Sample records for patient care management

  1. Collaborative care management effectively promotes self-management: patient evaluation of care management for depression in primary care.

    PubMed

    DeJesus, Ramona S; Howell, Lisa; Williams, Mark; Hathaway, Julie; Vickers, Kristin S

    2014-03-01

    Chronic disease management in the primary care setting increasingly involves self-management support from a nurse care manager. Prior research had shown patient acceptance and willingness to work with care managers. This survey study evaluated patient-perceived satisfaction with care management and patient opinions on the effectiveness of care management in promoting self-management. Qualitative and quantitative survey responses were collected from 125 patients (79% female; average age 46; 94% Caucasian) enrolled in care management for depression. Qualitative responses were coded with methods of content analysis by 2 independent analysts. Patients were satisfied with depression care management. Patients felt that care management improved their treatment above and beyond other aspects of their depression treatment (mean score, 6.7 [SD, 2]; 10 = Very much), increased their understanding of depression self-management (mean score, 7.2 [SD, 2]; 10 = Very much), and increased the frequency of self-management goal setting (mean score, 6.9 [SD, 3]; 10 = Very much). Predominant qualitative themes emphasized that patients value emotional, motivational, and relational aspects of the care manager relationship. Patients viewed care managers as caring and supportive, helpful in creating accountability for patients and knowledgeable in the area of depression care. Care managers empower patients to take on an active role in depression self-management. Some logistical challenges associated with a telephonic intervention are described. Care manager training should include communication and motivation strategies, specifically self-management education, as these strategies are valued by patients. Barriers to care management, such as scheduling telephone calls, should be addressed in future care management implementation and study.

  2. Managing Patient Trust in Managed Care

    PubMed Central

    Davies, Huw T.O.; Rundall, Thomas G.

    2000-01-01

    Patient trust has been identified as an important element in the patient-physician relationship. However, common features of managed care, such as risk-sharing, utilization review, and limitations on benefits, may erode the traditionally high trust that patients have in their physicians. High trust is not always justified; rather, an optimal level of trust arises from the level of interdependence between patients and physicians. This analysis of the interrelationship between patient-physician trust and some of the key facets of managed care has important implications for managed care. A return to high levels of trust may be impracticable, and new strategies for balancing trust-building efforts by caregivers with checking mechanisms accessible to patients are recommended. PMID:11191451

  3. Care management redesign: increasing care manager time with patients and providers while improving metrics.

    PubMed

    Kowinsky, Amy; Greenhouse, Pamela K; Zombek, Victoria L; Rader, Sandra L; Reidy, Margaret E

    2009-09-01

    In many hospitals, addressing increasing financial and regulatory requirements has resulted in a decline in care managers' time spent communicating directly with patients, families, and healthcare providers. The authors discuss the redesign of a hospital care management model that increased the time care managers spend with patients, families, and other care professionals, while patient satisfaction increased, labor cost remained neutral, length of stay decreased, and the payment denial rate remained among the country's lowest.

  4. Using patient acuity data to manage patient care outcomes and patient care costs.

    PubMed

    Van Slyck, A; Johnson, K R

    2001-01-01

    This article describes actual reported uses for patient acuity data that go beyond historical uses in determining staffing allocations. These expanded uses include managing patient care outcomes and health care costs. The article offers the patient care executive examples of how objective, valid, and reliable data are used to drive approaches to effectively influence decision making in an increasingly competitive health care environment.

  5. Intensive Care Management of Patients with Cirrhosis.

    PubMed

    Olson, Jody C

    2018-06-01

    Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU. Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit. Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.

  6. European hospital managers' perceptions of patient-centred care.

    PubMed

    Taylor, Angelina; Groene, Oliver

    2015-01-01

    The spotlight has recently been placed on managers' responsibility for patient-centred care as a result of Mid Staffordshire NHS Foundation Trust failings. In previous research, clinicians reported that managers do not have an adequate structured plan for implementing patient-centred care. The purpose of this paper is to assess the perceptions of European hospital management with respect to factors affecting the implementation of a patient-centred approach. In total, 15 semi-structured interviews were conducted with hospital managers (n=10), expert country informants (n=2), patient organisations (n=2) and a user representative (n=1) from around Europe. Participants were purposively and snowball sampled. Interviews were analysed using framework analysis. Most participants felt that current levels of patient-centred care are inadequate, but accounted that there were a number of macro, meso and micro challenges they faced in implementing this approach. These included budget constraints, political and historical factors, the resistance of clinicians and other frontline staff. Organisational culture emerged as a central theme, shaped by these multi-level factors and influencing the way in which patient-centred care was borne out in the hospital. Participants proposed that the needs of patients might be better met through increasing advocacy by patient organisations and greater staff contact with patients. This study is the first of its kind to obtain management views from around Europe. It offers an insight into different models of how patient-centred care is realised by management. It indicates that managers see the value of a patient-centred approach but that they feel restricted by a number of factors at multiple levels.

  7. Impact of generalist care managers on patients with diabetes.

    PubMed

    Dorr, David A; Wilcox, Adam; Donnelly, Steven M; Burns, Laurie; Clayton, Paul D

    2005-10-01

    To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes. Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network. A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients. Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels. In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c <7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant. Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

  8. Managing high-risk patients: the Mass General care management programme

    PubMed Central

    Kodner, Dennis L.

    2015-01-01

    The Massachusetts General Care Management Program (Mass General CMP or CMP) was designed as a federally supported demonstration to test the impact of intensive, practice-based care management on high-cost Medicare fee-for-service (FFS) beneficiaries—primarily older persons—with multiple hospitalisations and multiple chronic conditions. The Massachusetts General Care Management Program operated over a 6-year period in two phases (3 years each). It started during the first phase at Massachusetts General Hospital, a major academic medical centre in Boston, Massachusetts in collaboration with Massachusetts General Physicians Organisation. During the second phase, the programme expanded to two more affiliated sites in and around the Boston area, including a community hospital, as well as incorporated several modifications primarily focused on the management of transitions to post-acute care in skilled nursing facilities. At the close of the demonstration in July 2012, Mass General Massachusetts General Care Management Program became a component of a new Pioneer accountable care organisation (ACO). The Massachusetts General Care Management Program is focused on individuals meeting defined eligibility criteria who are offered care that is integrated by a case manager embedded in a primary care practice. The demonstration project showed substantial cost savings compared to fee-for-service patients served in the traditional Medicare system but no impact on hospital readmissions. The Massachusetts General Care Management Program does not rest upon a “whole systems” approach to integrated care. It is an excellent example of how an innovative care co-ordination programme can be implemented in an existing health-care organisation without making fundamental changes in its underlying structure or the way in which direct patient care services are paid for. The accountable care organisation version of the Massachusetts General Care Management Program includes the staffing

  9. Implementing practice management strategies to improve patient care: the EPIC project.

    PubMed

    Attwell, David; Rogers-Warnock, Leslie; Nemis-White, Joanna

    2012-01-01

    Healthcare gaps, the difference between usual care and best care, are evident in Canada, particularly with respect to our aging, ailing population. Primary care practitioners are challenged to identify, prevent and close care gaps in their practice environment given the competing demands of informed, litigious patients with complex medical needs, ever-evolving scientific evidence with new treatment recommendations across many disciplines and an enhanced emphasis on quality and accountability in healthcare. Patient-centred health and disease management partnerships using measurement, feedback and communication of practice patterns and outcomes have been shown to narrow care gaps. Practice management strategies such as the use of patient registries and recall systems have also been used to help practitioners better understand, follow and proactively manage populations of patients in their practice. The Enhancing Practice to Improve Care project was initiated to determine the impact of a patient-centred health and disease management partnership using practice management strategies to improve patient care and outcomes for patients with chronic kidney disease (CKD). Forty-four general practices from four regions of British Columbia participated and, indeed, demonstrated that care and outcomes for patients with CKD could be improved via the implementation of practice management strategies in a patient-centred partnership measurement model of health and disease management.

  10. Use of Care Paths to Improve Patient Management

    ERIC Educational Resources Information Center

    Campbell, Suzann K.

    2013-01-01

    The purpose of this special issue of Physical & Occupational Therapy in Pediatrics is to present an evidence-based system to guide the physical therapy management of patients in the Neonatal Intensive Care Unit (NICU). Two systematic guides to patient management will be presented. The first is a care path intended primarily for use by physical…

  11. Case management in an acute-care hospital: collaborating for quality, cost-effective patient care.

    PubMed

    Grootveld, Kim; Wen, Victoria; Bather, Michelle; Park, Joan

    2014-01-01

    Case management has recently been advanced as a valuable component in achieving quality patient care that is also cost-effective. At St. Michael's Hospital, in Toronto, Ontario, case managers from a variety of professional backgrounds are central to a new care initiative--Rapid Assessment and Planning to Inform Disposition (RAPID)--in the General Internal Medicine (GIM) Unit that is designed to improve patient care and reconcile high emergency department volumes through "smart bed spacing." Involved in both planning and RAPID, GIM's case managers are the link between patient care and utilization management. These stewards of finite resources strive to make the best use of dollars spent while maintaining a commitment to quality care. Collaborating closely with physicians and others across the hospital, GIM's case managers have been instrumental in bringing about significant improvements in care coordination, utilization management and process redesign. Copyright © 2014 Longwoods Publishing.

  12. Medication therapy management: its relationship to patient counseling, disease management, and pharmaceutical care.

    PubMed

    McGivney, Melissa Somma; Meyer, Susan M; Duncan-Hewitt, Wendy; Hall, Deanne L; Goode, Jean-Venable R; Smith, Randall B

    2007-01-01

    To delineate the relationship, including similarities and differences, between medication therapy management (MTM) and contemporary pharmacist-provided services, including patient counseling, disease management, and pharmaceutical care, to facilitate the continued evolution of commonly used language and a standard of practice across geographic areas and practice environments. Incorporation of MTM services into the array of Medicare-funded services affords an opportunity for pharmacists to develop direct patient care services in the community. Defining the role of MTM within the scope of pharmacist-provided patient care activities, including patient counseling, disease management, and all currently provided pharmacy services is essential to the delineation of a viable and sustainable practice model for pharmacists. The definitions of each of these services are offered, as well as comparisons and contrasts of the individual services. In addition to Medicare-eligible patients, MTM services are appropriate for anyone with medication-related needs. MTM is offered as an all-encompassing model that incorporates the philosophy of pharmaceutical care, techniques of patient counseling, and disease management in an environment that facilitates the direct collaboration of patients, pharmacists, and other health professionals. Defining the role of MTM within the current patient care models, including patient counseling, disease management, and all who provide pharmacy services, is essential in delineating a viable and sustainable practice model for pharmacists.

  13. Nurse middle managers contributions to patient-centred care: A 'managerial work' analysis.

    PubMed

    Lalleman, Pcb; Smid, Gac; Dikken, J; Lagerwey, M D; Schuurmans, M J

    2017-10-01

    Nurse middle managers are in an ideal position to facilitate patient-centred care. However, their contribution is underexposed in literature due to difficulties to articulate this in practice. This paper explores how nurse middle managers contribute to patient-centred care in hospitals. A combination of time-use analysis and ethnographic work was used to disclose their contribution to patient-centred care at a micro level. Sixteen nurse managers were shadowed for over 560 hours in four hospitals. Some nurse middle managers seldom contribute to patient-centred care. Others are involved in direct patient care, but this does not result in patient-centred practices. At one hospital, the nurse middle managers did contribute to patient-centred care. Here balancing between "organizing work" and "caring work" is seen as a precondition for their patient-centeredness. Other important themes are feedback mechanisms; place matters; with whom to talk and how to frame the issues at stake; and behavioral style. Both "hands-on" and "heads-on" caring work of nurse middle managers enhances their patient-centeredness. This study is the first of its kind to obtain insight in the often difficult to articulate "doings" of nurse middle managers with regard to patient-centred care through combining time-use analysis with ethnographic work. © 2017 John Wiley & Sons Ltd.

  14. Primary care management of patients following bariatric surgery.

    PubMed

    Doolen, Jessica L; Miller, Sally K

    2005-11-01

    To evaluate the nutritional, psychosocial, and other primary care issues faced by nurse practitioners (NPs) and their patients in the long-term management of the increasing population of patients who have had bariatric surgery. An extensive review of the literature provides the foundation for development of assessment and management strategies highlighted in a case study. Management of the patient after bariatric surgery does not end with successful surgical healing. Numerous long-term implications, including significant psychosocial and nutritional issues, require the informed attention of the primary care provider for the rest of the life span. Each year an increasing number of obese patients pursue a surgical solution to obesity, up to an estimated 100,000 in 2004. Numerous long-term health implications are specific to this population. NPs can improve the quality of primary care to these patients by being informed regarding the different procedures and their impact on physiologic phenomena, and the psychosocial issues inherent to extreme weight loss.

  15. Palliative wound care management strategies for palliative patients and their circles of care.

    PubMed

    Woo, Kevin Y; Krasner, Diane L; Kennedy, Bruce; Wardle, David; Moir, Olivia

    2015-03-01

    To provide information about palliative wound care management strategies for palliative patients and their circles of care. This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to: 1. Recognize study findings, assessment tools, and non-pharmacologic strategies used for patients with palliative wounds. 2. Summarize pharmacologic and dressing treatment strategies used for wound care management of palliative patients. The principles of palliative wound care should be integrated along the continuum of wound care to address the whole person care needs of palliative patients and their circles of care, which includes members of the patient unit including family, significant others, caregivers, and other healthcare professionals that may be external to the current interprofessional team. Palliative patients often present with chronic debilitating diseases, advanced diseases associated with major organ failure (renal, hepatic, pulmonary, or cardiac), profound dementia, complex psychosocial issues, diminished self-care abilities, and challenging wound-related symptoms. This article introduces key concepts and strategies for palliative wound care that are essential for interprofessional team members to incorporate in clinical practice when caring for palliative patients with wounds and their circles of care.

  16. Online chemotherapy symptom care and patient management system: an evaluative study.

    PubMed

    Chan, Moon Fai; Ang, Neo Kim Emily; Cho, Aye Aye; Chow, Ying Leng; Taylor, Beverly

    2014-02-01

    Health delivery practices are shifting toward home care, because of better possibilities for managing chronic care, controlling health delivery costs, and increasing the quality of life and quality of health services, and the distinct possibility of predicting and thus avoiding serious complications. The study aimed to explore the benefits of an online Symptom Care and Management System in the home for patients receiving chemotherapy. A single-group experimental design was used. Thirty patients aged between 37 and 77 years undergoing their first or commencing a new course of chemotherapy treatment were recruited from November 2010 and December 2012 at a cancer center in Singapore. All patients used the Symptom Care and Management System to send daily symptom reports to the cancer center and received symptom management advice from the oncology nurse via teleconferencing during the first four chemotherapy treatment cycles. Patients' perceptions of the use of the Symptom Care and Management System were evaluated. All participants perceived the Symptom Care and Management System as a user-friendly interface and believed that they felt more involved in their care, and the system made it easier to understand some of the problems they experienced and helped them manage the symptoms more easily during the treatment. In addition, 29 participants (96.7%) felt that the nurse could contact them better via the Symptom Care and Management System, the Symptom Care and Management System helped them explain their symptoms to the nurse, and that it was simple to understand. The results presented in this study suggested that the Symptom Care and Management System has the potential to enhance remote monitoring and provides a feasible and acceptable way for a specific group of cancer patients to manage their symptoms at home.

  17. Human resource management in patient-centered pharmaceutical care.

    PubMed

    White, S J

    1994-04-01

    Patient-centered care may have the pharmacists and technicians reporting either directly or in a matrix to other than pharmacy administration. The pharmacy administrative people will need to be both effective leaders and managers utilizing excellent human resource management skills. Significant creativity and innovation will be needed for transition from departmental-based services to patient care team services. Changes in the traditional methods of recruiting, interviewing, hiring, training, developing, inspiring, evaluating, and disciplining are required in this new environment.

  18. Primary care managers' perceptions of their capability in providing care planning to patients with complex needs.

    PubMed

    Larsson, Lena Gunvor; Bäck-Pettersson, Siv; Kylén, Sven; Marklund, Bertil; Carlström, Eric

    2017-01-01

    The aim of this study was to investigate primary care managers' perceptions of their capability in providing care planning to patients with complex needs. Care planning is defined as a process where the patient, family and health professionals engage in dialogue about the patient's care needs and plan care interventions together. Semi-structured interviews with 18 primary care managers in western Sweden were conducted using Westrin's theoretical cooperation model. Data were analysed using a qualitative deductive method. Results reveal that the managers' approach to care planning was dominated by non-cooperation and separation. The managers were permeated by uncertainty about the meaning of the task of care planning as such. They did not seem to be familiar with the national legislation stipulating that every healthcare provider must meet patients' need for care interventions and participate in the care planning. To accomplish care planning, the process needs to cross - and overcome - both professional and organisational boundaries. There is also a need for incentives to develop working methods that promote local cooperation in order to facilitate optimal care for patients with complex needs. Copyright © 2016. Published by Elsevier Ireland Ltd.

  19. The Oral Health Care Manager in a Patient-Centered Health Facility.

    PubMed

    Theile, Cheryl Westphal; Strauss, Shiela M; Northridge, Mary Evelyn; Birenz, Shirley

    2016-06-01

    The dental hygienist team member has an opportunity to coordinate care within an interprofessional practice as an oral health care manager. Although dental hygienists are currently practicing within interprofessional teams in settings such as pediatric offices, hospitals, nursing homes, schools, and federally qualified health centers, they often still assume traditional responsibilities rather than practicing to the full extent of their training and licenses. This article explains the opportunity for the dental hygiene professional to embrace patient-centered care as an oral health care manager who can facilitate integration of oral and primary care in a variety of health care settings. Based on an innovative model of collaboration between a college of dentistry and a college of nursing, an idea emerged among several faculty members for a new management method for realizing continuity and coordination of comprehensive patient care. Involved faculty members began working on the development of an approach to interprofessional practice with the dental hygienist serving as an oral health care manager who would address both oral health care and a patient's related primary care issues through appropriate referrals and follow-up. This approach is explained in this article, along with the results of several pilot studies that begin to evaluate the feasibility of a dental hygienist as an oral health care manager. A health care provider with management skills and leadership qualities is required to coordinate the interprofessional provision of comprehensive health care. The dental hygienist has the opportunity to lead closer integration of oral and primary care as an oral health care manager, by coordinating the team of providers needed to implement comprehensive, patient-centered care. Copyright © 2016 Elsevier Inc. All rights reserved.

  20. Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery.

    PubMed

    Trosman, Julia R; Carlos, Ruth C; Simon, Melissa A; Madden, Debra L; Gradishar, William J; Benson, Al B; Rapkin, Bruce D; Weiss, Elisa S; Gareen, Ilana F; Wagner, Lynne I; Khan, Seema A; Bunce, Mikele M; Small, Art; Weldon, Christine B

    2016-11-01

    Cancer care is highly complex and suffers from fragmentation and lack of coordination across provider specialties and clinical domains. As a result, patients often find that they must coordinate care on their own. Coordinated delivery teams may address these challenges and improve quality of cancer care. Task interdependence is a core principle of rigorous teamwork and is essential to addressing the complexity of cancer care, which is highly interdependent across specialties and modalities. We examined challenges faced by a patient with early-stage breast cancer that resulted from difficulties in understanding and managing task interdependence across clinical domains involved in this patient's care. We used team science supported by the project management discipline to discuss how various task interdependence aspects can be recognized, deliberately designed, and systematically managed to prevent care breakdowns. This case highlights how effective task interdependence management facilitated by project management methods could markedly improve the course of a patient's care. This work informs efforts of cancer centers and practices to redesign cancer care delivery through innovative, practical, and patient-centered approaches to management of task interdependence in cancer care. Future patient-reported outcomes research will help to determine optimal ways to engage patients, including those who are medically underserved, in managing task interdependence in their own care.

  1. Patient empowerment and motivational interviewing: engaging patients to self-manage their own care.

    PubMed

    McCarley, Patricia

    2009-01-01

    Patient empowerment is centered on the belief that patients should be in control of their own care and that behavioral changes and adherence to therapies cannot be achieved unless patients internalize the need for self-change. Data have consistently shown improved outcomes among patients on dialysis who are engaged, empowered and self-managing. Motivational interviewing provides a technique that can be applied by nephrology nurses to partner with patients and engage them in the management of their own care.

