information was also collected on whether the child currently had health insurance (public and/or private) and whether the child had a medical home. A child was classified as having a medical home if the survey respondent reported a source of well care that was the same as the source of sick care and that this place was not an emergency department. PARTICIPANTS: Children 12 to 35 months of age in Detroit, New York, San Diego, and rural Colorado. OUTCOME MEASURE: Community-wide up-to-date (UTD) immunization coverage levels at 19 to 35 months of age, defined as receipt of 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of poliovirus vaccine, 1 dose of measles, mumps, and rubella vaccine, 3 doses of Haemophilus influenzae type B vaccine, and 3 doses of hepatitis B vaccine (the 4:3:1:3:3 series). ANALYSIS: We examined the association between coverage level and independent variables and performed chi2 and t tests to determine whether differences observed within and between groups and sites were significant. RESULTS: The overall response rate for eligible children ranged from 79.4% to 88.1%. Coverage levels for most individual vaccines were >90% in all sites except Detroit. Coverage for the 4:3:1:3:3 series was significantly higher for children in New York (84%) and San Diego (86%) than for children in Detroit (66%) and rural Colorado (75%). Demographic risk factors related to UTD immunization status varied by site. Although differences in coverage levels by ethnicity varied by site, differences were not significant. In Colorado and New York, coverage was slightly lower among Hispanic than white children (71% vs 76% and 83% vs 91%, respectively). In San Diego, coverage was lower among whites, compared with Hispanics (76% vs 85%). Coverage was also lower for African American than white children only in New York (75% vs 91%). However, in San Diego and Colorado, children receiving their vaccinations from private providers had lower coverage levels than children receiving their vaccinations from other providers (78% vs 91% and 71% vs 57%, respectively). Ictively). In all 4 sites, children for whom respondents reported having an immunization card at the time of the interview were more likely to have higher series coverage levels than children for whom a parent-held card was not available. Also, children who were UTD at 3 months of age had significantly higher vaccination-series coverage levels than children who were not UTD at 3 months of age. In addition, the vaccination coverage was lower for children in Detroit whose parents reported problems accessing the health care system because lack of transportation (46%), compared with those who did not report such problems (65%); however, this difference did not reach significance (chi2 = 6.0). In Colorado, the small proportion of children in families without a phone had a lower vaccination coverage level (58%) than those in households with a phone (75%) (chi2 = 6.3). In all sites, children who were UTD at 3 months of age and had a parent-held vaccination card were more likely to be UTD at 19 to 35 months of age. CONCLUSIONS: Preschoolers in these medically underserved areas were not at uniform risk for underimmunization. Because they were designated as health professional shortage areas, the 4 sites in this study were expected to have low immunization-coverage rates. However, this was not the case. In fact, coverage in 3 of the 4 areas was quite high compared with US national figures (73%); only Detroit had a much lower UTD rate (66%). Efforts are needed to improve methods to identify areas with low immunization coverage so that resources can be directed to places where interventions are needed. Our results reveal that an area's need for childhood immunization interventions is not well predicted by a low number of providers per capita. Other criteria must be developed to predict areas or populations with low immunization coverage. Understanding more about the characteristics of children/provider pairs for children who are UTD at 3 months and more about the role of parental hand-held cards, along with finding strategies to improve immunization delivery by providers in Vaccines for Children Program facilities, suggest potentially productive avenues for increasing and sustaining high coverage levels.
Any caries control or caries protocol program must consider compliance as a measure of success. Lower bacterial counts on saliva tests and lower defs and DMFS scores suggest that some change has occurred. However, compliance with a caries risk protocol is about more than simple and convenient clinical outcome measures. We tend to think of compliance as an individual activity, but all influences on an individual need to be considered. Change may be from external influences rather than from the individual or even from providers interacting with an individual or community. Few studies have directly addressed caries risk protocol. The paradigm change described in this manuscript suggests six key global areas--beneficiary education, health provider network education, community and state agencies, legislative commitment, access to care, and research--as significant factors to be considered in compliance. An outline of the major areas and subheadings for a global caries protocol compliance paradigm are presented.
OBJECTIVE: To examine risk factors for preterm delivery in women who present to nontertiary care hospitals with preterm contractions. METHODS: Women who presented to a network of community hospitals in Wisconsin with preterm contractions were followed until delivery. The main outcomes were preterm delivery before completion of 36 weeks of gestation and delivery within 1 week of initial presentation. RESULTS: Of the 266 women presenting with contractions over the 2-year study period, 90% (n=239) consented to participate. Multiple factors were associated with premature delivery, but when examined with a multivariate model, only four (ruptured membranes, multiple gestation, cervical effacement at least 80%, and nonwhite race) were associated with prematurity, whereas five (ruptured membranes, multiple gestation, cervical effacement at least 80%, dilation exceeding 1 cm, and being a nonsmoker) predicted delivery within 1 week. A decision model that combined the presence of ruptured membranes and effacement at least 80% could predict delivery at 34 weeks or less within 7 days of presentation with a sensitivity of 71% and a specificity of 98%. CONCLUSION: Only two clinical cues (ruptured membranes and effacement of the cervix of 80% or more) can predict premature delivery within 7 days. If these results are confirmed prospectively, women with either of these signs could be targeted for administration of steroids, antibiotics, or transfer to tertiary care facilities.