  2. Experience of hypertensive patients with self-management of health care.

    PubMed

    Balduino, Anice de Fátima Ahmad; Mantovani, Maria de Fátima; Lacerda, Maria Ribeiro; Marin, Maria José Sanches; Wal, Marilene Loewen

    2016-11-01

    The aim of this study was to interpret how hypertensive patients experience health care self-management. Hypertension is one of the most prevalent chronic diseases worldwide. The involvement of individuals in the management of their health care to treat this disease is fundamental, with aid and advice from healthcare professionals, especially nurses, so that hypertensive patients can effectively self-manage their health care. Qualitative study. Hypertensive patients were recruited using theoretical sampling. The study sample consisted of 28 hypertensive patients aged 18-59 years who were registered in the e-Health programme of the Ministry of Health. Data were collected and analyzed between September 2012-October 2014 using a semi-structured interview based on the methodological framework of the constructivist grounded theory. The participants' statements depicted an outline of their experience with the disease: the beginning of the illness; understanding the disease process; incorporating behaviour for self-management of the disease; experiencing attitudes and actions in the control and treatment of the disease; and being treated in the public healthcare system. A central phenomenon emerged, namely hypertensive patients' experience of self-management of health care. This phenomenon has paths, actions and interactions. When patients discover that they have the disease and become aware of the disease process, they assume the identity of being hypertensive and become proactive in their health care and in living with their families and in communities. © 2016 John Wiley & Sons Ltd.

  3. Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery

    PubMed Central

    Carlos, Ruth C.; Simon, Melissa A.; Madden, Debra L.; Gradishar, William J.; Benson, Al B.; Rapkin, Bruce D.; Weiss, Elisa S.; Gareen, Ilana F.; Wagner, Lynne I.; Khan, Seema A.; Bunce, Mikele M.; Small, Art; Weldon, Christine B.

    2016-01-01

    Cancer care is highly complex and suffers from fragmentation and lack of coordination across provider specialties and clinical domains. As a result, patients often find that they must coordinate care on their own. Coordinated delivery teams may address these challenges and improve quality of cancer care. Task interdependence is a core principle of rigorous teamwork and is essential to addressing the complexity of cancer care, which is highly interdependent across specialties and modalities. We examined challenges faced by a patient with early-stage breast cancer that resulted from difficulties in understanding and managing task interdependence across clinical domains involved in this patient’s care. We used team science supported by the project management discipline to discuss how various task interdependence aspects can be recognized, deliberately designed, and systematically managed to prevent care breakdowns. This case highlights how effective task interdependence management facilitated by project management methods could markedly improve the course of a patient’s care. This work informs efforts of cancer centers and practices to redesign cancer care delivery through innovative, practical, and patient-centered approaches to management of task interdependence in cancer care. Future patient-reported outcomes research will help to determine optimal ways to engage patients, including those who are medically underserved, in managing task interdependence in their own care. PMID:27577619

  4. Antidepressant Medication Management among Older Patients Receiving Home Health Care

    PubMed Central

    Bao, Yuhua; Shao, Huibo; Bruce, Martha L.; Press, Matthew J.

    2014-01-01

    Objective Antidepressant management for older patients receiving home health care (HHC) may occur through two pathways: nurse-physician collaboration (without patient visits to the physician) and physician management through office visits. This study examines the relative contribution of the two pathways and how they interplay. Methods Retrospective analysis was conducted using Medicare claims of 7,389 depressed patients 65 or older who received HHC in 2006–7 and who possessed antidepressants at the start of HHC. A change in antidepressant therapy (vs. discontinuation or refill) was the main study outcome and could take the form of a change in dose, switch to a different antidepressant, or augmentation (addition of a new antidepressant). Logistic regressions were estimated to examine how use of home health nursing care, patient visits to physicians, and their interactions predict a change in antidepressant therapy. Results About 30% of patients experienced a change in antidepressants versus 51% who refilled and 18% who discontinued. Receipt of mental health specialty care was associated with a statistically significant, 10–20 percentage-point increase in the probability of antidepressant change; receipt of primary care was associated with a small and statistically significant increase in the probability of antidepressant change among patients with no mental health specialty care and above-average utilization of nursing care. Increased home health nursing care in absence of physician visits was not associated with increased antidepressant change. Conclusions Active antidepressant management resulting in a change in medication occurred on a limited scale among older patients receiving HHC. Addressing knowledge and practice gaps in antidepressant management by primary care providers and home health nurses and improving nurse-physician collaboration will be promising areas for future interventions. PMID:25158915

  5. Demand management: enabling patients to use medical care appropriately.

    PubMed

    Vickery, D M; Lynch, W D

    1995-05-01

    A rationale is presented for considering demand management as well as supply management (managed care) in the current debate on health care reform. Demand management is the support of individuals so that they may make rational health and medical decisions based on a consideration of benefits and risks. The concept of demand for medical services is examined within a theoretical framework of four components: morbidity, perceived need, patient preference, and nonhealth motives. Two components, perceived need and patient preference, are suggested to offer considerable potential for making utilization more appropriate and reducing costs. Current demand services and potential hazards related to their continued expansion are discussed.

  6. Managing social awkwardness when caring for morbidly obese patients in intensive care: A focused ethnography.

    PubMed

    Hales, Caz; de Vries, Kay; Coombs, Maureen

    2016-06-01

    Critically ill morbidly obese patients pose considerable healthcare delivery and resource utilisation challenges in the intensive care setting. These are resultant from specific physiological responses to critical illness in this population and the nature of the interventional therapies used in the intensive care environment. An additional challenge arises for this population when considering the social stigma that is attached to being obese. Intensive care staff therefore not only attend to the physical and care needs of the critically ill morbidly obese patient but also navigate, both personally and professionally, the social terrain of stigma when providing care. To explore the culture and influences on doctors and nurses within the intensive care setting when caring for critically ill morbidly obese patients. A focused ethnographic approach was adopted to elicit the 'situated' experiences of caring for critically ill morbidly obese patients from the perspectives of intensive care staff. Participant observation of care practices and interviews with intensive care staff were undertaken over a four month period. Analysis was conducted using constant comparison technique to compare incidents applicable to each theme. An 18 bedded tertiary intensive care unit in New Zealand. Sixty-seven intensive care nurses and 13 intensive care doctors involved with the care and management of seven critically ill patients with a body mass index ≥40kg/m(2). Interactions between intensive care staff and morbidly obese patients were challenging due to the social stigma surrounding obesity. Social awkwardness and managing socially awkward moments were evident when caring for morbidly obese patients. Intensive care staff used strategies of face-work and mutual pretence to alleviate feelings of discomfort when engaged in aspects of care and caring. This was a strategy used to prevent embarrassment and distress for both the patients and staff. This study has brought new understandings

  7. Leveraging Interactive Patient Care Technology to Improve Pain Management Engagement.

    PubMed

    Rao-Gupta, Suma; Kruger, David; Leak, Lonna D; Tieman, Lisa A; Manworren, Renee C B

    2018-06-01

    Most children experience pain in hospitals; and their parents report dissatisfaction with how well pain was managed. Engaging patients and families in the development and evaluation of pain treatment plans may improve perceptions of pain management and hospital experiences. The aim of this performance improvement project was to engage patients and families to address hospitalized pediatric patients' pain using interactive patient care technology. The goal was to stimulate conversations about pain management expectations and perceptions of treatment plan effectiveness among patients, parents, and health care teams. Plan-Do-Study-Act was used to design, develop, test, and pilot new workflows to integrate the interactive patient care technology system with the automated medication dispensing system and document actions from both systems into the electronic health record. The pediatric surgical unit and hematology/oncology unit of a free-standing, university-affiliated, urban children's hospital were selected to pilot this performance improvement project because of the high prevalence of pain from surgeries and hematologic and oncologic diseases, treatments, and invasive procedures. Documentation of pain assessments, nonpharmacologic interventions, and evaluation of treatment effectiveness increased. The proportion of positive family satisfaction responses for pain management significantly increased from fiscal year 2014 to fiscal year 2016 (p = .006). By leveraging interactive patient care technologies, patients and families were engaged to take an active role in pain treatment plans and evaluation of treatment outcomes. Improved active communication and partnership with patients and families can effectively change organizational culture to be more sensitive to patients' pain and patients' and families' hospital experiences. Copyright © 2017 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

  8. Patient understanding of diabetes self-management: participatory decision-making in diabetes care.

    PubMed

    Quinn, Charlene C; Royak-Schaler, Renee; Lender, Dan; Steinle, Nanette; Gadalla, Shahinaz; Zhan, Min

    2011-05-01

    Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication. A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25-85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care. African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient-physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education. Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c. © 2011 Diabetes Technology Society.

  9. Expectations outpace reality: physicians' use of care management tools for patients with chronic conditions.

    PubMed

    Carrier, Emily; Reschovsky, James

    2009-12-01

    Use of care management tools--such as group visits or patient registries--varies widely among primary care physicians whose practices care for patients with four common chronic conditions--asthma, diabetes, congestive heart failure and depression--according to a new national study by the Center for Studying Health System Change (HSC). For example, less than a third of these primary care physicians in 2008 reported their practices use nurse managers to coordinate care, and only four in 10 were in practices using registries to keep track of patients with chronic conditions. Physicians also used care management tools for patients with some chronic conditions but not others. Practice size and setting were strongly related to the likelihood that physicians used care management tools, with solo and smaller group practices least likely to use care management tools. The findings suggest that, along with experimenting with financial incentives for primary care physicians to adopt care management tools, policy makers might consider developing community-level care management resources, such as nurse managers, that could be shared among smaller physician practices.

  10. Differential effectiveness of depression disease management for rural and urban primary care patients.

    PubMed

    Adams, Scott J; Xu, Stanley; Dong, Fran; Fortney, John; Rost, Kathryn

    2006-01-01

    Federally qualified health centers across the country are adopting depression disease management programs following federally mandated training; however, little is known about the relative effectiveness of depression disease management in rural versus urban patient populations. To explore whether a depression disease management program has a comparable impact on clinical outcomes over 2 years in patients treated in rural and urban primary care practices and whether the impact is mediated by receiving evidence-based care (antidepressant medication and specialty care counseling). A preplanned secondary analysis was conducted in a consecutively sampled cohort of 479 depressed primary care patients recruited from 12 practices in 10 states across the country participating in the Quality Enhancement for Strategic Teaming study. Depression disease management improved the mental health status of urban patients over 18 months but not rural patients. Effects were not mediated by antidepressant medication or specialty care counseling in urban or rural patients. Depression disease management appears to improve clinical outcomes in urban but not rural patients. Because these programs compete for scarce resources, health care organizations interested in delivering depression disease management to rural populations need to advocate for programs whose clinical effectiveness has been demonstrated for rural residents.

  11. Patient costs in anticoagulation management: a comparison of primary and secondary care.

    PubMed Central

    Parry, D; Bryan, S; Gee, K; Murray, E; Fitzmaurice, D

    2001-01-01

    BACKGROUND: The demand for anticoagulation management is increasing. This has led to care being provided in non-hospital settings. While clinical studies have similarly demonstrated good clinical care in these settings, it is still unclear as to which alternative is the most efficient. AIM: To determine the costs borne by patients when attending an anticoagulation management clinic in either primary or secondary care and to use this information to consider the cost-effectiveness of anticoagulation management in primary and secondary care, both from the National Health Service and patient perspectives. DESIGN OF STUDY: Observational study comparing two cohorts of patients currently attending anticoagulation management clinics. SETTING: Four primary care clinics in Birmingham and one in Warwickshire, and the haematology clinics at the University of Birmingham Hospitals Trust and the City Hospital NHS Trust. METHOD: The survey of patients attending the clinics was used to ascertain patient costs. This information was then used in conjunction with the findings of a recent randomised controlled trial to establish cost-effectiveness. RESULTS: Patient costs were lower in primary care than in secondary care settings; the mean (standard deviation) costs per visit were Pound Sterling6.78 (Pound Sterling5.04) versus Pound Sterling14.58 (Pound Sterling9.08). While a previous cost-effectiveness analysis from a health sector perspective alone found a higher cost for primary care, the adoption of the societal perspective lead to a marked change in the result: a similar total cost per patient in both sectors. CONCLUSION: There are significantly higher costs borne by patients attending secondary care anticoagulation management clinics than similar patients attending primary care clinics. This study also demonstrates that the perspective adopted in an economic evaluation can influence the final result. PMID:11766869

  12. Remote access to medical specialists: home care interactive patient management system

    NASA Astrophysics Data System (ADS)

    Martin, Peter J.; Draghic, Nicole; Wiesmann, William P.

    1999-07-01

    Diabetes management involves constant care and rigorous compliance. Glucose control is often difficult to maintain and onset of complications further compound health care needs. Status can be further hampered by geographic isolation from immediate medical infrastructures. The Home Care Interactive Patient Management System is an experimental telemedicine program that could improve chronic illness management through Internet-based applications. The goal of the system is to provide a customized, integrated approach to diabetes management to supplement and coordinate physician protocol while supporting routine patient activity, by supplying a set of customized automated services including health data collection, transmission, analysis and decision support.

  13. Patient-centeredness and quality management in Dutch diabetes care organizations after a 1-year intervention.

    PubMed

    Campmans-Kuijpers, Marjo Je; Lemmens, Lidwien C; Baan, Caroline A; Rutten, Guy Ehm

    2016-01-01

    More focus on patient-centeredness in care for patients with type 2 diabetes requests increasing attention to diabetes quality management processes on patient-centeredness by managers in primary care groups and outpatient clinics. Although patient-centered care is ultimately determined by the quality of interactions between patients and clinicians at the practice level, it should be facilitated at organizational level too. This nationwide study aimed to assess the state of diabetes quality management on patient-centeredness at organizational level and its possibilities to improve after a tailored intervention. This before-after study compares the quality management on patient-centeredness within Dutch diabetes care groups and outpatient clinics before and after a 1-year stepwise intervention. At baseline, managers of 51 diabetes primary care groups and 28 outpatient diabetes clinics completed a questionnaire about the organization's quality management program. Patient-centeredness (0%-100%) was operationalized in six subdomains: facilitating self-management support, individualized care plan support, patients' access to medical files, patient education policy, safeguarding patients' interests, and formal patient involvement. The intervention consisted of feedback and benchmark and if requested a telephone call and/or a consultancy visit. After 1 year, the managers completed the questionnaire again. The 1-year changes were examined by dependent (non) parametric tests. Care groups improved significantly on patient-centeredness (from 47.1% to 53.3%; P =0.002), and on its subdomains "access to medical files" (from 42.0% to 49.4%), and "safeguarding patients' interests" (from 58.1% to 66.2%). Outpatient clinics, which scored higher at baseline (66.7%) than care groups, did not improve on patient-centeredness (65.6%: P =0.54) or its subdomains. "Formal patient involvement" remained low in both care groups (23.2%) and outpatient clinics (33.9%). After a simple intervention

  14. How Technology in Care at Home Affects Patient Self-Care and Self-Management: A Scoping Review

    PubMed Central

    Peeters, José M.; Wiegers, Therese A.; Friele, Roland D.

    2013-01-01

    The use of technology in care at home has potential benefits such as improved quality of care. This includes greater focus on the patients’ role in managing their health and increased patient involvement in the care process. The objective of this scoping review is to analyse the existing evidence for effects of technology in home-based care on patients’ self-care and self-management. Using suitable search terms we searched the databases of Pubmed, Embase, Cochrane Library, Cinahl, Picarta and NIVEL dating from 2002 to 2012. Thirty-three studies (six review studies and twenty-seven individual studies) were selected. Effects were extracted from each study and were classified. In almost all the studies, the concepts self-care and self-management are not clearly defined or operationalized. Therefore, based on a meta-analysis, we made a new classification of outcome measures, with hierarchical levels: (1) competence (2) illness-management (3) independence (social participation, autonomy). In general, patient outcomes appear to be positive or promising, but most studies were pilot studies. We did not find strong evidence that technology in care at home has (a positive) effect on patient self-care and self-management according to the above classification. Future research is needed to clarify how technology can be used to maximize its benefits. PMID:24173139

  15. A multilevel modelling approach to analysis of patient costs under managed care.

    PubMed

    Carey, K

    2000-07-01

    The growth of the managed care model of health care delivery in the USA has led to broadened interest in the performance of health care providers. This paper uses multilevel modelling to analyse the effects of managed care penetration on patient level costs for a sample of 24 medical centres operated by the Veterans Health Administration (VHA). The appropriateness of a two level approach to this problem over ordinary least squares (OLS) is demonstrated. Results indicate a modicum of difference in institutions' performance after controlling for patient effects. Facilities more heavily penetrated by the managed care model may be more effective at controlling costs of their sicker patients. Copyright 2000 John Wiley & Sons, Ltd.

  16. What Do High-Risk Patients Value? Perspectives on a Care Management Program.

    PubMed

    Ganguli, Ishani; Orav, E John; Weil, Eric; Ferris, Timothy G; Vogeli, Christine

    2018-01-01

    There is growing interest in coordinating care for high-risk patients through care management programs despite inconsistent results on cost reduction. Early evidence suggests patient-centered benefits, but we know little about how participants engage with the programs and what aspects they value. To explore care management program participants' awareness and perceived utility of program offerings. Cross-sectional telephone survey administered December 2015-January 2016. Patients enrolled in a Boston-area primary care-based care management program. Our main outcome was the number of topics in which patients reported having "very helpful" interactions with their care team in the past year. We analyzed awareness of one's care manager as an intermediate outcome, and then as a primary predictor of the main outcome, along with patient demographics, years in the program, attitudes, and worries as secondary predictors. The survey response rate was 45.8% (n = 1220); non-respondents were similar to respondents. More respondents reported worrying about family (72.8%) or financial issues (52.5%) than about their own health (41.6%). Seventy-four percent reported care manager awareness, particularly women (OR 1.33, 95% CI 1.01-1.77) and those with more years in the program (OR 1.16, 95% CI 1.03-1.30). While interaction rates ranged from 19.8% to 72.4% across topics, 81.3% rated at least one interaction as very helpful. Those who were aware of their care manager reported very helpful interactions on more topics (OR 2.77, 95% CI 2.15-3.56), as did women (OR 1.25, 95% CI 1.00-1.55), younger respondents (OR 0.98 for older age, 95% CI 0.97-0.99), and those with higher risk scores (OR 1.04, 95% CI 1.02-1.06), preference for deferring treatment decisions to doctors (OR 2.00, 95% CI 1.60-2.50), and reported control over their health (OR 1.67, 95% CI 1.33-2.10). High-risk patients reported helpful interactions with their care team around medical and social determinants of health

  17. Patient perspectives of an individualized diabetes care management plan

    PubMed Central

    Saucier, Ashley N.; Ansa, Benjamin; Coffin, Janis; Akhtar, Mariam; Miller, Andre; Mahoney, Holly; Hodo, Denise M.; Duffie, Carla; Fontenot, Brittney; Andrews, Holly E.; Smith, Selina A.

    2017-01-01

    Purpose This cross sectional study examines patients’ knowledge, attitudes and beliefs about a diabetic care management plan (DCMP) that was developed to provide patient education on diabetes guidelines and display individual diabetic core measures. Secondary objectives included a comparison of diabetic core measures [hemoglobin A1C (HbA1C), systolic and diastolic blood pressure (SBP, DBP), low-density lipoprotein (LDL) and urine microalbumin (Um)] before and after DCMP implementation. We hypothesize this tool will contribute to patients’ awareness of current disease status, diabetes knowledge and diabetic core value improvement over time. Methods A consecutive sample of 102 adult patients with diabetes mellitus type 2 in a primary care setting participated. Patients’ perspectives on the care plan and knowledge about diabetes was collected via survey after care plan implementation. A comparison of selected diabetic core measures was conducted at baseline and post-DCMP. Descriptive statistics summarized survey response and diabetic core measures. A repeated measures ANOVA was used to assess change in diabetic core measures over time. Results Participants understood the DCMP (96%), found it important because it explained their laboratory results and medications (89%) and believed it would help them to have better diabetic control (99%). There was a significant interaction between time and being at goal pre-DCMP for HbA1c, SBP and LDL. Patients not at goal pre-DCMP for the above measures decreased significantly over time (P = <0.01 for HbA1c, SBP and LDL). Participants at goal for all diabetic core measures increased pre- to post-DCMP from 13% to 20% (P = 0.28). Conclusion Patients perceived the diabetic care management plan favorably and their diabetic core measurements improved over time. This simple and reproducible self-management intervention can enhance self-management in a patient population with diabetes mellitus type 2. PMID:28835847

  18. Patient compliance with managed care emergency department referral: an orthopaedic view.

    PubMed

    Saroff, Don; Dell, Rick; Brown, E Richard

    2002-04-01

    Patient compliance with emergency department (ED)-generated referral is an important part of the delivery of quality health care. Although many studies from non-managed care health centers have reported on ED patient compliance, no studies have reported on this in a managed care setting. The objective of this study is to examine patient compliance with ED-generated referral and to produce a benchmark of follow-up rates possible in a capitated managed care system. That is to say, in a health care system whose members pay a uniform per capita payment or fee, one that has salaried physicians, owns its own hospitals, and has a mechanism of transition from ED to outpatient clinic that ensures referral accessibility. Retrospective review of consecutive ED patient compliance with ED-generated referral. All consecutive patients who presented to a managed care hospital's ED with an acute fracture and who were given an outpatient referral during the period from 23rd December 1998 to 23rd January, 1999. Of 8000 consecutive ED patients, 234 were included in the study. Compliance with ED-generated referral was determined from outpatient clinic records. Of the 234 patients treated in the ED and referred, 222 (94.9%) complied with follow-up appointments. We have demonstrated that an ED patient follow-up compliance rate of 94.9% can be obtained. It is probable that the high compliance rate is due to the features of the system studied. The high rate may also be related to the specific diagnosis studied, although previous literature reports poor ED patient compliance for the same diagnosis in a different ED setting. Additional research is needed to determine whether the high compliance rate reported in this study can be obtained in ED settings that are not part of a similar managed care system and to determine the role of referral accessibility (or inaccessibility) in current ED settings.

  19. Patient-centeredness and quality management in Dutch diabetes care organizations after a 1-year intervention

    PubMed Central

    Campmans-Kuijpers, Marjo JE; Lemmens, Lidwien C; Baan, Caroline A; Rutten, Guy EHM

    2016-01-01

    Background More focus on patient-centeredness in care for patients with type 2 diabetes requests increasing attention to diabetes quality management processes on patient-centeredness by managers in primary care groups and outpatient clinics. Although patient-centered care is ultimately determined by the quality of interactions between patients and clinicians at the practice level, it should be facilitated at organizational level too. This nationwide study aimed to assess the state of diabetes quality management on patient-centeredness at organizational level and its possibilities to improve after a tailored intervention. Methods This before–after study compares the quality management on patient-centeredness within Dutch diabetes care groups and outpatient clinics before and after a 1-year stepwise intervention. At baseline, managers of 51 diabetes primary care groups and 28 outpatient diabetes clinics completed a questionnaire about the organization’s quality management program. Patient-centeredness (0%–100%) was operationalized in six subdomains: facilitating self-management support, individualized care plan support, patients’ access to medical files, patient education policy, safeguarding patients’ interests, and formal patient involvement. The intervention consisted of feedback and benchmark and if requested a telephone call and/or a consultancy visit. After 1 year, the managers completed the questionnaire again. The 1-year changes were examined by dependent (non) parametric tests. Results Care groups improved significantly on patient-centeredness (from 47.1% to 53.3%; P=0.002), and on its subdomains “access to medical files” (from 42.0% to 49.4%), and “safeguarding patients’ interests” (from 58.1% to 66.2%). Outpatient clinics, which scored higher at baseline (66.7%) than care groups, did not improve on patient-centeredness (65.6%: P=0.54) or its subdomains. “Formal patient involvement” remained low in both care groups (23.2%) and

  20. [Evaluations by hospital-ward physicians of patient care management quality for patients hospitalized after an emergency department admission].

    PubMed

    Bartiaux, M; Mols, P

    2017-01-01

    patient management in the acute and sub-acute setting of an Emergency Department is challenging. An assessment of the quality of provided care enables an evaluation of failings. It contributes to the identification of areas for improvement. to obtain an analysis, by hospital-ward physicians, of adult patient care management quality, as well as of the correctness of diagnosis made during emergency admissions. To evaluate the consequences of inadequate patient care management on morbidity, mortality and cost and duration of hospitalization. prospective data analysis obtained between the 1/12/2009 and the 21/12/2009 from physicians using a questionnaire on adult-patient emergency admissions and subsequent hospitalization. questionnaires were completed for 332 patients. Inadequate management of patient care were reported for 73/332 (22 %) cases. Incorrect diagnoses were reported for 20/332 (6 %) cases. 35 cases of inadequate care management (10.5 % overall) were associated with morbidity (34 cases) or mortality (1 case), including 4 cases (1.2 % ) that required emergency intensive-care or surgical interventions. this quality study analyzed the percentage of patient management cases and incorrect diagnoses in the emergency department. The data for serious outcome and wrong diagnosis are comparable with current literature. To improve performance, we consider the process for establishing a diagnosis and therapeutic care.

  1. Collaboration of hospital case managers and home care liaisons when transitioning patients.

    PubMed

    Kelly, Margaret M; Penney, Erika D

    2011-01-01

    Hospital case managers frequently collaborate with home care liaisons when coordinating special discharge plans. This article focuses on the collaborative relationship between the hospital case manager and on-site liaison whose primary role centers around care coordination and patient teaching. Ineffective collaboration between hospital case managers and these clinical on-site liaisons can lead to serious lapses in care and services for patients, families, and the health care team when transitioning from hospital to home care. In a review of literature, little detail was found about the collaborative practice between hospital case managers and home care liaisons. This article discusses how collegiality, collaboration, and role clarification between hospital case managers and on-site home care liaisons can improve coordination of care and services for patients and their families in the transition from hospital to home care. Included is a set of guidelines developed by case managers at a major metropolitan acute care hospital to inform and improve their practice with home care liaisons. The authors are nursing case managers who practice in a major metropolitan teaching hospital. They met by telephone and in person with case managers from 3 metropolitan medical centers as well as on-site liaisons from 2 skilled nursing facilities and 5 home care agencies to develop practice recommendations for their department regarding work with home care liaisons. Conversations between hospital case managers and on-site home care liaisons revealed that all had experiences in which suboptimal collaboration negatively impacted home care coordination for patients and their families. Furthermore, outcomes in similar patient scenarios varied widely based on the individual practices of the case managers and liaisons involved in discharge coordination. Multiple issues were discussed, including blurred role and responsibility delineations, variations in communication styles and practices

  2. How Family Physicians Address Diagnosis and Management of Depression in Palliative Care Patients

    PubMed Central

    Warmenhoven, Franca; van Rijswijk, Eric; van Hoogstraten, Elise; van Spaendonck, Karel; Lucassen, Peter; Prins, Judith; Vissers, Kris; van Weel, Chris

    2012-01-01

    PURPOSE Depression is highly prevalent in palliative care patients. In clinical practice, there is concern about both insufficient and excessive diagnosis and treatment of depression. In the Netherlands, family physicians have a central role in delivering palliative care. We explored variation in family physicians’ opinions regarding the recognition, diagnosis, and management of depression in palliative care patients. METHODS We conducted a focus group study in a sample of family physicians with varied practice locations and varying expertise in palliative care. Transcripts were analyzed independently by 2 researchers using constant comparative analysis in ATLAS.ti. RESULTS In 4 focus group discussions with 22 family physicians, the physicians described the diagnostic and therapeutic process for depression in palliative care patients as a continuous and overlapping process. Differentiating between normal and abnormal sadness was viewed as challenging. The physicians did not strictly apply criteria of depressive disorder but rather relied on their clinical judgment and strongly considered patients’ context and background factors. They indicated that managing depression in palliative care patients is mainly supportive and nonspecific. Antidepressant drugs were seldom prescribed. The physicians described difficulties in diagnosing and treating depression in palliative care, and gave suggestions to improve management of depression in palliative care patients in primary care. CONCLUSIONS Family physicians perceive the diagnosis and management of depression in palliative care patients as challenging. They rely on open communication and a long-standing physician-patient relationship in which the patient’s context is of great importance. This approach fits with the patient-centered care that is promoted in primary care. PMID:22778121

  3. Managing care.

    PubMed

    Sandifer, Q D

    1997-09-01

    The terms 'managed care' and 'disease management' are gaining common usage in the health service but their meaning is not widely understood. Managed care is a generic term describing any health care system that integrates the financing and delivery of medical care. Its growth in the United States has been driven by pressure to control costs, and there is circumstantial evidence that costs are slowing as a result of better management of resources. However, it is not clear how much of this is due to managed care, the selection of more favourable enrollees to health plans or other factors. Research evidence is limited, and that available is constrained by the rapidly changing nature of managed care. In the United States a bewildering variety of managed care arrangements have emerged, although several common characteristics can be identified: limited choice of physician providers; controlled access to secondary care; selective contracting; financial incentives; quality management; and utilization management. All are present in the National Health Service (NHS), which exemplifies a nationalized managed care system. Disease management is an extension of managed care that takes a global approach to patient care by attempting to co-ordinate resources across the entire health care delivery system throughout the life cycle of the disease. This is poorly developed in the NHS, so that the attention of commercial organizations has been attracted. However, concern has been expressed about the implications of commercial involvement: the fragmentation of general medical services; effect of for-profit status; and use of patient-based data. Recent policy developments could allow disease management to develop within the NHS.

  4. Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project.

    PubMed

    Harrington, J Timothy; Barash, Harvey L; Day, Sherry; Lease, Joellen

    2005-04-15

    To develop new processes that assure more reliable, population-based care of fragility fracture patients. A 4-year clinical improvement project was performed in a multispecialty, community practice health system using evidence-based guidelines and rapid cycle process improvement methods (plan-do-study-act cycles). Prior to this project, appropriate osteoporosis care was provided to only 5% of our 1999 hip fracture patients. In 2001, primary physicians were provided prompts about appropriate care (cycle 1), which resulted in improved care for only 20% of patients. A process improvement pilot in 2002 (cycle 2) and full program implementation in 2003 (cycle 3) have assured osteoporosis care for all willing and able patients with any fragility fracture. Altogether, 58% of 2003 fragility fracture patients, including 46% of those with hip fracture, have had a bone measurement, have been assigned to osteoporosis care with their primary physician or a consultant, and are being monitored regularly. Only 19% refused osteoporosis care. Key process improvements have included using orthopedic billings to identify patients, referring patients directly from orthopedics to an osteoporosis care program, organizing care with a nurse manager and process management computer software, assigning patients to primary or consultative physician care based on disease severity, and monitoring adherence to therapy by telephone. Reliable osteoporosis care is achievable by redesigning clinical processes. Performance data motivate physicians to reconsider traditional approaches. Improving the care of osteoporosis and other chronic diseases requires coordinated care across specialty boundaries and health system support.

  5. The 5As team patient study: patient perspectives on the role of primary care in obesity management.

    PubMed

    Torti, Jacqueline; Luig, Thea; Borowitz, Michelle; Johnson, Jeffrey A; Sharma, Arya M; Campbell-Scherer, Denise L

    2017-02-08

    Over 60% of people have overweight or obesity, but only a third report receiving counselling from primary care providers. We explored patients' perspectives on the role of primary care in obesity management and their experience with existing resources, with a view to develop an improved understanding of this perspective, and more effective management strategies. Qualitative study employing semi-structured interviews and thematic analysis, with a sample of 28 patients from a cohort of 255 patients living with obesity and receiving care to support their weight management in a large Primary Care Network of family practices in Alberta. Four illustrative themes emerged: (1) the patient-physician relationship plays an important role in the adequacy of obesity management; (2) patients have clear expectations of substantive conversations with their primary care team; (3) complex conditions affect weight and patients require assistance tailored to individual obesity drivers; (4) current services provide support in important ways (accessibility, availability, accountability, affordability, consistency of messaging), but are not yet meeting patient needs for individual plans, advanced education, and follow-up opportunities. Patients have clear expectations that their primary care physician asks them about weight within a supportive therapeutic relationship. They see obesity as a complex phenomenon with multiple drivers. They want their healthcare providers to assess and address their root causes - not simplistic advice to "eat less, move more". Patients felt that the current services were positive resources, but expressed needs for tailored weight management plans, and longer-term follow-up.

  6. In Connecticut: improving patient medication management in primary care.

    PubMed

    Smith, Marie; Giuliano, Margherita R; Starkowski, Michael P

    2011-04-01

    Medications are a cornerstone of the management of most chronic conditions. However, medication discrepancies and medication-related problems-some of which can cause serious harm-are common. Pharmacists have the expertise to identify, resolve, monitor, and prevent these problems. We present findings from a Centers for Medicare and Medicaid Services demonstration project in Connecticut, in which nine pharmacists worked closely with eighty-eight Medicaid patients from July 2009 through May 2010. The pharmacists identified 917 drug therapy problems and resolved nearly 80 [corrected] percent of them after four encounters. The result was an estimated annual saving of $1,123 per patient on medication claims and $472 per patient on medical, hospital, and emergency department expenses-more than enough to pay for the contracted pharmacist services. We recommend that the Center for Medicare and Medicaid Innovation support the evaluation of pharmacist-provided medication management services in primary care medical homes, accountable care organizations, and community health and care transition teams, as well as research to explore how to enhance team-based care.

  7. Care coordination and provider stress in primary care management of high-risk patients.

    PubMed

    Okunogbe, Adeyemi; Meredith, Lisa S; Chang, Evelyn T; Simon, Alissa; Stockdale, Susan E; Rubenstein, Lisa V

    2018-01-01

    Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members' stress. To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress. Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses. A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems. The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them. The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04-0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model. Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.

  8. Caring for 'Very Important Patients'--Ethical Dilemmas and Suggestions for Practical Management.

    PubMed

    Alfandre, David; Clever, Sarah; Farber, Neil J; Hughes, Mark T; Redstone, Paul; Lehmann, Lisa Soleymani

    2016-02-01

    The care of Very Important Patients (VIPs) is different from other patients because they may receive greater access, attention, and resources from health care staff. Although the term VIP is used regularly in the medical literature and is implicitly understood, in practice it constitutes a wide and heterogeneous group of patients that have a strong effect on health care providers. We define a VIP as a very influential patient whose individual attributes and characteristics (eg, social status, occupation, position), coupled with their behavior, have the potential to significantly influence a clinician's judgment or behavior. Physicians, celebrities, the politically powerful, and philanthropists, may all become VIPs in the appropriate context. The quality of care may be inferior because health care professionals may deviate from standard practices when caring for them. Understanding the common features among what may otherwise be very different groups of patients can help health care providers manage ethical concerns when they arise. We use a series of vignettes to demonstrate how VIPs behavior and status can influence a clinician's judgment or actions. Appreciating the ethical principles in these varied circumstances provides health care professionals with the tools to manage ethical conflicts that arise in the care of VIPs. We conclude each vignette with guidance for how health care providers and administrators can manage the ethical concern. Published by Elsevier Inc.

  9. Care management for low-risk patients with heart failure: a randomized, controlled trial.

    PubMed

    DeBusk, Robert Frank; Miller, Nancy Houston; Parker, Kathleen Marie; Bandura, Albert; Kraemer, Helena Chmura; Cher, Daniel Joseph; West, Jeffrey Alan; Fowler, Michael Bruce; Greenwald, George

    2004-10-19

    Nurse care management programs for patients with chronic illness have been shown to be safe and effective. To determine whether a telephone-mediated nurse care management program for heart failure reduced the rate of rehospitalization for heart failure and for all causes over a 1-year period. Randomized, controlled trial of usual care with nurse management versus usual care alone in patients hospitalized for heart failure from May 1998 through October 2001. 5 northern California hospitals in a large health maintenance organization. Of 2786 patients screened, 462 met clinical criteria for heart failure and were randomly assigned (228 to intervention and 234 to usual care). Nurse care management provided structured telephone surveillance and treatment for heart failure and coordination of patients' care with primary care physicians. Time to first rehospitalization for heart failure or for any cause and time to a combined end point of first rehospitalization, emergency department visit, or death. At 1 year, half of the patients had been rehospitalized at least once and 11% had died. Only one third of rehospitalizations were for heart failure. The rate of first rehospitalization for heart failure was similar in both groups (proportional hazard, 0.85 [95% CI, 0.46 to 1.57]). The rate of all-cause rehospitalization was similar (proportional hazard, 0.98 [CI, 0.76 to 1.27]). The findings of this study, conducted in a single health care system, may not be generalizable to other health care systems. The overall effect of the intervention was minor. Among patients with heart failure at low risk on the basis of sociodemographic and medical attributes, nurse care management did not statistically significantly reduce rehospitalizations for heart failure or for any cause. Such programs may be less effective for patients at low risk than those at high risk.

  10. Quality of care provided to patients with diabetes mellitus in Puerto Rico; managed care versus fee-for-service experience.

    PubMed

    Rodríguez-Vigil, Efraín; Kianes-Pérez, Zaira

    2005-01-01

    To evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico. This retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects--226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed. From the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A lc testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits. The quality of diabetes management and the subsequent outcomes are related to patient and health-care provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes.

  11. [Economic impact of AFId management with modern management system in Intensive Care patients: comparison between ICUs].

    PubMed

    Fuoco, Giovanni; Di Giulio, Paola

    2016-01-01

    . Economic impact of AFId management with modern management systems in Intensive Care patients: comparison between ICUs. Acute fecal incontinence associated with diarrhea (AFId) affects up to 40% of intensive care unit (ICU) patients and may be responsible for pressure ulcers (PU). The FMS (Fecal Management System) though improving the management of these patients is not often provided due to its cost. To measure the costs of the use of FMS compared to routine care in three intensive care units (ICU) of Piedmont (Italy). All patients admitted from January to June 2016, > 18 years with at least three AFId episodes in the previous 24 hours were included. The costs for hygiene, medications and nursing time spent were calculated on 10 patients without FMS, accounting for the mean number of diarrhea attacks (3.04 per day), and mean days of FMS use. The FMS generated savings compared to routine care in nursing time, equipments for hygiene and pressure sores medications in patients with sacral sores. Savings depended on length of use (LoU) of the device: ICU with 10 patients (7 with PUs), mean LoU FMS 11.9 days, savings 1.210 euros; ICU with 10 patients (2 with PUs), mean LoU FMS 17.3 days, savings 5.317 euros; ICU with 45 patients (11 with PUs) mean LoU FMS 9.3 days, cost increase 1.057 euros. The cost of FMS is quickly amortised in patients with PUs. No FMS patients developed a new PUs. The FMS gives rise to savings when used in patients with PUs or for more than 10 days. The savings related to the prevention of PUs should be also added.

  12. Diabetes Management and Self-Care Education for Hospitalized Patients With Cancer

    PubMed Central

    Leak, Ashley; Davis, Ellen D.; Houchin, Laura B.; Mabrey, Melanie

    2009-01-01

    Managing diabetes can be a daunting task for patients with cancer. Empowerment-based diabetes education and motivational interviewing are complementary approaches. Oncology nurses may feel unprepared to teach patients and their families about self-care for diabetes, but they provide individualized information on symptom management of cancer throughout hospitalization and at discharge. The essential self-care issues include food, exercise, medication, blood glucose monitoring, prevention, recognition and treatment of hypoglycemia and hyperglycemia, and when and how to get additional medical and educational support. This patient-centered model of diabetes education differs from the older “compliance” model that covers many universal rules for all patients, which are predetermined by the nurse. Informing nurses about their role in care of patients with cancer and diabetes is critical. PMID:19349267

  13. Recognizing and managing depression in primary care: a standardized patient study.

    PubMed

    Carney, P A; Dietrich, A J; Eliassen, M S; Owen, M; Badger, L W

    1999-12-01

    Guidelines for recognition and management of depression in primary care provide a framework for detailed exploration of physician practice patterns. Our objective was to explore physician diagnosis and management approaches to depressive disorders according to type (major vs. minor) and presenting complaint (difficulty sleeping and concentrating vs. headache). The participants were community primary care internists and family physicians in northern New England, Washington, and Alabama (N = 149) who were randomly assigned to receive a visit from an unannounced actor portraying a standardized patient in 1 of 2 depression scenarios: (A) insomnia and poor concentration meeting Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depressive disorder; or (B) tension headaches meeting the criteria for minor depression. All physicians who were assigned to the standardized patients presenting with scenario A recognized depression, and 49% (38 of 78) of those assigned to scenario B patients diagnosed depression. Of those recognizing depression, 72% and 42% queried patients about anhedonia and mood, respectively. For both scenarios, if fewer than 2 DSM-III-R criteria were explored, depression was not diagnosed. Management for scenario A was compatible with Agency for Health Care Policy and Research guidelines, including the prescription of an antidepressant (94%), scheduling of a follow-up visit within 2 weeks (61%), and exploration of suicidal ideation (69.4%). For scenario B, management included over-the-counter analgesics for the headache (84%), exercise (63%), prescription for an antidepressant (53%), recommendation for ongoing counseling (100%), and follow-up within 2 weeks (42%). Major depression is recognized in primary care at a very high rate. Guidelines for recognizing and managing depression are often followed in primary care. Patients' presentations of depression influence its recognition and management.