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This paper describes an intervention technique that the psychiatric nurse may find useful in community mental health settings. This technique is called social network intervention. It attempts to combine the best of traditional clinical psychotherapeutic method with the advantages of a social systems approach for working with the patient in psychiatric distress. The technique is based on the assumption that the solution to a variety of human predicaments lies within the collective instrumental and affective resources of a patient's social network. The vehicle for accomplishing this is the "Network Session" during which a mental health clinician convenes the patient and his/her social network to help plan and resolve the difficulty. A Case Report demonstrating the use of the technique is included.
Health service reforms and structures have, in general, emphasised hierarchical systems to enable control and accountability. In doing so, policies have substantially sidelined networks and their potential for contributing to health service performance. Networks play a number of roles, such as in supporting expertise development, arranging referrals, coordinating programs, undertaking projects, sharing common interests and providing mutual support in managing common conditions. They handle knowledge, support expertise and deal with complexity in ways that hierarchies are unable to, and are fundamental to supporting professionalism. Until networks are used to a greater extent, the development of health services will be substantially impeded. This will require enhancing the role and contribution that networks play, which is dependent on resources, leadership and skills.
In Switzerland (7 million inhabitants), the organization of health care is in the hand of the cantons and not of the Confederation. The canton of Vaud (600,000 inhabitants), in the south-west part of the country, counts 4 psychiatric sectors, each with a psychogeriatric service. Otherwise the canton has 146 long-stay facilities with a total of 6,000 beds, of which 600 are for psychogeriatric cases. Home care is in charge of a network of 38 medico-social centres with multidisciplinary teams including psychiatric nurses. Several nursing homes, some specialized in psychogeriatrics, are equipped, besides long-stay beds, by units for temporary care, for medico-social emergencies and for medico-social observations. Moreover, in Lausanne (250,000 inhabitants) an 'Orientation Office of Medico-Social Emergencies', with psychiatric nurses, assumes emergencies at home and by-passes hospitalizations of medico-social cases in the General Hospital, by the resource of medico-social emergency beds in the nursing homes. The medico-social network thus designed in this way is profoundly permeated with the reality of psychogeriatrics.
The authors conducted a study on children undergoing treatment at major school refusal treatment centers in Hiroshima Prefecture. On the whole, school refusal in the prefecture was found to peak between 13 and 14 years of age. By age group, the main reason for school refusal in elementary school group was parent-child relationship with separation anxiety. Given additional problems such as neglect at home and complicated social situations in their schools, junior high school students were found to present diverse symptoms from introversion and self-analysis to extroversion, neglect of studies, and delinquency. Among high school students, there were more cases suffering withdrawal and schizophrenia spectrum disorders. The major task regarding treatment seems to lie in how to treat complex cases combining different problems. We summarized herein the studies we have carried out and propose a model for a network therapy system based on functional liaisons between treatment centers. With this system, a child psychiatric medical facility plays the part of a liaison center for the overall network system.
The Big Three automakers long have wanted Michigan health care providers to give them outcomes data so the care companies could gauge the cost-effectiveness of the care their workers get in the Detroit area. At first, the car companies saw the fledgling Michigan Health Management Information System as the way to finally get the data they've wanted. Eventually, though, after long discussions with other network participants, the carmakers opted to scale back expectations, agreeing that the network should focus first on moving administrative transactions between health care purchasers, payers and providers.
Antitrust concerns about large physician networks typically have focused on the risk-sharing aspects of such networks; little attention has been paid to the impact these networks have had on the healthcare market. However, the Department of Justice has recently issued three business review letters regarding physician networks or mergers in New Jersey, California, and Minnesota which indicate that the level of market dominance created by proposed physician mergers or networks probably will be subject to closer scrutiny in the future.
Since 1990, the home enteral nutrition (HEN) has been experienced by the Centre Médical de Forcilles (CMDF), according to the 1988 and 1993 instructions. This service has a regional vocation and forms an integral part of a partnership system in care including: the prescribing hospital, the usual physician and various specialists. We have a triple objective: 1) To define the structure and the action of this medical service, the only one in France. 2) To appreciate the 9 years experience with 4297 patients: Medical interest, with the nutritional care of patients suffering of heavy diseases, more particularly ORL cancers and neurological troubles disturbing deglutition. The use of regulating flow pumps, care avoid "Mendelson syndrome". Repercussion on patients quality of life, who stays in a family environment. This seems to be beneficial for 58.9% cases. More over, 95.8% patients prefer this solution instead an hospitalization. The permanent communication between the members of this plural disciplinary team guarantees safety, comfort and relief. Economical benefit with a computerized management, recovering of the products and reduction in purchase (large quantities). This allows a very reasonable "price per day" (120.38 F in 1999), to wit a thrift of 95% in comparison with a classical hospitalization. 3) To propose, according to the CMDF example, a quality charter for a HEN centers regional organisation, and the valuation of their activity. According to the fact that the HEN has to be legally realized all over the national territory, the CMDF exemplary fitted to local needs, should allow an appropriate solution, with a control of the costs, thanks to a real partnership in network of care, for this public health problem.
The centennial of the Medical Library Association offers an opportunity to reflect with some satisfaction on accomplishments and to consider the future. The Western Governors University is an illustration of the dynamic future. Professional values constitute both distinguishing characteristics and steadfast guides for succeeding in this complex environment. Powerful collaborative technologies now make it possible to overcome challenges that are beyond the capabilities of an individual librarian or library. Providing organized access to the Internet exemplifies these challenges. The profession has a strong history of cooperation but to take full advantage of collaboration, institutional and cultural barriers must be overcome. The National Network of Libraries of Medicine (NN/LM) should be the facilitating agent in this process.