  14. Specialist palliative care nurses' management of the needs of patients with depression.

    PubMed

    Hayes, Jessica Elizabeth; Hart, Bethne; Phillips, Jane

    2017-06-02

    Depression is an important condition to consider if we are to optimise the care outcomes for patients with palliative care needs. Depression has a high incidence in palliative patients, with up to 15% diagnosed with major depression and 37% expressing some form of depressive symptoms ( O'Connor et al, 2010 ). The challenge is to ensure that palliative care patients with depression are identified in a timely manner and that their depression is effectively managed. To examine how Australian specialist inpatient palliative care nurses perceive, assess and respond to depression in a patient case study. This descriptive pilot study is a replication of a United States study by Little et al (2005) , exploring contemporary Australian specialist palliative care nurses' screening, assessment and management of depression in people with a progressive life-limiting illness. A survey titled 'Specialist palliative care nurses managing patients with complex care needs' questioned the nursing assessment, knowledge and clinical care priorities related to a case vignette of a patient demonstrating signs of depression. A total of 33 nurses completed this survey. Less than half (39.4%) of the participants identified depression as a major issue arising from the case vignette. Depression screening tools were not widely known. Functionality assessments measuring activities of daily living were the most recognised and widely used tools by participants. This small sample pilot study demonstrated that specialist palliative care nurses are still not confident in their screening and responding to a patient with depression. The available evidenced based depression screening tools were unfamiliar to these nurses and not widely used which can result in depression remaining undetected and undermanaged. The connections between physical health and mental health need stronger recognition and response within nursing care of palliative patients.

  15. The myth of managed care. Moving beyond managing costs to really managing care.

    PubMed

    Houck, S

    1997-01-01

    Today's managed care manages costs, not care. Care is lopsided with costly physician and provider control of the information, decision-making and treatment processes that are built on outdated fee-for-service incentives. Fast moving providers who exploit opportunities to redesign care, shifting more responsibility and control to non-physician providers and to patients will gain a major competitive advantage. These providers are much more likely to stand out from their peers, enabling them to attract patients and contracts.

  16. Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension.

    PubMed

    Kiselev, Anton R; Gridnev, Vladimir I; Shvartz, Vladimir A; Posnenkova, Olga M; Dovgalevsky, Pavel Ya

    2012-01-01

    The use of short message services and mobile phone technology for ambulatory care management is the most accessible and most inexpensive way to transition from traditional ambulatory care management to active ambulatory care management in patients with arterial hypertension (AH). The aim of this study was to compare the clinical efficacy of active ambulatory care management supported by short message services and mobile phone technology with traditional ambulatory care management in AH patients. The study included 97 hypertensive patients under active ambulatory care management and 102 patients under traditional ambulatory care management. Blood pressure levels, body mass, and smoking history of patients were analyzed in the study. The duration of study was 1 year. In the active ambulatory care management group, 36% of patients were withdrawn from the study within a year. At the end of the year, 77% of patients from the active care management group had achieved the goal blood pressure level. That was more than 5 times higher than that in the traditional ambulatory care management group (P < .001). The risk ratio of achieving and maintaining the goal blood pressure in patients of active care management group was 5.44, CI (3.2-9.9; P = .005). Implementation of active ambulatory care management supported by short message services and mobile phone improves the quality of ambulatory care of hypertensive patients. Copyright © 2012 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

  17. Crew Management Processes Revitalize Patient Care

    NASA Technical Reports Server (NTRS)

    2009-01-01

    In 2005, two physicians, former NASA astronauts, created LifeWings Partners LLC in Memphis, Tennessee and began using Crew Resource Management (CRM) techniques developed at Ames Research Center in the 1970s to help improve safety and efficiency at hospitals. According to the company, when hospitals follow LifeWings? training, they can see major improvements in a number of areas, including efficiency, employee satisfaction, operating room turnaround, patient advocacy, and overall patient outcomes. LifeWings has brought its CRM training to over 90 health care organizations and annual sales have remained close to $3 million since 2007.

  18. Patient ratings of case managers in a medical home: associations with patient satisfaction and health care utilization.

    PubMed

    Jubelt, Lindsay E; Graham, Jove; Maeng, Daniel D; Li, Huilin; Epstein, Andrew J; Metlay, Joshua P

    2014-11-18

    Case managers are employed in medical homes to coordinate care for clinically complex patients. To measure the association of patient perceptions of case manager performance with overall satisfaction and subsequent health care utilization. Retrospective cohort study. Integrated health system in Pennsylvania. Members of the health system-owned health plan who 1) received primary care in the health system's clinics, 2) were exposed to clinic-embedded case managers, and 3) completed a survey of satisfaction with care. Survey assessment of case manager performance and overall satisfaction with care and claims-based assessment of case manager performance and subsequent hospitalizations or emergency department visits. Survey measures were dichotomized into very good versus less than very good. A total of 1755 patients (44%) completed the survey and 1415 met study criteria. Survey respondents who reported very good ratings of case manager performance across all items had a higher probability of reporting very good overall satisfaction with care (92.2% vs. 62.5%; P < 0.001) and had a lower incidence of subsequent emergency department visits (incidence rate ratio, 0.79 [95% CI, 0.64 to 0.98]; P = 0.029) but not hospitalizations (incidence rate ratio, 0.92 [CI, 0.75 to 1.11]; P = 0.37) up to 2 years after the survey compared with survey respondents who reported less-than-very good case manager performance on 1 or more questions on the survey. Satisfaction data demonstrated substantial ceiling effects. Survey nonresponse may have introduced bias in the results. Patients' favorable perceptions of case managers are associated with higher overall satisfaction with care and may lower risk for future acute care use. Robert Wood Johnson Foundation and the U.S. Department of Veterans Affairs.

  19. How do health care workers manage a patient with multiple care needs from both health and social care services? - A vignette study.

    PubMed

    Vehko, Tuulikki; Jolanki, Outi; Aalto, Anna-Mari; Sinervo, Timo

    2018-06-01

    To assess how health care professionals outline the management of care and explore which health or social care professionals were involved in the patient's treatment. A survey with a patient vignette for general practitioners (n = 31) and registered nurses (n = 31) working daily in Finnish health centres located in four cities. Respondents answered structural questions and explained in detail the care process that they tailored for the patient. The care process was examined using content analysis. A physician-nurse working pair was declared to be in charge of the care process by 27% of respondents, a registered nurse by 9% and a general practitioner by 11%. However, 53% reported that no single person or working pair was in charge of the care process (response rate 72%). The concluding result of the analyses of the presented process was that both treatment practices and the professionals participating in the patient's treatment varied. Collaboration with social services was occasional, and few care processes included referrals to social services. For the patient who needs both health and social care services, the management of care is a challenge. To improve the chances of patients being actively involved in making treatment plans at least three factors need to be addressed. Firstly, a written treatment plan should explicate the care process. Second, collaboration and interaction between health and social care services should be strengthened, and third, a contact person should be named to avoid care gaps in primary health care. Next-step data from patients need to be collected to get their views on care management and compare these with those from general practitioners and registered nurses.

  20. How do informal self-care strategies evolve among patients with chronic obstructive pulmonary disease managed in primary care? A qualitative study.

    PubMed

    Apps, Lindsay D; Harrison, Samantha L; Williams, Johanna E A; Hudson, Nicky; Steiner, Michael; Morgan, Mike D; Singh, Sally J

    2014-01-01

    There is much description in the literature of how patients with chronic obstructive pulmonary disease (COPD) manage their breathlessness and engage in self-care activities; however, little of this is from the perspective of those with less severe disease, who are primarily managed in primary care. This study aimed to understand the self-care experiences of patients with COPD who are primarily managed in primary care, and to examine the challenges of engaging in such behaviors. Semistructured interviews were carried out with 15 patients with COPD as part of a larger project evaluating a self-management intervention. Thematic analysis was supported by NVivo software (version 8, QSR International, Melbourne, Australia). Three main themes are described, ie, experiencing and understanding symptoms of COPD, current self-care activities, and the importance of family perceptions in managing COPD. Self-care activities evolved spontaneously as participants experienced symptoms of COPD. However, there was a lack of awareness about whether these strategies would impact upon symptoms. Perceptions of COPD by family members posed a challenge to self-care for some participants. Health care professionals should elicit patients' prior disease experiences and utilize spontaneous attempts at disease management in future self-management. These findings have implications for promoting self-management and enhancing quality of life.

  1. Disease Management, Case Management, Care Management, and Care Coordination: A Framework and a Brief Manual for Care Programs and Staff.

    PubMed

    Ahmed, Osman I

    2016-01-01

    With the changing landscape of health care delivery in the United States since the passage of the Patient Protection and Affordable Care Act in 2010, health care organizations have struggled to keep pace with the evolving paradigm, particularly as it pertains to population health management. New nomenclature emerged to describe components of the new environment, and familiar words were put to use in an entirely different context. This article proposes a working framework for activities performed in case management, disease management, care management, and care coordination. The author offers standard working definitions for some of the most frequently used words in the health care industry with the goal of increasing consistency for their use, especially in the backdrop of the Centers for Medicaid & Medicare Services offering a "chronic case management fee" to primary care providers for managing the sickest, high-cost Medicare patients. Health care organizations performing case management, care management, disease management, and care coordination. Road map for consistency among users, in reporting, comparison, and for success of care management/coordination programs. This article offers a working framework for disease managers, case and care managers, and care coordinators. It suggests standard definitions to use for disease management, case management, care management, and care coordination. Moreover, the use of clear terminology will facilitate comparing, contrasting, and evaluating all care programs and increase consistency. The article can improve understanding of care program components and success factors, estimate program value and effectiveness, heighten awareness of consumer engagement tools, recognize current state and challenges for care programs, understand the role of health information technology solutions in care programs, and use information and knowledge gained to assess and improve care programs to design the "next generation" of programs.

  2. Myasthenic crisis patients who require intensive care unit management.

    PubMed

    Sakaguchi, Hideya; Yamashita, Satoshi; Hirano, Teruyuki; Nakajima, Makoto; Kimura, En; Maeda, Yasushi; Uchino, Makoto

    2012-09-01

    The purpose of this report was to investigate predictive factors that necessitate intensive care in myasthenic crisis (MC). We retrospectively reviewed MC patients at our institution and compared ICU and ward management groups. Higher MG-ADL scale scores, non-ocular initial symptoms, infection-triggered findings, and higher MGFA classification were observed more frequently in the ICU group. In patients with these prognostic factors, better outcomes may be obtained with early institution of intensive care. Copyright © 2012 Wiley Periodicals, Inc.

  3. Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes (Project Leonardo).

    PubMed

    Ciccone, Marco Matteo; Aquilino, Ambrogio; Cortese, Francesca; Scicchitano, Pietro; Sassara, Marco; Mola, Ernesto; Rollo, Rodolfo; Caldarola, Pasquale; Giorgino, Francesco; Pomo, Vincenzo; Bux, Francesco

    2010-05-06

    Project Leonardo represented a feasibility study to evaluate the impact of a disease and care management (D&CM) model and of the introduction of "care manager" nurses, trained in this specialized role, into the primary health care system. Thirty care managers were placed into the offices of 83 general practitioners and family physicians in the Apulia Region of Italy with the purpose of creating a strong cooperative and collaborative "team" consisting of physicians, care managers, specialists, and patients. The central aim of the health team collaboration was to empower 1,160 patients living with cardiovascular disease (CVD), diabetes, heart failure, and/or at risk of cardiovascular disease (CVD risk) to take a more active role in their health. With the support of dedicated software for data collection and care management decision making, Project Leonardo implemented guidelines and recommendations for each condition aimed to improve patient health outcomes and promote appropriate resource utilization. Results show that Leonardo was feasible and highly effective in increasing patient health knowledge, self-management skills, and readiness to make changes in health behaviors. Patient skill-building and ongoing monitoring by the health care team of diagnostic tests and services as well as treatment paths helped promote confidence and enhance safety of chronic patient management at home. Physicians, care managers, and patients showed unanimous agreement regarding the positive impact on patient health and self-management, and attributed the outcomes to the strong "partnership" between the care manager and the patient and the collaboration between the physician and the care manager. Future studies should consider the possibility of incorporating a patient empowerment model which considers the patient as the most important member of the health team and care managers as key health care collaborators able to enhance and support services to patients provided by physicians in

  4. Collaborative depression care among Latino patients in diabetes disease management, Los Angeles, 2011-2013.

    PubMed

    Wu, Brian; Jin, Haomiao; Vidyanti, Irene; Lee, Pey-Jiuan; Ell, Kathleen; Wu, Shinyi

    2014-08-28

    The prevalence of comorbid diabetes and depression is high, especially in low-income Hispanic or Latino patients. The complex mix of factors in safety-net care systems impedes the adoption of evidence-based collaborative depression care and results in persistent disparities in depression outcomes. The Diabetes-Depression Care-Management Adoption Trial examined whether the collaborative depression care model is an effective approach in safety-net clinics to improve clinical care outcomes of depression and diabetes. A sample of 964 patients with diabetes from 5 safety-net clinics were enrolled in a quasi-experimental study that included 2 arms: usual care, in which primary medical providers and staff translated and adopted evidence-based depression care; and supportive care, in which providers of a disease management program delivered protocol-driven depression care. Because the study design established individual treatment centers as separate arms, we calculated propensity scores that interpreted the probability of treatment assignment conditional on observed baseline characteristics. Primary outcomes were 5 depression care outcomes and 7 diabetes care measures. Regression models with propensity score covariate adjustment were applied to analyze 6-month outcomes. Compared with usual care, supportive care significantly decreased Patient Health Questionnaire-9 scores, reduced the number of patients with moderate or severe depression, improved depression remission, increased satisfaction in care for patients with emotional problems, and significantly reduced functional impairment. Implementing collaborative depression care in a diabetes disease management program is a scalable approach to improve depression outcomes and patient care satisfaction among patients with diabetes in a safety-net care system.

  5. Framework to assess the effects of using patient-reported outcome measures in chronic care management.

    PubMed

    Santana, Maria-Jose; Feeny, David

    2014-06-01

    The inclusion of patient-reported outcome measures (PROMs) in the routine clinical care of chronically ill patients has the potential to add valuable information about the impact of the disease and its treatment and promotes effective patient self-management in which patients become more active participants in their own care. PROMs provide clinicians with timely information on patients' symptoms as well as functional and emotional status. PROMs are a useful tool for enhancing patient-clinician communication. We develop a conceptual framework describing the potential effects of the use of PROMs in chronic care management. The framework summarizes insights from the methods for evaluating the clinical effectiveness and methods for the health technology assessment of diagnostic technologies and results from the relevant studies. The framework describes potential effects, from proximal to distal, including communication (patient-clinician, patient-relative, clinician-clinician, and clinician-relative), engaging patients in shared clinical decision making, patient management (clinician management and patient self-management), and patient outcomes. Important potential effects also include enhancement in patient activation as well as improvements in clinician and patient satisfaction, and patient adherence to recommended treatment. Previous frameworks have described patient-physician communication, patient satisfaction, and health outcomes. Our framework adds unique domains, including patient engagement, patient activation, shared clinical decision making, and patient self-management. The framework can be used as a tool to guide the development of interventions to improve chronic care management through the use of PROMs.

  6. Ethics and managed care.

    PubMed

    Perkel, R L

    1996-03-01

    Managed care presents physicians with potential ethical dilemmas different from dilemmas in traditional fee-for-service practice. The ethical assumptions of managed care are explored, with special attention to the evolving dual responsibilities of physicians as patient advocates and as entrepreneurs. A number of proposals are described that delineate issues in support of and in opposition to managed care. Through an understanding of how to apply basic ethics principles to managed care participation, physicians may yet hold on to the basic ethic of the fiduciary doctor-patient relationship.

  7. Satisfaction of health care professionals managing patients with inflammatory bowel disease.

    PubMed

    Casellas, Francesc; Ginard, Daniel; Vera, Isabel; Torrejón, Antonio

    2013-08-01

    The aim of the present study was to analyze the satisfaction of health care professionals who attend patients with inflammatory bowel disease (IBD) and to determine the variables more related with satisfaction/dissatisfaction. Cross-sectional, self-administered written 15-item questionnaire was evaluated using a Likert scale, completed by Spanish gastroenterologists and nurse practitioners specialized in IBD patient care. A total of 202 surveys, 133 physicians (65.8%) and 69 nurses (34.2%) were conducted. Global scoring of satisfaction was 54.0 for physicians and 64.2 for nurses (p<0.001). In both groups the highest scores were achieved in those items related to their professional careers and management of personal and professional lives as well as those that refer to their interdisciplinary relationship with other medical units, management of patients within the hospital setting and finally communication with the patient. The items that attained the lowest score included those related to the length and staff available for the medical consult, work environment and the balance among health care provider needs for contribution, recognition and fulfillment. With regard to the variables involved with satisfaction, the results show that those physicians that only took care of IBD patients achieved a higher degree of satisfaction. This could be related with the fulfillment of their own professional expectations. The level of satisfaction of health care professionals that take care of IBD patients is low and may impact on patient care. Therefore, new strategies to increase the degree of satisfaction of IBD health care providers should be implemented. Copyright © 2012 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

  8. Disease Management Plus Recommended Care versus Recommended Care Alone for Ambulatory COPD Patients.

    PubMed

    Kalter-Leibovici, Ofra; Benderly, Michal; Freedman, Laurence S; Kaufman, Galit; Molcho Falkenberg Luft, Tchiya; Murad, Havi; Olmer, Liraz; Gluch, Meri; Segev, David; Gilad, Avi; Elkrinawi, Said; Cukierman-Yaffe, Tali; Chen, Baruch; Jacobson, Orit; Key, Calanit; Shani, Mordechai; Fink, Gershon

    2018-03-01

    The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain. To study the effect of disease management (DM) added to recommended care (RC) in ambulatory COPD patients. In this trial, 1,202 COPD patients (age >40 years), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists; inhaled long-acting bronchodilators and corticosteroids; smoking cessation intervention; nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and remote contacts with the patients between these visits, included patient self-care education; monitoring patients' symptoms and adherence to treatment; provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 (47.2%) patients in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95%CI: 0.77 to 1.08). DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory COPD patients. Clinical trial registration available at www.clinicaltrials.gov, ID NCT00982384.

  9. The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

    PubMed Central

    Hawthorne, Margaret; LaNoue, Marianna; Brenner, Jeffrey

    2016-01-01

    Abstract In the movement to improve the health of patients with multiple chronic conditions and vulnerabilities, while reducing the need for hospitalizations, care management programs have garnered wide attention and support. The qualitative data presented in this paper sheds new light on key components of successful chronic care management programs. By going beyond a task- and temporal-based framework, this analysis identifies and defines the importance of “authentic healing relationships” in driving individual and systemic change. Drawing on the voices of 30 former clients of the Camden Coalition of Healthcare Providers, the investigators use qualitative methods to identify and elaborate the core elements of the authentic healing relationship—security, genuineness, and continuity—a relationship that is linked to patient motivation and active health management. Although not readily found in the traditional health care delivery system, these authentic healing relationships present significant implications for addressing the persistent health-related needs of patients with frequent hospitalizations. (Population Health Management 2016;19:248–256) PMID:26565379

  10. Effects of state managed care patient protection laws on physician satisfaction.

    PubMed

    Sloan, Frank A; Rattliff, John R; Hall, Mark A

    2007-10-01

    Physician dissatisfaction often drives public policy, and is associated with lower quality of care and disruption of treatment relationships. Physicians expressed strong dissatisfaction with managed care, leading to enactment of patient protection laws. By 2001, almost all states enacted laws to curb alleged abuses of managed care organizations. To date, no studies have examined whether such laws improved physician satisfaction. This article examines whether enactment of these laws improved physician satisfaction, using responses to the Physician Survey component of the Community Tracking Study (CTS), supplemented with data on state statutes/regulations. Career satisfaction increased for both primary care physicians (PCPs) and specialists following enactment of such laws; improvements were limited to early-adopting states. Enactment was associated with improvements in early-adopting states for specialists but not for PCPs on: ability to provide high quality care, clinical freedom, and ability to make clinical decisions in patients' interests without sacrificing physician income.

  11. Improving performance management for delivering appropriate care for patients no longer needing acute hospital care.

    PubMed

    Penney, Christine; Henry, Effie

    2008-01-01

    The public, providers and policy-makers are interested in a service continuum where care is provided in the appropriate place. Alternate level of care is used to define patients who no longer need acute care but remain in an acute care bed. Our aims were to determine how subacute care and convalescent care should be defined in British Columbia (BC); how these care levels should be aligned with existing legislation to provide more consistent service standards to patients and what reporting requirements were needed for system planning and performance management. A literature review was conducted to understand the international trends in performance management, care delivery models and change management. A Canada-wide survey was carried out to determine the directions of other provinces on the defined issues and a BC survey provided a current state analysis of programming within the five regional health authorities (HAs). A provincial policy framework for subacute and convalescent care has been developed to begin to address the concerns raised and provide a base for performance measurement. The policy has been approved and disseminated to BC HAs for implementation. An implementation plan has been developed and implementation activities have been integrated into the work of existing provincial committees. Evaluation will occur through performance measurement. The benefits anticipated include: clear policy guidance for programme development; improved comparability of performance information for system monitoring, planning and integrity of the national acute care Discharge Abstracting Database; improved efficiency in acute care bed use; and improved equity of access, insurability and quality for patients requiring subacute and convalescent care. While a national reporting system exists for acute care in Canada, this project raises questions about the implications for this system, given the shifting definition of acute care as other care levels emerge. Questions are also

  12. How can the German Electronic Health Card support patient's role in care management.

    PubMed

    Pharow, Peter; Blobel, Bernd; Hildebrand, Claudia

    2008-01-01

    All types of advanced communication, collaboration, and cooperation in healthcare require a strong involvement of all addressed parties including health professionals and patients. Modern healthcare aims at involving patients having them take over responsibility for their own health status. Allowing them to take on their changed roles as emancipated partners in advanced care management, health professionals need to be educated and patients need to be empowered. From a security viewpoint, health issues have to be communicated via trusted health networks. To provide communication and cooperation between professionals and patients as well as to guarantee the required level of involvement of patients in shared care management environments, cards are widely used as person identifiers, on the one hand, and as security tokens, on the other. Being introduced as storage media and portable personalized application system, cards enable a patient controlled access to personalized health services as well as proper use and exchange of personal health data for specific purposes such as emergency. Furthermore, cards allow access to the wider electronic patient record via pointers or tickets. Cards can empower patients. The German Electronic Health Card (eGK) shall thus support care management and specific workflow processes e.g. for prescription and disease management. Regardless whether designed as data or pointer card - international standardization is a prerequisite also for national solutions. The more information patients have regarding different procedures and processes in healthcare, the more are they able to play their dedicated role within care management. Cards can and will contribute by allowing patients to get controlled access to administrative and medical data stored either on cards or in networks. Card holders determine who has access to their health information.

  13. Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation

    PubMed Central

    Roland, Martin; Lewis, Richard; Steventon, Adam; Abel, Gary; Adams, John; Bardsley, Martin; Brereton, Laura; Chitnis, Xavier; Conklin, Annalijn; Staetsky, Laura; Tunkel, Sarah; Ling, Tom

    2012-01-01

    Introduction In 2009, the English Department of Health appointed 16 integrated care pilots which aimed to provide better integrated care. We report the quantitative results from a multi-method evaluation of six of the demonstration projects which used risk profiling tools to identify older people at risk of emergency hospital admission, combined with intensive case management for people identified as at risk. The interventions focused mainly on delivery system redesign and improved clinical information systems, two key elements of Wagner’s Chronic Care Model. Methods Questionnaires to staff and patients. Difference-in-differences analysis of secondary care utilisation using data on 3646 patients and 17,311 matched controls, and changes in overall secondary care utilisation. Results Most staff thought that care for their patients had improved. More patients reported having a care plan but they found it significantly harder to see a doctor or nurse of their choice and felt less involved in decisions about their care. Case management interventions were associated with a 9% increase in emergency admissions. We found some evidence of imbalance between cases and controls which could have biased this estimate, but simulations of the possible effect of unobserved confounders showed that it was very unlikely that the sites achieved their goal of reducing emergency admissions. However, we found significant reductions of 21% and 22% in elective admissions and outpatient attendance in the six months following an intervention, and overall inpatient and outpatient costs were significantly reduced by 9% during this period. Area level analyses of whole practice populations suggested that overall outpatient attendances were significantly reduced by 5% two years after the start of the case management schemes. Conclusion Case management may result in improvements in some aspects of care and has the potential to reduce secondary care costs. However, to improve patient experience

  14. Patient-centered care in chronic disease management: a thematic analysis of the literature in family medicine.

    PubMed

    Hudon, Catherine; Fortin, Martin; Haggerty, Jeannie; Loignon, Christine; Lambert, Mireille; Poitras, Marie-Eve

    2012-08-01

    The objective was to provide a synthesis of the results of the research and discourse lines on main dimensions of patient-centered care in the context of chronic disease management in family medicine, building on Stewart et al.'s model. We developed search strategies for the Medline, Embase, and Cochrane databases, from 1980 to April 2009. All articles addressing patient-centered care in the context of chronic disease management in family medicine were included. A thematic analysis was performed using mixed codification, based on Stewart's model of patient-centered care. Thirty-two articles were included. Six major themes emerged: (1) starting from the patient's situation; (2) legitimizing the illness experience; (3) acknowledging the patient's expertise; (4) offering realistic hope; (5) developing an ongoing partnership; (6) providing advocacy for the patient in the health care system. The context of chronic disease management brings forward new dimensions of patient-centered care such as legitimizing the illness experience, acknowledging patient expertise, offering hope and providing advocacy. Chronic disease management calls for the adaptation of the family physician's role to patients' fluctuating needs. Literature also suggests the involvement of the family physician in care transitions as a component of patient-centered care. Crown Copyright © 2012. Published by Elsevier Ireland Ltd. All rights reserved.

  15. A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes.

    PubMed

    Luo, Zhehui; Chen, Qiaoling; Annis, Ann M; Piatt, Gretchen; Green, Lee A; Tao, Min; Holtrop, Jodi Summers

    2016-07-01

    The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM). We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases. We used a quasi-experimental two-group pre-post design using the difference-in-differences method. Commercially insured patients, with any of the five chronic diseases-congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study. Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up. A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: -2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: -2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %). Both care management delivery modes may be viable options for improving care for patients with chronic

  16. Need and disparities in primary care management of patients with diabetes

    PubMed Central

    2014-01-01

    Background An aging population means that chronic illnesses, such as diabetes, are becoming more prevalent and demands for care are rising. Members of primary care teams should organize and coordinate patient care with a view to improving quality of care and impartial adherence to evidence-based practices for all patients. The aims of the present study were: to ascertain the prevalence of diabetes in an Italian population, stratified by age, gender and citizenship; and to identify the rate of compliance with recommended guidelines for monitoring diabetes, to see whether disparities exist in the quality of diabetes patient management. Methods A population-based analysis was performed on a dataset obtained by processing public health administration databases. The presence of diabetes and compliance with standards of care were estimated using appropriate algorithms. A multilevel logistic regression analysis was applied to assess factors affecting compliance with standards of care. Results 1,948,622 Italians aged 16+ were included in the study. In this population, 105,987 subjects were identified as having diabetes on January 1st, 2009. The prevalence of diabetes was 5.43% (95% CI 5.33-5.54) overall, 5.87% (95% CI 5.82-5.92) among males, and 5.05% (95% CI 5.00-5.09) among females. HbA1c levels had been tested in 60.50% of our diabetic subjects, LDL cholesterol levels in 57.50%, and creatinine levels in 63.27%, but only 44.19% of the diabetic individuals had undergone a comprehensive assessment during one year of care. Statistical differences in diabetes care management emerged relating to gender, age, diagnostic latency period, comorbidity and citizenship. Conclusions Process management indicators need to be used not only for the overall assessment of health care processes, but also to monitor disparities in the provision of health care. PMID:25011729

  17. Collaborative Depression Care Among Latino Patients in Diabetes Disease Management, Los Angeles, 2011–2013

    PubMed Central

    Wu, Brian; Jin, Haomiao; Vidyanti, Irene; Lee, Pey-Jiuan; Ell, Kathleen

    2014-01-01

    Introduction The prevalence of comorbid diabetes and depression is high, especially in low-income Hispanic or Latino patients. The complex mix of factors in safety-net care systems impedes the adoption of evidence-based collaborative depression care and results in persistent disparities in depression outcomes. The Diabetes–Depression Care-Management Adoption Trial examined whether the collaborative depression care model is an effective approach in safety-net clinics to improve clinical care outcomes of depression and diabetes. Methods A sample of 964 patients with diabetes from 5 safety-net clinics were enrolled in a quasi-experimental study that included 2 arms: usual care, in which primary medical providers and staff translated and adopted evidence-based depression care; and supportive care, in which providers of a disease management program delivered protocol-driven depression care. Because the study design established individual treatment centers as separate arms, we calculated propensity scores that interpreted the probability of treatment assignment conditional on observed baseline characteristics. Primary outcomes were 5 depression care outcomes and 7 diabetes care measures. Regression models with propensity score covariate adjustment were applied to analyze 6-month outcomes. Results Compared with usual care, supportive care significantly decreased Patient Health Questionnaire-9 scores, reduced the number of patients with moderate or severe depression, improved depression remission, increased satisfaction in care for patients with emotional problems, and significantly reduced functional impairment. Conclusion Implementing collaborative depression care in a diabetes disease management program is a scalable approach to improve depression outcomes and patient care satisfaction among patients with diabetes in a safety-net care system. PMID:25167093

  18. Barriers to Care for Persons With Sickle Cell Disease: The Case Manager's Opportunity to Improve Patient Outcomes.

    PubMed

    Brennan-Cook, Jill; Bonnabeau, Emily; Aponte, Ravenne; Augustin, Christina; Tanabe, Paula

    The purpose of this discussion is to review the barriers to care for patients with sickle cell disease (SCD). Chronic pain and the perception of addiction, implicit bias, frequent hospitalizations and emergency department visits, clinician and patient knowledge deficits, and SCD stigma all impede the ability to provide evidence-based care for patients with SCD. Case managers can coordinate and advocate for appropriate care that improves patient outcomes. This discussion is relevant to case managers working with patients with SCD in the clinic, hospital, and emergency department. Case managers can serve an important advocacy role and intervene to improve the coordination of services and efficient use of resources. This will lead to improved quality of life and optimal health care utilization for persons with SCD. As a constant member of the health care team, the case manager may be the only health care team member who has a broad knowledge of the patient's experience of acute and chronic pain, usual state of health, social behavioral health needs, and how these factors may affect both inpatient and outpatient health care use and health outcomes. This article explores the barriers to care and suggests specific interventions within the role of the case manager that can improve care delivered and ultimately contribute to improved patient outcomes. Specifically, these interventions can improve communication among members of the health care team. Case manager interventions can guide coordination, prevent hospital readmissions, reduce health care utilization, and contribute to overall improved patient quality of life and health outcomes.

  19. Clinical review: The critical care management of the burn patient

    PubMed Central

    2013-01-01

    Between 4 and 22% of burn patients presenting to the emergency department are admitted to critical care. Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects. Burn care has seen renewed interest in colloid resuscitation, a change in transfusion practice and the development of anti-catabolic therapies. A literature search was conducted with priority given to review articles, meta-analyses and well-designed large trials; paediatric studies were included where adult studies were lacking with the aim to review the advances in adult intensive care burn management and place them in the general context of day-to-day practical burn management. PMID:24093225

  20. Controlling inpatient psychiatric utilization through managed care.

    PubMed

    Wickizer, T M; Lessler, D; Travis, K M

    1996-03-01

    There is little current understanding of how managed care strategies affect hospital inpatient psychiatric care for mentally ill patients. This study examined one prominent form of managed care, utilization management, which reviews requests for psychiatric care and authorizes provision of care deemed appropriate and clinically necessary. The authors analyzed data on 2,265 utilization management reviews conducted during 1989-1992 for patients insured by a single large commercial insurance company. Three utilization management procedures were examined: preadmission review, continued-stay review, and case management. The performance indicators analyzed included percent of admission requests granted, number of days requested and approved, and number of treatment extensions granted. Utilization management initially approved inpatient psychiatric treatment for nearly all (98.8%) of the patients but authorized, on average, only one-third of the days requested (6.9 versus 19.0). On average, 23.5 (total) days of care were requested and 16.8 days were approved. Care for patients with alcohol or drug dependence diagnoses was more restricted than was care for other patients. These data suggest that managed care does restrict inpatient psychiatric care, primarily by managing length of stay. The fact that almost all patients were approved for the same initial length of stay implies adherence to strict treatment protocols that do not distinguish among different clinical or patient factors. There is a need for careful study of the effects of managed care on outcomes and quality of psychiatric care.

  1. From managing access to managing care: the impact of primary care on health care delivery organizations.

    PubMed

    Hickey, M E

    1995-10-01

    Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.

  2. Management of obesity in patients with type 2 diabetes mellitus in primary care.

    PubMed

    Mohammad, Shoaib; Ahmad, Jamal

    2016-01-01

    Obesity and being overweight is the most powerful risk factor accounting for 80-90% of patients with type 2 diabetes mellitus (T2DM). The epidemic of obesity is driving the diabetes epidemic to alarming levels and primary care is becoming an important setting for obesity management in T2DM in India. Yet many primary care providers feel ill-equipped or inadequately supported to address obesity in patients with diabetes. This article reviews the most recent and strongest evidence-based strategies that may aid physicians in management of obesity in patients with T2DM in primary care. A systematic literature search of MEDLINE using the search terms Obesity, Obesity in T2DM, weight loss and Primary Care was conducted. The American Diabetes Association, National Institute for Health, National Institute of Health and Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and World Health Organization websites were also searched. Most studies in this area are observational in design with few randomized controlled trials (RCTs). Articles and studies involving meta-analysis or RCTs were preferred over other types. Effective weight management treatment in T2DM patient can be implemented in the primary care setting. Evidence based individualized lifestyle and pharmacologic measures supported by behavioral intervention and counseling with appropriate and informed surgical referrals has the potential to improve the success of weight management within primary care. Copyright © 2016 Diabetes India. Published by Elsevier Ltd. All rights reserved.

  3. Self-management intervention to improve self-care and quality of life in heart failure patients.

    PubMed

    Tung, Heng-Hsin; Lin, Chun-Yu; Chen, Kuei-Ying; Chang, Chien-Jung; Lin, Yu-Ping; Chou, Cheng-Hui

    2013-01-01

    Self-management intervention is a good method to improve self-care ability, as such, to promote quality of life. However, the research focused on self-management intervention in heart failure patients in Taiwan is very limited. Therefore, the purposes of this study were to test the effectiveness of self-management intervention in patients with heart failure in Taiwan and examine the relationship between self-care ability and quality of life. A quasi-experimental design was used in this study with convenience sampling. Of the 82 subjects participating in this study, 40 of them chose to join the experimental (self-management intervention plus usual care) and 42 of them chose to join control (usual care) group. Three questionnaires were used to collect the data, which were the demographic questionnaire, the self-care questionnaire (Self-Care of HF Index V 6), and the quality of life questionnaire (Minnesota Living with Heart Failure Questionnaire). To examine the effectiveness of the intervention, self-care ability and quality of life were measured, using a pretest, 1- and 2-month follow-up assessment. Generalized estimation equations (GEE) were used to compare changes over time among groups for outcomes to ensure the effectiveness of the intervention. This study confirmed the effectiveness of the self-management intervention. The clinical provider should increase the awareness of the importance of self-management skills and self-care ability especially for heart failure patients. The designated disease-specific self-management patient book and individualize intervention should be dispensing and implementing. © 2012 Wiley Periodicals, Inc.

  4. Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care.

    PubMed

    Kaptein, Ad A; Fischer, Maarten J; Scharloo, Margreet

    2014-01-01

    In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients' functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD.

  5. Determinants of Heart Failure Self-Care Maintenance and Management in Patients and Caregivers: A Dyadic Analysis.

    PubMed

    Bidwell, Julie T; Vellone, Ercole; Lyons, Karen S; D'Agostino, Fabio; Riegel, Barbara; Juárez-Vela, Raúl; Hiatt, Shirin O; Alvaro, Rosaria; Lee, Christopher S

    2015-10-01

    Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self-management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how a HF dyad manages the patient's care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (daily adherence and symptom monitoring) and management (appropriate recognition and response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 dyads of Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients averaged 76.2 (SD = 10.7) years old, and a slight majority (56.9%) was male, whereas caregivers averaged 57.4 (SD = 14.6) years old, and about half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Significant individual and dyadic determinants of self-care maintenance and self-care management included gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and optimize outcomes. © 2015 Wiley Periodicals, Inc.

  6. The relationship between intraoperative teamwork and management skills in patient care.

    PubMed

    Phitayakorn, Roy; Minehart, Rebecca D; Hemingway, Maureen W; Pian-Smith, May C M; Petrusa, Emil

    2015-11-01

    Optimal team performance in the operating room (OR) requires a combination of interactions among OR professionals and adherence to clinical guidelines. Theoretically, it is possible that OR teams could communicate very well but fail to follow acceptable standards of patient care and vice versa. OR simulations offer an ideal research environment to study this relationship. The goal of this study was to determine the relationship between ratings of OR teamwork and communication with adherence to patient care guidelines in a simulated scenarios of malignant hyperthermia (MH). An interprofessional research team (2 anesthesiologists, 1 surgeon, an OR nurse, and a social scientist) reviewed videos of 5 intraoperative teams managing a simulated patient who manifested MH while undergoing general anesthesia for an epigastric herniorraphy in a high-fidelity, in situ OR. Participant teams consisted of 2 residents from anesthesiology, 1 from surgery, 1 OR nurse, and 1 certified surgical technician. Teamwork and communication were assessed with 4 published tools: Anesthesiologists' Non-Technical Skills (ANTS), Scrub Practitioners List of Intra-operative Non-Technical Skills (SPLINTS), Non-Technical Skills for Surgeons (NOTSS), and Objective Teamwork Assessment System (OTAS). We developed an evidence-based MH checklist to assess overall patient care. Interrater agreement for teamwork tools was moderate. Average rater agreement was 0.51 For ANTS, 0.67 for SPLINTS, 0.51 for NOTSS, and 0.70 for OTAS. Observer agreement for the MH checklist was high (0.88). Correlations between teamwork and MH checklist were not significant. Teams were different in percent of the MH actions taken (range, 50-91%; P = .006). In this pilot study, intraoperative teamwork and communication were not related to overall patient care management. Separating nontechnical and technical skills when teaching OR teamwork is artificial and may even be damaging, because such an approach could produce teams with

  7. Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach.

    PubMed

    Timpel, P; Lang, C; Wens, J; Contel, J C; Gilis-Januszewska, A; Kemple, K; Schwarz, P E

    2017-11-13

    Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and

  8. Consumer Health Informatics: Promoting Patient Self-care Management of Illnesses and Health.

    PubMed

    Jung, Minsoo

    Consumer health informatics (CHI) is propelling important changes for medical providers and the lives of patients through information and communications technology. Independently, medical consumers seek, collect, and use health information for decision making. However, when constructing a CHI-based medical platform, high technology must be applied in a fully understandable and usable format for both health care providers and consumers. This study examines the present status of CHI and its effect on medical consumers. For the development of CHI, we discuss the need for tailored health communications and capacity building with chronic patients at the medical center. First, empowerment is a key characteristic needed for medical consumer health care management. However, promoting patient self-care management of illnesses and health is necessary to create conjugation where cooperation with medical service providers is possible. Also, establishing a health care delivery system that will support cooperation is necessary. Second, tailored health communications can uniquely construct the health information of patients, which prevents unnecessary or excessive information from leading patients to confused and inappropriate decisions. Ultimately, through the present environment of health communication, the innovation of a consumer health care information system has become the tide of the times and the positive effect of improved health can be expected.

  9. Is there an increased clinical severity of patients with eating disorders under managed care?

    PubMed

    Bravender, T; Robertson, L; Woods, E R; Gordon, C M; Forman, S

    1999-06-01

    We sought to examine possible differences in medical status at presentation in 1996, compared to 1991, of adolescents with eating disorders (EDs) at a hospital-based multidisciplinary care program to reflect the increasing market penetration of managed care. Charts were reviewed for all new patients scheduled in a hospital-based outpatient ED program in 1996 and 1991. The 92-item standardized data extraction form included information on demographics, indicators of illness severity at the first visit, and subsequent hospitalization. The need for primary care referral was verified using billing records. Data were analyzed with Student's t-test, Chi-square, Fisher's exact, and Mann-Whitney U tests using SPSS 7.5. Of the 153 total patients, 133 kept their intake appointment and 130 (98%) of these had charts available for review. The age, racial/ethnic characteristics, and average length of disordered eating behaviors were not significantly different over the 5-year period. Referral from a primary care clinician was more commonly required in 1996 than 1991 (59% vs. 11%; p < .0001). Eighteen percent of the patients seen in 1996 were admitted from the initial appointment for medical stabilization, compared to 1.5% in 1991 (p = .002). Comparing 1996 to 1991, a similar number of patients had symptoms consistent with anorexia nervosa, whereas fewer patients in 1996 gave a history of bingeing and purging (22% vs. 40%; p = .027). There were no significant differences in indicators of illness severity, treatment by primary care clinician prior to referral, or hospitalization rates for those patients with and without managed care. Patients in 1996 were more likely to require referrals, were less likely to have symptoms consistent with bulimia nervosa, and were more likely to be admitted for medical stabilization. There were no differences in patient presentation characteristics or initial hospitalization rates based on their managed care status. Further research is needed to

  10. Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer.

    PubMed

    Katz, Steven J; Hawley, Sarah T; Morrow, Monica; Griggs, Jennifer J; Jagsi, Reshma; Hamilton, Ann S; Graff, John J; Friese, Christopher R; Hofer, Timothy P

    2010-01-01

    The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions. We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%). Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes. Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.

  11. Determinants of Heart Failure Self-Care Maintenance and Management in Patients and Caregivers: A Dyadic Analysis

    PubMed Central

    Bidwell, Julie T.; Vellone, Ercole; Lyons, Karen S.; D’Agostino, Fabio; Riegel, Barbara; Vela, Raúl Juárez; Hiatt, Shirin O.; Alvaro, Rosaria; Lee, Christopher S.

    2015-01-01

    Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self- management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how HF dyads manage the patient’s care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (i.e., daily adherence and symptom monitoring) and management (i.e., appropriate recognition & response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients were 76.2 (SD=10.7) years, a slight majority (56.9%) was male, while caregivers were 57.4 (SD=14.6) years, and fewer than half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Several significant individual and dyadic determinants of self-care maintenance and self-care management were identified, including gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and maximize outcomes. PMID:26355702

  12. Management and care of patients undergoing total knee arthroplasty: variations across different health care settings.

    PubMed

    Lingard, E A; Berven, S; Katz, J N

    2000-06-01

    To examine variation in the process of care for total knee arthroplasty (TKA) and to highlight the need for rigorous research into the ideal management of TKA. We hypothesize that variation in the process of care for TKA across and within health care systems is associated with identifiable financial and historical factors. We compared access to TKA and typical postoperative rehabilitation management in 12 orthopedic centers in the United States (4 centers), United Kingdom (6 centers), and Australia (2 centers). We collected data from two sources: 1) Empirical data on length of stay and discharge management were collected as part of a prospective study of the outcomes of primary TKA for patients with a diagnosis of osteoarthritis; 2) Structured qualitative interviews were conducted at each of the participating centers to collect data on academic status and reimbursement structure, as well as waiting times for orthopedic consultation and TKA surgery once it had been scheduled. We demonstrated differences in length of acute hospital stay, use of extended care facilities, home physical therapy, and outpatient physical therapy within our cohort of hospitals. The publicly funded hospitals had a significantly longer acute hospital length of stay (mean 11.8 days, SD 7.1) than the private hospitals (mean 6.6 days, SD 4.1; P < 0.0001). Variation in waiting times was associated with the method of surgeon reimbursement and whether the hospital is publicly funded or private. Patients attending private hospitals waited 1-8 weeks for the first consultation and 2-12 weeks for a surgical date after scheduling. In contrast, patients attending publicly funded hospitals waited 4-12 months for a first consultation and 12-18 months for a surgical date after scheduling. Our observations are consistent with the hypothesis that financial reimbursement schemes influence the management of TKA. Further research needs to be done to quantify effects of varying processes of care on the outcome

  13. Self-management in patients with COPD: theoretical context, content, outcomes, and integration into clinical care

    PubMed Central

    Kaptein, Ad A; Fischer, Maarten J; Scharloo, Margreet

    2014-01-01

    In this narrative review, we put self-management in the context of a 50-year history of research about how patients with COPD respond to their illness. We review a definition of self-management, and emphasize that self-management should be combined with disease management and the chronic care model in order to be effective. Reviewing the empirical status of self-management in COPD, we conclude that self-management is part and parcel of modern, patient-oriented biopsychosocial care. In pulmonary rehabilitation programs, self-management is instrumental in improving patients’ functional status and quality of life. We conclude by emphasizing how studying the way persons with COPD make sense of their illness helps in refining self-management, and thereby patient-reported outcomes in COPD. PMID:25214777

  14. The Impact of Management on Knowledge and Patient Care

    ERIC Educational Resources Information Center

    Iversen, Hans Petter

    2011-01-01

    How do approaches to management affect knowledge and patient care? In this paper, the establishment and dismantling of an organisational unit for research and development (R&D) in a mental health department of a Norwegian health enterprise are analysed. The characteristics of two adverse treatment ideologies and their coherence with approaches…

  15. A disease management program for heart failure: collaboration between a home care agency and a care management organization.

    PubMed

    Gorski, Lisa A; Johnson, Kathy

    2003-01-01

    This article describes a collaborative approach to manage patients with heart failure between a home care agency and a care management agency. The resulting disease management program used a combination of home visits and phone contact. Care management plans emphasized patient education on increasing adherence to medical and diet regimens, and recognizing early symptoms of exacerbation that could lead to rehospitalization. Clinician activities and patient outcomes are described.

  16. Managed care implications in managing rheumatoid arthritis.

    PubMed

    Owens, Gary M

    2014-05-01

    Rheumatoid arthritis (RA) is a systemic inflammatory form of arthritis characterized by joint inflammation, pain, swelling, and stiffness. While contemporary treatment strategies based on early diagnosis, aggressive treatment, and regular monitoring have helped a significant number of patients achieve evidence-based treatment goals, RA still presents substantial management challenges to both clinicians and patients, and has the potential to lead to severe disability over time. In addition to its significant clinical consequences, RA has important economic implications. Both direct and indirect medical costs associated with RA are significant, including costs of medications, ambulatory and office-based care, and quality-of-life and productivity costs. In addition, a significant proportion of patients with prevalent RA have associated cardiovascular disease and other comorbidities, further compounding healthcare costs and complicating management of this disorder. Clinically favorable and cost-effective management must focus on prevention of disease progression and the improved patient health status and productivity than can result from optimal disease control. With the myriad of treatment options both available and emerging, managed care organizations are faced with difficult decisions surrounding the most clinically and cost-effective allocation of treatments designed to improve disease outcomes for patients with RA. It is vital that managed care clinicians and providers analyze both the overall burden and the specific costs of RA. This will allow a better understanding of how costs and issues relating to healthcare utilization affect the treatment of patients with RA and impact individualized therapy, care coordination, and outcomes.

  17. Patient engagement with infection management in secondary care: a qualitative investigation of current experiences

    PubMed Central

    Rawson, Timothy M; Moore, Luke S P; Hernandez, Bernard; Castro-Sanchez, Enrique; Charani, Esmita; Georgiou, Pantelis; Ahmad, Raheelah; Holmes, Alison H

    2016-01-01

    Objective To understand patient engagement with decision-making for infection management in secondary care and the consequences associated with current practices. Design A qualitative investigation using in-depth focus groups. Participants Fourteen members of the public who had received antimicrobials from secondary care in the preceding 12 months in the UK were identified for recruitment. Ten agreed to participate. All participants had experience of infection management in secondary care pathways across a variety of South-East England healthcare institutes. Study findings were subsequently tested through follow-up focus groups with 20 newly recruited citizens. Results Participants reported feelings of disempowerment during episodes of infection in secondary care. Information is communicated in a unilateral manner with individuals ‘told’ that they have an infection and will receive an antimicrobial (often unnamed), leading to loss of ownership, frustration, anxiety and ultimately distancing them from engaging with decision-making. This poor communication drives individuals to seek information from alternative sources, including online, which is associated with concerns over reliability and individualisation. Failures in communication and information provision by clinicians in secondary care influence individuals’ future ideas about infections and their management. This alters their future actions towards antimicrobials and can drive prescription non-adherence and loss to follow-up. Conclusions Current infection management and antimicrobial prescribing practices in secondary care fail to engage patients with the decision-making process. Secondary care physicians must not view infection management episodes as discrete events, but as cumulative experiences which have the potential to shape future patient behaviour and understanding of antimicrobial use. PMID:27799238

  18. Patient experience in a coordinated care model featuring diabetes self-management education integrated into the patient-centered medical home.

    PubMed

    Janiszewski, Debra; O'Brian, Catherine A; Lipman, Ruth D

    2015-08-01

    The purpose of this study is to gain insight about patient experience of diabetes self-management education in a patient-centered medical home. Six focus groups consisting of 37 people with diabetes, diverse in race and ethnicity, were conducted at 3 sites. Participants described their experience in the program and their challenges in diabetes self-management; they also suggested services to meet their diabetes care needs. The most common theme was ongoing concerns about care and support. There was much discussion about the value of the support provided by health navigators integrated in the diabetes health care team. Frequent concerns expressed by participants centered on personal challenges in engaging in healthy lifestyle behaviors. Ongoing programmatic support of self-management goals was widely valued. Individuals who received health care in a patient-centered medical home and could participate in diabetes self-management education with integrated support valued both activities. The qualitative results from this study suggest need for more formalized exploration of effective means to meet the ongoing support needs of people with diabetes. © 2015 The Author(s).

  19. Designing the role of the embedded care manager.

    PubMed

    Hines, Patricia; Mercury, Marge

    2013-01-01

    : The role of the professional case manager is changing rapidly. Health reform has called upon the industry to ensure that care is delivered in an efficient, effective, and high-quality and low cost manner. As a means to achieve this objective, health plans and health systems are moving the care manager out of a centralized location within their organizations to "embedding" them into physician offices. This move enables the care manager to work alongside the primary care physicians and their high-risk patients. This article discusses the framework for designing and implementing an embedded care manager role into a physician practice. Key elements of the program are discussed. IMPLICATIONS FOR CARE MANAGEMENT:: Historically care management has played a foundational role in improving the quality of care for individuals and populations via the efficient and effective use of resources. Now with the goals of health care reform, a successful transition from a volume-based to value-based reimbursement system requires primary care physicians to welcome care managers into their practices to improve patient care, quality, and costs through care coordination across health care settings and populations. : As patient-centered medical homes and integrated delivery systems formulate their plans for population health management, their efforts have included embedding a care manager in the primary practice setting. Having care managers embedded at the physician offices increases their ability to collaborate with the physician and their staff in the implementation and monitoring care plans for their patients. : Implementing an embedded care manager into an existing physician's practice requires the following:Although the embedded care manager is a highly evolving role, physician groups are beginning to realize the benefits from their care management collaborations. Examples cited include improved outreach and coordination, patient adherence to care plans, and improved quality of life.

  20. Image management and communication in patient care: perspectives on implementation and impact.

    PubMed

    Greberman, M; Mun, S K

    1989-02-01

    Image management and communication (IMAC) systems are automated and integrated systems that capture digital medical images and related patient information and transmit them electronically, display them for interpretation, and store them for future retrieval. The IMAC system concept includes images and relevant information from all clinical sources. The First International Conference on Image Management and Communication in Patient Care (IMAC 89) provides a forum for expert presentations, poster sessions, and discussion and debate among all attendees interested in the implementation and impact of IMAC systems. Plenary sessions provide an international perspective and explore the role of image-based information in patient care, approaches to improved IMAC systems, current technical barriers, quality of care issues, evaluation approaches, and scenarios for the future. Invited participants are from North America, Europe, Japan, Australia, and the WHO. Conference organizers are working with numerous professional organizations and representatives of meetings which focus on IMAC-related technology to complement, and not duplicate, the contribution of other groups.

  1. Self-management practices among primary care patients with musculoskeletal pain and depression.

    PubMed

    Damush, Teresa M; Wu, Jingwei; Bair, Matthew J; Sutherland, Jason M; Kroenke, Kurt

    2008-08-01

    The objective of this study was to assess the effect of clinical depression on pain self-management practices. We employed a cross-sectional analysis of baseline data from the Stepped Care for Affective disorders and Musculoskeletal Pain (SCAMP) study. Participants included 250 patients with pain and comorbid depression and 250 patients with pain only and were enrolled from urban university and VA primary care clinics. Musculoskeletal pain was defined as low back, hip or knee pain present >or=3 months and with at least a moderate, Brief Pain Inventory severity score >or=5. Depression was defined as a PHQ-9 score >or=10. We used multiple logistic and Poisson regression to assess the relationship between individual and combined effects of depression and pain severity on two core pain self-management skills: exercise duration and cognitive strategies. Depressed patients exercised less per week than did nondepressed patients but showed a trend towards more frequent use of cognitive strategies. On multivariable analysis, depression severity substantially decreased the use of exercise as a pain self-management strategy. In contrast, depression and pain severity interacted to increase the use of cognitive strategies. Depression and pain severity have differential effects on self-management practices. Understanding the differences between preferential strategies of pain patients with and without depression may be useful in tailoring pain self-management programs.

  2. Managing risk during care transitions when approaching end of life: A qualitative study of patients' and health care professionals' decision making.

    PubMed

    Coombs, Maureen A; Parker, Roses; de Vries, Kay

    2017-07-01

    Increasing importance is being placed on the coordination of services at the end of life. To describe decision-making processes that influence transitions in care when approaching the end of life. Qualitative study using field observations and longitudinal semi-structured interviews. Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3-4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken. Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making 'safe' discharge options informed hospital discharge decisions. While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life.

  3. Expert patient self-management program versus usual care in bronchiectasis: a randomized controlled trial.

    PubMed

    Lavery, Katherine A; O'Neill, Brenda; Parker, Michael; Elborn, J Stuart; Bradley, Judy M

    2011-08-01

    To investigate the efficacy of a disease-specific Expert Patient Programme (EPP) compared with usual care in patients with bronchiectasis. Proof-of-concept randomized controlled trial. Regional respiratory center. Adult patients (N=64; age, >18y) with a primary diagnosis of bronchiectasis based on a respiratory physician's assessment including a computed tomographic scan. Patients were randomly assigned to an intervention (usual care plus EPP; n=32) or control group (usual care only; n=32). The primary outcome measure was the Chronic Disease Self-efficacy Scale (CDSS). Other outcome measures included the Revised Illness Perception Questionnaire (IPQ-R), the St Georges Respiratory Questionnaire, and standard EPP questionnaires. Data were collected at baseline, postintervention, and 3 and 6 months postintervention. This disease-specific EPP for patients with bronchiectasis significantly improved self-efficacy in 6 of 10 subscales (CDSS subscales: exercise regularly [P=.02]; get information about disease [P=.03]; obtain help from community, family, and friends [P=.06]; communicate with physician [P=.85]; manage disease in general [P=.05]; do chores [P=.04]; social/recreational activities [P=.03]; manage symptoms [P<.01]; manage shortness of breath [P=.08]; control/manage depression [P=.01]) compared with usual care. There was no improvement on IPQ-R score. Patients who received the intervention reported more symptoms and decreased quality of life between 3 and 6 months postintervention and an increase in some components of self reported health care use. Patients receiving the disease-specific EPP indicated they were satisfied with the intervention and learned new self-management techniques. There were no significant differences in lung function over time. This original study indicates that a disease-specific EPP results in short-term improvements in self-efficacy. Based on these positive preliminary findings, a larger adequately powered study is justified to

  4. Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care

    PubMed Central

    Norton, Jenna M.; Boulware, L. Ebony

    2016-01-01

    Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD. PMID:26536899

  5. Confronting Disparities in Diabetes Care: The Clinical Effectiveness of Redesigning Care Management for Minority Patients in Rural Primary Care Practices

    ERIC Educational Resources Information Center

    Bray, Paul; Thompson, Debra; Wynn, Joan D.; Cummings, Doyle M.; Whetstone, Lauren

    2005-01-01

    Context: Diabetes mellitus and its complications disproportionately affect minority citizens in rural communities, many of whom have limited access to comprehensive diabetes management services. Purpose: To explore the efficacy of combining care management and interdisciplinary group visits for rural African American patients with diabetes…

  6. The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox?

    PubMed

    Armstrong, Susan J; Rispel, Laetitia C; Penn-Kekana, Loveday

    2015-01-01

    Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers' recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care.

  7. Connecting Patients to mHealth Applications to Enhance Self-care Management.

    PubMed

    Conroy, Meghan K

    2015-09-01

    Smartphone use and the desire to use mHealth are growing in the population of patients who most commonly use home healthcare (HHC) services, a population with chronic conditions and complex healthcare management needs. HHC nurses are positioned to connect HHC patients with mHealth Apps to access health-related information, engage in interactive monitoring, and manage self-care activities. The challenge of finding reputable Apps is discussed and resources are presented to overcome this challenge at the business orindividual level.

  8. Primary Care Provider Perceptions of the Effectiveness of Two Self-Management Support Programs for Vulnerable Patients with Diabetes

    PubMed Central

    Ratanawongsa, Neda; Bhandari, Vijay K; Handley, Margaret; Rundall, Thomas; Hammer, Hali; Schillinger, Dean

    2012-01-01

    Background Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs' perspectives on the effectiveness of two language-concordant diabetes self-management support programs. Methods One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering. Results Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01). Conclusions Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multilinguistic populations. PMID:22401329

  9. Evaluation of the ESRD Managed Care Demonstration Operations

    PubMed Central

    Oppenheimer, Caitlin Carroll; Shapiro, Jennifer R.; Beronja, Nancy; Dykstra, Dawn M.; Gaylin, Daniel S.; Held, Philip J.; Rubin, Robert J.

    2003-01-01

    Individuals with end stage renal disease (ESRD), most of whom are insured by Medicare, are generally prohibited from enrolling in Medicare managed care plans (MCPs). CMS offered ESRD patients the opportunity to participate in an ESRD managed care demonstration mandated by Congress. The demonstration tested whether managed care systems would be of interest to ESRD patients and whether these approaches would be operationally feasible and efficient for treating ESRD patients. This article examines the structure, implementation, and operational outcomes of the three demonstration sites, focusing on: the structure of these managed care programs for ESRD patients, requirements needed to attract and enroll patients, and the challenges of introducing managed care programs in the ESRD arena. PMID:14628397

  10. The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox?

    PubMed Central

    Armstrong, Susan J.; Rispel, Laetitia C.; Penn-Kekana, Loveday

    2015-01-01

    Background Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. Objective This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. Methods During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. Results The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers’ recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. Conclusion The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high

  11. Remote patient management: technology-enabled innovation and evolving business models for chronic disease care.

    PubMed

    Coye, Molly Joel; Haselkorn, Ateret; DeMello, Steven

    2009-01-01

    Remote patient management (RPM) is a transformative technology that improves chronic care management while reducing net spending for chronic disease. Broadly deployed within the Veterans Health Administration and in many small trials elsewhere, RPM has been shown to support patient self-management, shift responsibilities to non-clinical providers, and reduce the use of emergency department and hospital services. Because transformative technologies offer major opportunities to advance national goals of improved quality and efficiency in health care, it is important to understand their evolution, the experiences of early adopters, and the business models that may support their deployment.

  12. Primary Care Providers Report Challenges to Cirrhosis Management and Specialty Care Coordination.

    PubMed

    Beste, Lauren A; Harp, Bonnie K; Blais, Rebecca K; Evans, Ginger A; Zickmund, Susan L

    2015-09-01

    Two-thirds of patients with cirrhosis do not receive guideline-concordant liver care. Cirrhosis patients are less likely to receive recommended care when followed exclusively by primary care providers (PCPs), as opposed to specialty co-management. Little is known about how to optimize cirrhosis care delivered by PCPs. We conducted a qualitative analysis to explore PCPs' attitudes and self-reported roles in caring for patients with cirrhosis. We recruited PCPs from seven Veterans Affairs facilities in the Pacific Northwest via in-service trainings and direct email from March to October 2012 (n = 24). Trained staff administered structured telephone interviews covering: (1) general attitudes; (2) roles and practices; and (3) barriers and facilitators to cirrhosis management. Two trained, independent coders reviewed each interview transcript and thematically coded responses. Three overarching themes emerged in PCPs' perceptions of cirrhosis patients: the often overwhelming complexity of comorbid medical, psychiatric, and substance issues; the importance of patient self-management; and challenges surrounding specialty care involvement and co-management of cirrhosis. While PCPs felt they brought important skills to bear, such as empathy and care coordination, they strongly preferred to defer major cirrhosis management decisions to specialists. The most commonly reported barriers to care included patient behaviors, access issues, and conflicts with specialists. PCPs perceive Veterans with cirrhosis as having significant medical and psychosocial challenges. PCPs tend not to see their role as directing cirrhosis-related management decisions. Educational efforts directed at PCPs must foster PCP empowerment and improve comfort with managing cirrhosis.

  13. Fibromyalgia: management strategies for primary care providers.

    PubMed

    Arnold, L M; Gebke, K B; Choy, E H S

    2016-02-01

    Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management. We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements. The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes. The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training. Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting. © 2016 John Wiley & Sons Ltd.

  14. Understanding patient requirements for technology systems that support pain management in palliative care services: A qualitative study.

    PubMed

    Allsop, Matthew J; Taylor, Sally; Bennett, Michael I; Bewick, Bridgette M

    2017-11-01

    Approaches to pain management using electronic systems are being developed for use in palliative care. This article explores palliative care patients' perspectives on managing and talking about pain, the role of technology in their lives and how technology could support pain management. Face-to-face interviews were used to understand patient needs and concerns to inform how electronic systems are developed. A total of 13 interviews took place with a convenience sample of community-based patients with advanced cancer receiving palliative care through a hospice. Data were analysed using framework analysis. Four meta-themes emerged: Technology could be part of my care; I'm trying to understand what is going on; My pain is ever-changing and difficult to control; and I'm selective about who to tell about pain. Patients described technology as peripheral to existing processes of care. To be relevant, systems may need to take account of the complexity of a patient's pain experience alongside existing relationships with health professionals.

  15. Evaluating the link between human resource management decisions and patient satisfaction with quality of care.

    PubMed

    Oppel, Eva-Maria; Winter, Vera; Schreyögg, Jonas

    Patient satisfaction with quality of care is becoming increasingly important in the competitive hospital market. Simultaneously, the growing shortage of clinical staff poses a considerable challenge to ensuring a high quality of care. In this context, a question emerges regarding whether and how human resource management (HRM) might serve as a means to reduce staff shortage problems and to increase patient satisfaction. Although considerable efforts have been devoted to understanding the concepts of patient satisfaction and HRM, little is known about the interrelationships between these concepts or about the link between staff shortage problems and patients' satisfaction with quality of care. The aim of this study was to investigate the relationship between strategic human resource management (SHRM), staff shortage problems, and patients' satisfaction with care. Furthermore, we analyze how the HRM decision to fill short-term vacancies through temporary staffing affects patient satisfaction. We differentiate between physicians and nurses. We develop and empirically test a theoretical model. The data (n = 165) are derived from a survey on SHRM that was sent to 732 German hospitals and from a survey on patient satisfaction that comprises 436,848 patient satisfaction ratings. We use a structural equation modeling approach to test the model. The results indicate that SHRM significantly reduces staff shortage problems for both occupational groups. Having fewer physician shortage problems is significantly associated with higher levels of patient satisfaction, whereas this effect is not significant for nurses. Furthermore, the use of temporary staffing considerably reduces patients' satisfaction with care. Hospital managers are advised to consider the effects of HRM decisions on patients' satisfaction with care. In particular, investments in SHRM targeted at physicians have significantly positive effects on patient satisfaction, whereas the temporary staffing of physicians

  16. Mother-infant home care drives quality in a managed care environment.

    PubMed

    Malnory, M

    1997-04-01

    Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting equivalent patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures.

  17. A program of symptom management for improving self-care for patients with HIV/AIDS.

    PubMed

    Chiou, Piao-Yi; Kuo, Benjamin Ing-Tiau; Chen, Yi-Ming; Wu, Shiow-Ing; Lin, Li-Chan

    2004-09-01

    The purpose of this study was to investigate the effect of a symptom management program on self-care of medication side effects among AIDS/HIV-positive patients. Sixty-seven patients from a sexually transmitted disease control center, a medical center, and a Catholic AIDS support group in Taipei were randomly assigned to three groups: one-on-one teaching, group teaching, and a control group. All subjects in each teaching group attended a 60- or 90-minute program on highly active antiretroviral therapy (HAART) side effect self-care education and skill training once per week for 3 weeks; subjects also underwent counseling by telephone. A medication side effect self-care knowledge questionnaire, Rosenberg's Self-Esteem Scale (RSES), and unscheduled hospital visits were used to evaluate the effectiveness of the symptom management program. The results revealed there were significant differences in mean difference of knowledge and unscheduled hospital visits between baseline and post-testing at 3 months for symptom management in the two groups. The mean difference of the self-esteem scale was not significant between the two groups. In summary, the symptom management program effectively increased the ability of AIDS/HIV-positive patients to self-care for medication side effects. We recommend that this program be applied in the clinical nursing practice.

  18. Critical care considerations in the management of the trauma patient following initial resuscitation

    PubMed Central

    2012-01-01

    Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients. PMID:22989116

  19. Patient-provider relationship as mediator between adult attachment and self-management in primary care patients with multiple chronic conditions.

    PubMed

    Brenk-Franz, Katja; Strauß, Bernhard; Tiesler, Fabian; Fleischhauer, Christian; Schneider, Nico; Gensichen, Jochen

    2017-06-01

    The conceptual model of attachment theory has been applied to understand the predispositions of patients in medical care and the patient-provider relationship. In patients with chronic conditions insecure attachment was connected to poorer self-management. The patient-provider relationship is associated with a range of health related outcomes and self-management skills. We determined whether the quality of the patient-provider relationship mediates the link between adult attachment and self-management among primary care patients with multiple chronic diseases. 209 patients with a minimum of three chronic diseases (including type II diabetes, hypertension and at least one other chronic condition) between the ages of 50 and 85 from eight general practices were included in the APRICARE cohort study. Adult attachment was measured via self-report (ECR-RD), self-management skills by the FERUS and the patient-provider relationship by the PRA-D. The health status and chronicity were assessed by the GP. Multiple mediation analyses were used to examine whether aspects of the patient-provider relationship (communication, information, affectivity) are a mediators of associations between adult attachment and self-management. The analysis revealed that the quality of the patient-provider relationship mediated the effect of attachment on self-management in patients with multiple chronic conditions. Particularly the quality of communication and information over the course of treatment has a significant mediating influence. A personalized, attachment-related approach that promotes active patient-provider communication and gives information about the treatment to the patient may improve self-management skills in patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  20. Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials

    PubMed Central

    2012-01-01

    Background Osteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care. Methods / Design One study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the

  1. Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

    PubMed

    Reddy, Ashok; Sessums, Laura; Gupta, Reshma; Jin, Janel; Day, Tim; Finke, Bruce; Bitton, Asaf

    2017-09-01

    Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services. © 2017 Annals of Family Medicine, Inc.

  2. Ethics in practice: managed care and the changing health care environment: medicine as a profession managed care ethics working group statement.

    PubMed

    Povar, Gail J; Blumen, Helen; Daniel, John; Daub, Suzanne; Evans, Lois; Holm, Richard P; Levkovich, Natalie; McCarter, Alice O; Sabin, James; Snyder, Lois; Sulmasy, Daniel; Vaughan, Peter; Wellikson, Laurence D; Campbell, Amy

    2004-07-20

    Cost pressures and changes in the health care environment pose ethical challenges and hard choices for patients, physicians, policymakers, and society. In 2000 and 2001, the American College of Physicians, with the Harvard Pilgrim Health Care Ethics Program, convened a working group of stakeholders--patients, physicians, and managed care representatives, along with medical ethicists--to develop a statement of ethics for managed care. The group explored the impact of a changing health care environment on patient-physician relationships and how to best apply the principles of professionalism in this environment. The statement that emerged offers guidance on preserving the patient-clinician relationship, patient rights and responsibilities, confidentiality and privacy, resource allocation and stewardship, the obligation of health plans to foster an ethical environment for the delivery of care, and the clinician's responsibility to individual patients, the community, and the public health, among other issues.

  3. Managing multimorbidity in primary care in patients with chronic respiratory conditions.

    PubMed

    Morrison, Deborah; Agur, Karolina; Mercer, Stewart; Eiras, Andreia; González-Montalvo, Juan I; Gruffydd-Jones, Kevin

    2016-09-15

    The term multimorbidity is usually defined as the coexistence of two or more chronic conditions within an individual, whereas the term comorbidity traditionally describes patients with an index condition and one or more additional conditions. Multimorbidity of chronic conditions markedly worsens outcomes in patients, increases treatment burden and increases health service costs. Although patients with chronic respiratory disease often have physical comorbidities, they also commonly experience psychological problems such as depression and anxiety. Multimorbidity is associated with increased health-care utilisation and specifically with an increased number of prescription drugs in individuals with multiple chronic conditions such as chronic obstructive pulmonary disease. This npj Primary Care Respiratory Medicine Education Section case study involves a patient in a primary care consultation presenting several common diseases prevalent in people of this age. The patient takes nine different drugs at this moment, one or more pills for each condition, which amounts to polypharmacy. The problems related with polypharmacy recommend that a routine medication review by primary care physicians be performed to reduce the risk of adverse effects of polypharmacy among those with multiple chronic conditions. The primary care physician has the challenging role of integrating all of the clinical problems affecting the patient and reviewing all medicaments (including over-the-counter medications) taken by the patient at any point in time, and has the has the key to prevent the unwanted consequences of polypharmacy. Multimorbid chronic disease management can be achieved with the use of care planning, unified disease templates, use of information technology with appointment reminders and with the help of the wider primary care and community teams.

  4. "They don't want anything to do with you": patient views of primary care management of chronic pain.

    PubMed

    Upshur, Carole C; Bacigalupe, Gonzalo; Luckmann, Roger

    2010-12-01

    Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care. Wiley Periodicals, Inc.

  5. Perceived determinants of cardiovascular risk management in primary care: disconnections between patient behaviours, practice organisation and healthcare system.

    PubMed

    Huntink, E; Wensing, M; Klomp, M A; van Lieshout, J

    2015-12-15

    Although conditions for high quality cardiovascular risk management in primary care in the Netherlands are favourable, there still remains a gap between practice guideline recommendations and practice. The aim of the current study was to identify determinants of cardiovascular primary care in the Netherlands. We performed a qualitative study, using semi-structured interviews with healthcare professionals and patients with established cardiovascular diseases or at high cardiovascular risk. A framework analysis was used to cluster the determinants into seven domains: 1) guideline factors, 2) individual healthcare professional factors, 3) patient factors, 4) professional interaction, 5) incentives and recourses, 6) mandate, authority and accountability, and 7) social, political and legal factors. Twelve healthcare professionals and 16 patients were interviewed. Healthcare professionals and patients mentioned a variety of factors concerning all seven domains. Determinants of practice according to the health care professionals were related to communication between healthcare professionals, patients' lack of knowledge and self-management, time management, market mechanisms in the Dutch healthcare system and motivational interviewing skills of healthcare professionals. Patients mentioned determinants related to their knowledge of risk factors for cardiovascular diseases, medication adherence and self-management as key determinants. A key finding is the mismatch between healthcare professionals' and patients' views on patient's knowledge and self-management. Perceived determinants of cardiovascular risk management were mainly related to patient behaviors and (but only for health professionals) to the healthcare system. Though health care professionals and patients agree upon the importance of patients' knowledge and self-management, their judgment of the current state of knowledge and self-management is entirely different.

  6. Differences in perspectives regarding diabetes management between health care providers and patients.

    PubMed

    Loskutova, Natalia Y; Tsai, Adam G; Callen, Elisabeth; Ajayi, Kemi; Carroll, Jennifer K; Harrington, Michael; Turner, Tamela J; Pace, Wilson D

    2018-05-23

    Chronic conditions such as type 2 diabetes are challenging to manage. This is often due to failure of both the practice of effective diabetes self-care management by the patient and inadequate intervention strategies and follow-up by the health care provider (HCP). The aims of the study are (i) to use a social marketing survey approach to understand the gaps in perceptions between patients with type 2 diabetes and HCPs on diabetes-related topics such as levels of awareness, use and satisfaction with community resources, and perceived barriers to self-management and (ii) to present the results of a public awareness campaign/diabetes management demonstration project (Cities for Life) on change in discordant views between HCPs and patients. The study was conducted as a separate sample pre-post quasiexperimental design study as part of a clinical-community program, Cities for Life in Birmingham, AL. The surveys were administered before (Wave 1 or W1 in 2012) and after (Wave 2 or W2 in 2013) implementation of the Cities for Life program. HCPs (n = 50 and 48) and patients with type 2 diabetes and prediabetes (n = 201 and 204) responded to surveys at W1 and W2, respectively. At both timepoints, HCPs and patients identified diabetes as a major health priority and stated education and information as the most valuable aspects of community-based programs (CBPs). Although 86% of HCPs reported recommending CBPs for lifestyle modification and that their patients frequently participated in CBPs (W1 = 70%; W2 = 82%), fewer patients reported participation (W1 = 31%; W2 = 22%). Patients frequently were not able to name any CBPs for diabetes prevention or treatment (W1 = 45%; W2 = 59%) despite a large proportion perceiving CBPs as valuable (W1 = 41%; W2 = 39%). A substantial percentage of patients reported receiving "a lot of support" from family/friends/or coworkers (W1 = 54%; W2 = 64%; p < .05), but HCPs believed that a much lower proportion of their patients received "a lot of

  7. Capitated risk-bearing managed care systems could improve end-of-life care.

    PubMed

    Lynn, J; Wilkinson, A; Cohn, F; Jones, S B

    1998-03-01

    Capitated or salaried managed care systems offer an important opportunity to provide high quality, cost-effective end-of-life care. However, capitated healthcare delivery systems have strong incentives to avoid patient populations in need of such care. Care currently provided at the end of life in fee-for-service practice is commonly deficient, with high rates of avoidable pain and other burdens. Only hospice offers a better track record, yet access to hospice is limited, and length of stay is short. Traditional staff- or group-model managed care plans, with their emphasis on prevention, patient education, cost efficiency, service coordination, and integrated provider networks, present a dynamic set of conditions and organizational structures that would support real change. Advantages derived from managed care systems providing quality end-of-life care include coordinated care across delivery sites, interdisciplinary teams, integrated services, and opportunities to develop innovative care programs, service arrays, utilization controls, and accountability for care standards. We propose a special comprehensive system of managed care, which we call MediCaring, for seriously ill persons nearing the end of life. MediCaring would encompass the best elements of palliative care within a managed care structure: comprehensive, supportive, community-based services that meet personal and medical needs, a focus on patient preferences, symptom management, family counseling, and support. Other programs, such as hospice, have shown that continuity and coordinated care, financed through a capitated payment and directed at a special population, are both feasible and effective. There are obstacles to improving care at the end of life. Managed care systems, like most of medical care, have largely ignored the terminally ill patient. Current financing arrangements make it financially undesirable for insurers to recruit or retain the very sick; very ill patients can be costly over a

  8. Technology-facilitated depression care management among predominantly Latino diabetes patients within a public safety net care system: comparative effectiveness trial design.

    PubMed

    Wu, Shinyi; Ell, Kathleen; Gross-Schulman, Sandra G; Sklaroff, Laura Myerchin; Katon, Wayne J; Nezu, Art M; Lee, Pey-Jiuan; Vidyanti, Irene; Chou, Chih-Ping; Guterman, Jeffrey J

    2014-03-01

    Health disparities in minority populations are well recognized. Hispanics and Latinos constitute the largest ethnic minority group in the United States; a significant proportion receives their care via a safety net. The prevalence of diabetes mellitus and comorbid depression is high among this group, but the uptake of evidence-based collaborative depression care management has been suboptimal. The study design and baseline characteristics of the enrolled sample in the Diabetes-Depression Care-management Adoption Trial (DCAT) establishes a quasi-experimental comparative effectiveness research clinical trial aimed at accelerating the adoption of collaborative depression care in safety net clinics. The study was conducted in collaboration with the Los Angeles County Department of Health Services at eight county-operated clinics. DCAT has enrolled 1406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares usual care with a collaborative care team support model and a technology-facilitated depression care model that provides automated telephonic depression screening and monitoring tailored to patient conditions and preferences. Call results are integrated into a diabetes disease management registry that delivers provider notifications, generates tasks, and issues critical alerts. All subjects receive comprehensive assessments at baseline, 6, 12, and 18 months by independent English-Spanish bilingual interviewers. Study outcomes include depression outcomes, treatment adherence, satisfaction, acceptance of assessment and monitoring technology, social and economic stress reduction, diabetes self-care management, health care utilization, and care management model cost and cost-effectiveness comparisons. DCAT's goal is to optimize depression screening, treatment, follow-up, outcomes, and cost savings to reduce health disparities. Copyright © 2013 Elsevier Inc. All rights

  9. Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic.

    PubMed

    Tapp, Hazel; Phillips, Shay E; Waxman, Dael; Alexander, Matthew; Brown, Rhett; Hall, Mary

    2012-01-01

    Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.

  10. Curbing the urge to care: A Bourdieusian analysis of the effect of the caring disposition on nurse middle managers' clinical leadership in patient safety practices.

    PubMed

    Lalleman, P C B; Smid, G A C; Lagerwey, M D; Shortridge-Baggett, L M; Schuurmans, M J

    2016-11-01

    Nurse managers play an important role in implementing patient safety practices in hospitals. However, the influence of their professional background on their clinical leadership behaviour remains unclear. Research has demonstrated that concepts of Bourdieu (dispositions of habitus, capital and field) help to describe this influence. It revealed various configurations of dispositions of the habitus in which a caring disposition plays a crucial role. We explore how the caring disposition of nurse middle managers' habitus influences their clinical leadership behaviour in patient safety practices. Our paper reports the findings of a Bourdieusian, multi-site, ethnographic case study. Two Dutch and two American acute care, mid-sized, non-profit hospitals. A total of 16 nurse middle managers of adult care units. Observations were made over 560h of shadowing nurse middle managers, semi-structured interviews and member check meetings with the participants. We observed three distinct configurations of dispositions of the habitus which influenced the clinical leadership of nurse middle managers in patient safety practices; they all include a caring disposition: (1) a configuration with a dominant caring disposition that was helpful (via solving urgent matters) and hindering (via ad hoc and reactive actions, leading to quick fixes and 'compensatory modes'); (2) a configuration with an interaction of caring and collegial dispositions that led to an absence of clinical involvement and discouraged patient safety practices; and (3) a configuration with a dominant scientific disposition showing an investigative, non-judging, analytic stance, a focus on evidence-based practice that curbs the ad hoc repertoire of the caring disposition. The dispositions of the nurse middle managers' habitus influenced their clinical leadership in patient safety practices. A dominance of the caring disposition, which meant 'always' answering calls for help and reactive and ad hoc reactions, did not

  11. Generalist care managers for the treatment of depressed medicaid patients in North Carolina: a pilot study.

    PubMed

    Landis, Suzanne E; Gaynes, Bradley N; Morrissey, Joseph P; Vinson, Nina; Ellis, Alan R; Domino, Marisa E

    2007-03-05

    In most states, mental illness costs are an increasing share of Medicaid expenditures. Specialized depression care managers (CM) have consistently demonstrated improvements in patient outcomes relative to usual primary care (UC), but are costly and may not be fully utilized in smaller practices. A generalist care manager (GCM) could manage multiple chronic conditions and be more accepted and cost-effective than the specialist depression CM. We designed a pilot program to demonstrate the feasibility of training/deploying GCMs into primary care settings. We randomized depressed adult Medicaid patients in 2 primary care practices in Western North Carolina to a GCM intervention or to UC. GCMs, already providing services in diabetes and asthma in both study arms, were further trained to provide depression services including self-management, decision support, use of information systems, and care management. The following data were analyzed: baseline, 3- and 6-month Patient Health Questionnaire (PHQ9) scores; baseline and 6-month Short Form (SF) 12 scores; Medicaid claims data; questionnaire on patients' perceptions of treatment; GCM case notes; physician and office staff time study; and physician and office staff focus group discussions. Forty-five patients were enrolled, the majority with preexisting depression. Both groups improved; the GCM group did not demonstrate better clinical and functional outcomes than the UC group. Patients in the GCM group were more likely to have prescriptions of correct dosing by chart data. GCMs most often addressed comorbid conditions (36%), then social issues (27%) and appointment reminders (14%). GCMs recorded an average of 46 interactions per patient in the GCM arm. Focus group data demonstrated that physicians valued using GCMs. A time study documented that staff required no more time interacting with GCMs, whereas physicians spent an average of 4 minutes more per week. GCMs can be trained in care of depression and other chronic

  12. Using an electronic self-management tool to support patients with chronic kidney disease (CKD): a CKD clinic self-care model.

    PubMed

    Ong, Stephanie W; Jassal, Sarbjit V; Porter, Eveline; Logan, Alexander G; Miller, Judith A

    2013-01-01

    New healthcare delivery models are needed to enhance the patient experience and improve quality of care for individuals with chronic conditions such as kidney disease. One potential avenue is to implement self-management strategies. There is growing evidence that self-management interventions help optimize various aspects of chronic disease management. With the increasing use of information technology (IT) in health care, chronic disease management programs are incorporating IT solutions to support patient self-management practices. IT solutions have the ability to promote key principles of self-management, namely education, empowerment, and collaboration. Positive clinical outcomes have been demonstrated for a number of chronic conditions when IT solutions were incorporated into self-management programs. There is a paucity of evidence for self-management in chronic kidney disease (CKD) patients. Furthermore, IT strategies have not been tested in this patient population to the same extent as other chronic conditions (e.g., diabetes, hypertension). Therefore, it is currently unknown if IT strategies will promote self-management behaviors and lead to improvements in overall patient care. We designed and developed an IT solution called My KidneyCare Centre to support self-management strategies for patients with CKD. In this review, we discuss the rationale and vision of incorporating an electronic self-management tool to support the care of patients with CKD. © 2013 Wiley Periodicals, Inc.

  13. Perception of barriers to self-care management among diabetic patients.

    PubMed

    Gazmararian, Julie A; Ziemer, David C; Barnes, Catherine

    2009-01-01

    The purpose of this study was to explore individual, educational, and system barriers that limit low-income diabetes patients' ability to achieve optimal diabetes self-management. Economically disadvantaged patients with diabetes who used the Diabetes Clinic of Grady Health System in Atlanta, Georgia, participated in 3 focus group discussions. The discussions were held with mostly African Americans (n = 35) to explore barriers to achieving optimal diabetes self-management. Most participants were not married, approximately one-third had less than high school level reading skills, and 40% were not currently working. In terms of individual barriers, the emotional toll from the diagnosis of and lifestyle changes to treat diabetes was a recurrent theme, and included stress, frustration, social isolation, interpersonal conflicts, depression, and fear. Denial was often mentioned as the key factor that inhibited adherence to a healthy mode of living. The educational barriers were failure to recognize the risks and consequences of an asymptomatic condition. Many participants did not understand A1C. Finally, several system barriers were identified. The participants identified needed services, including follow-up and refresher courses, support group discussions, nutrition and medication education, availability of different education modalities, and expanded clinic hours. The focus group discussions identified both barriers to diabetes management and opportunities for improving care for underserved patients with diabetes. The results are useful to improve the delivery of care and to develop quantitative studies to explore particular areas of interest. Based on these results, the current system needs to provide more support and education to patients with diabetes.

  14. Primary Care Physicians' Experience with Disease Management Programs

    PubMed Central

    Fernandez, Alicia; Grumbach, Kevin; Vranizan, Karen; Osmond, Dennis H; Bindman, Andrew B

    2001-01-01

    OBJECTIVE To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN Cross-sectional mailed survey. SETTING The 13 largest urban counties in California. PARTICIPANTS General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction. PMID:11318911

  15. Improving care of post-infarct patients: effects of disease management programmes and care according to international guidelines.

    PubMed

    Stark, Renee; Kirchberger, Inge; Hunger, Matthias; Heier, Margit; Leidl, Reiner; von Scheidt, Wolfgang; Meisinger, Christa; Holle, Rolf

    2014-03-01

    Cardiac disease management programmes (CHD-DMPs) and secondary cardiovascular prevention guidelines aim to improve complex care of post-myocardial infarction (MI) patients. In Germany, CHD-DMPs, in addition to incorporating medical care according to guidelines (guideline-care), also ensure regular quarterly follow-up. Thus, our aim was to examine whether CHD-DMPs increase the frequency of guideline-care and whether CHD-DMPs and guideline-care improve survival over 4 years. The study included 975 post-MI patients, registered by the KORA-MI Registry (Augsburg, Germany), who completed a questionnaire in 2006. CHD-DMP enrolment was reported by physicians. Guideline-care was based on patient reports regarding medical advice (smoking, diet, or exercise) and prescribed medications (statins and platelet aggregation inhibitors plus beta-blockers or renin-angiotensin inhibitors). All-cause mortality until December 31, 2010 was based on municipal registration data. Cox regression analyses were adjusted for age, sex, education, years since last MI, and smoking and diabetes. Physicians reported that 495 patients were CHD-DMP participants. CHD-DMP participation increased the likelihood of receiving guideline-care (odds ratio 1.55, 95% CI 1.20; 2.02) but did not significantly improve survival (hazard rate 0.90, 95% CI 0.64-1.27). Guideline-care significantly improved survival (HR 0.41, 95% CI 0.28; 0.59). Individual guideline-care components, which significantly improved survival, were beta-blockers, statins and platelet aggregation inhibitors. However, these improved survival less than guideline-care. This study shows that CHD-DMPs increase the likelihood of guideline care and that guideline care is the important component of CHD-DMPs for increasing survival. A relatively high percentage of usual care patients receiving guideline-care indicate high quality of care of post-MI patients. Reasons for not implementing guideline-care should be investigated.

  16. Impact of managed care on the treatment, costs, and outcomes of fee-for-service Medicare patients with acute myocardial infarction.

    PubMed

    Bundorf, M Kate; Schulman, Kevin A; Stafford, Judith A; Gaskin, Darrell; Jollis, James G; Escarce, José J

    2004-02-01

    To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

  17. Health Care Waste Management Practice in Health Care Institutions of Nepal.

    PubMed

    Joshi, H D; Acharya, T; Ayer, R; Dhakal, P; Karki, K B; Dhimal, M

    2017-01-01

    Medical waste is considered as a major public health hazard. In a developing country like Nepal, there is much concern about the management practice of medical waste. This study aimed to assess Health Care Waste Management practice among Health Care Institutions in Nepal. A cross sectional study was carried out between July 2012 to June 2013 in 62 different Health Care Institutions, selected from stratified proportionate random sampling technique from all administrative regions of Nepal. A structured questionnaire and observation checklist were used for data collection. The waste generation rate is found significantly correlated with bed capacity, patient flow rate and annual budget spent in the hospital. It is found significantly higher in Teaching hospital than other Health Care Institutions of Nepal. An average of 3.3 kg/day/patient of medical waste (2.0 kg/day/patient non-hazardous and 1.0 kg/day/patient hazardous waste) was generated during the study period. Further, it was found that most of the Health care wastes were not disinfected before transportation to waste disposal sites. Very limited number of Health Care Institutions had conducted Environmental Assessment. Similarly, some of the Health Care Institutions had not followed Health care waste management guideline 2009 of Nepal Government. We found poor compliance of medical waste management practice as per existing legislation of Government of Nepal. Hence, additional effort is needed for improvement of Health care waste management practice at Health Care Institutions of Nepal.

  18. Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis.

    PubMed

    Stokes, Jonathan; Panagioti, Maria; Alam, Rahul; Checkland, Kath; Cheraghi-Sohi, Sudeh; Bower, Peter

    2015-01-01

    An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care. This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the

  19. A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families

    PubMed Central

    Rangachari, Pavani

    2017-01-01

    Asthma is associated with substantial health care expenditures, including an estimated US$56 billion per year in direct costs. A recurring theme in the asthma management literature is that costly asthma symptoms, including hospitalizations and multiple emergency department (ED)/outpatient visits, can often be prevented through patient/family adherence to the national (National Institutes of Health Expert Panel Report-3) guidelines for effective self-management of asthma, specifically 1) medication adherence and 2) environmental trigger avoidance, as outlined in the patient’s personalized Asthma-Action Plan. It is important to note however that while effective self-management of asthma is known to reduce ED visits and hospitalizations, the relationship between asthma self-management effectiveness and outpatient visit frequency remains ambiguous, reflecting a gap in the literature. For instance, do patients/families who self-manage effectively visit outpatient clinics more frequently for asthma care (compared to those who do not self-manage effectively), after accounting for differences in asthma severity, demographic characteristics, and risk factors? Do patients/families who visit outpatient clinics more frequently for asthma care, in turn have fewer ED and inpatient encounters for asthma? On the other hand, do patients/families who do not revisit outpatient clinics regularly have higher ED visits and hospitalizations? It is important to address these gaps, in order to reduce the costs and public health burden of asthma. This paper provides a foundation for addressing these gaps, by conducting an integrative review of the asthma management literature, to develop a conceptual framework for measuring self-management effectiveness and health care use among pediatric asthma patients/families. In doing so, the paper lays the groundwork for future research seeking to explicate the relationship between asthma self-management effectiveness and health care use, which in

  20. A managed clinical network for cardiac services: set-up, operation and impact on patient care.

    PubMed

    Stc Hamilton, Karen E; Sullivan, Frank M; Donnan, Peter T; Taylor, Rex; Ikenwilo, Divine; Scott, Anthony; Baker, Chris; Wyke, Sally

    2005-01-01

    To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and 'bed down'. Its primary "modus operand" was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not statistically significant. There was no difference

  1. How wide is the gap in defining quality care? Comparison of patient and nurse perceptions of important aspects of patient care.

    PubMed

    Young, W B; Minnick, A F; Marcantonio, R

    1996-05-01

    The authors determine the importance that patients, nurses, and nurse managers place on aspects of care and measure nurses' care values based on their perceptions of their patients and nurse manager care values and their desire to meet these care expectations. The literature has documented gaps in how nurses and patients define quality and value specific care aspects, but little is known about the situation in the current continuous quality improvement and patient-centered care environment, which emphasizes a customer focus. Misunderstanding patients' values and expectations may impede service improvement. Information about any existing gaps could help managers begin to devise patient satisfaction improvement strategies. Two thousand fifty-one medical-surgical patients, 1264 staff members, and 97 nurse managers from 17 randomly selected hospitals participated in study activities related to selected aspects of patient care. Trained interviewers surveyed patients by telephone within 26 days of discharge using a pretested instrument. Staff members and managers completed a coordinated written tool. Descriptive and correlational statistics were used in individual and unit-level analyses. Staff members perceive correctly that patients value differently various aspects of care but do not agree with their managers on patients' value of aspects of care. Unit staff members' and managers' beliefs regarding patients' care values did not match those of their patients (-14 to 0.11 and -0.01 to 0.06 zero order correlations, respectively). A unit's errors in defining patients' values may be self-reinforcing. Strategies to reorient personnel, including adoption of those suggested by the diffusion of innovation literature, may help bridge the gap and change practice.

  2. [Managed care. Its impact on health care in the USA, especially on anesthesia and intensive care].

    PubMed

    Bauer, M; Bach, A

    1998-06-01

    Managed care, i.e., the integration of health insurance and delivery of care under the direction of one organization, is gaining importance in the USA health market. The initial effects consisted of a decrease in insurance premiums, a very attractive feature for employers. Managed care promises to contain expenditures for health care. Given the shrinking public resources in Germany, managed care seems attractive for the German health system, too. In this review the development of managed care, the principal elements, forms of organisation and practical tools are outlined. The regulation of the delivery of care by means of controlling and financial incentives threatens the autonomy of physicians: the physician must act as a "double agent", caring for the interest for the individual patient and being restricted by the contract with the managed care organisation. Cost containment by managed care was achieved by reducing the fees for physicians and hospitals (and partly by restricting care for patients). Only a fraction of this cost reduction was handed over to the enrollee or employer, and most of the money was returned with profit to the shareholders of the managed care organisations. The preeminent role of primary care physicians as gatekeepers of the health network led to a reduced demand for specialist services in general and for university hospitals and anesthesiologists in particular. The paradigm of managed care, i.e., to guide the patient and the care giver through the health care system in order to achieve cost-effective and high quality care, seems very attractive. The stress on cost minimization by any means in the daily practice of managed care makes it doubtful if managed care should be an option for the German health system, in particular because there are a number of restrictions on it in German law.

  3. A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care.

    PubMed

    Von Korff, M; Moore, J E; Lorig, K; Cherkin, D C; Saunders, K; González, V M; Laurent, D; Rutter, C; Comite, F

    1998-12-01

    Randomized, controlled trial. To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group

  4. Differences in cardiovascular disease risk factor management in primary care by sex of physician and patient.

    PubMed

    Tabenkin, Hava; Eaton, Charles B; Roberts, Mary B; Parker, Donna R; McMurray, Jerome H; Borkan, Jeffrey

    2010-01-01

    The purpose of this study was to evaluate differences in the management of cardiovascular disease (CVD) risk factors based upon the sex of the patient and physician and their interaction in primary care practice. We evaluated CVD risk factor management in 4,195 patients cared for by 39 male and 16 female primary care physicians in 30 practices in southeastern New England. Many of the sex-based differences in CVD risk factor management on crude analysis are lost once adjusted for confounding factors found at the level of the patient, physician, and practice. In multilevel adjusted analyses, styles of CVD risk factor management differed by the sex of the physician, with more female physicians documenting diet and weight loss counseling for hypertension (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.12-4.40) and obesity (OR = 2.14; 95% CI, 1.30-3.51) and more physical activity counseling for obesity (OR = 2.03; 95% CI, 1.30-3.18) and diabetes (OR = 6.55; 95% CI, 2.01-21.33). Diabetes management differed by the sex of the patient, with fewer women receiving glucose-lowering medications (OR = 0.49; 95% CI, 0.25-0.94), angiotensin-converting enzyme inhibitor therapy (OR = 0.39; 95% CI, 0.22-0.72), and aspirin prophylaxis (OR = 0.30; 95% CI, 0.15-0.58). Quality of care as measured by patients meeting CVD risk factors treatment goals was similar regardless of the sex of the patient or physician. Selected differences were found in the style of CVD risk factor management by sex of physician and patient.

  5. Involvement of a Case Manager in Palliative Care Reduces Hospitalisations at the End of Life in Cancer Patients; A Mortality Follow-Back Study in Primary Care.

    PubMed

    van der Plas, Annicka G M; Vissers, Kris C; Francke, Anneke L; Donker, Gé A; Jansen, Wim J J; Deliens, Luc; Onwuteaka-Philipsen, Bregje D

    2015-01-01

    Case managers have been introduced in primary palliative care in the Netherlands; these are nurses with expertise in palliative care who offer support to patients and informal carers in addition to the care provided by the general practitioner (GP) and home-care nurse. To compare cancer patients with and without additional support from a case manager on: 1) the patients' general characteristics, 2) characteristics of care and support given by the GP, 3) palliative care outcomes. This article is based on questionnaire data provided by GPs participating in two different studies: the Sentimelc study (280 cancer patients) and the Capalca study (167 cancer patients). The Sentimelc study is a mortality follow-back study amongst a representative sample of GPs that monitors the care provided via GPs to a general population of end-of-life patients. Data from 2011 and 2012 were analysed. The Capalca study is a prospective study investigating the implementation and outcome of the support provided by case managers in primary palliative care. Data were gathered between March 2011 and December 2013. The GP is more likely to know the preferred place of death (OR 7.06; CI 3.47-14.36), the place of death is more likely to be at the home (OR 2.16; CI 1.33-3.51) and less likely to be the hospital (OR 0.26; CI 0.13-0.52), and there are fewer hospitalisations in the last 30 days of life (none: OR 1.99; CI 1.12-3.56 and one: OR 0.54; CI 0.30-0.96), when cancer patients receive additional support from a case manager compared with patients receiving the standard GP care. Involvement of a case manager has added value in addition to palliative care provided by the GP, even though the role of the case manager is 'only' advisory and he or she does not provide hands-on care or prescribe medication.

  6. Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities.

    PubMed

    Song, Mi-Kyung; Hanson, Laura C; Gilet, Constance A; Jo, Minjeong; Reed, Teresa J; Hladik, Gerald A

    2014-09-01

    There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities. To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed. A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed. The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges. The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

  7. Information technology-enabled team-based, patient-centered care: The example of depression screening and management in cancer care.

    PubMed

    Randhawa, Gurvaneet S; Ahern, David K; Hesse, Bradford W

    2017-03-01

    The existing healthcare delivery systems across the world need to be redesigned to ensure high-quality care is delivered to all patients. This redesign needs to ensure care is knowledge-based, patient-centered and systems-minded. The rapid advances in the capabilities of information and communication technology and its recent rapid adoption in healthcare delivery have ensured this technology will play a vital role in the redesign of the healthcare delivery system. This commentary highlights promising new developments in health information technology (IT) that can support patient engagement and self-management as well as team-based, patient-centered care. Collaborative care is an effective approach to screen and treat depression in cancer patients and it is a good example of the benefits of team-based and patient-centered care. However, this approach was developed prior to the widespread adoption and use of health IT. We provide examples to illustrate how health IT can improve prevention and treatment of depression in cancer patients. We found several knowledge gaps that limit our ability to realize the full potential of health IT in the context of cancer and comorbid depression care. These gaps need to be filled to improve patient engagement; enhance the reach and effectiveness of collaborative care and web-based programs to prevent and treat depression in cancer patients. We also identify knowledge gaps in health IT design and implementation. Filling these gaps will help shape policies that enable clinical teams to deliver high-quality cancer care globally.

  8. Leading processes of patient care and treatment in hierarchical healthcare organizations in Sweden--process managers' experiences.

    PubMed

    Nilsson, Kerstin; Sandoff, Mette

    2015-01-01

    The purpose of this study is to gain better understanding of the roles and functions of process managers by describing Swedish process managers' experiences of leading processes involving patient care and treatment when working in a hierarchical health-care organization. This study is based on an explorative design. The data were gathered from interviews with 12 process managers at three Swedish hospitals. These data underwent qualitative and interpretative analysis with a modified editing style. The process managers' experiences of leading processes in a hierarchical health-care organization are described under three themes: having or not having a mandate, exposure to conflict situations and leading process development. The results indicate a need for clarity regarding process manager's responsibility and work content, which need to be communicated to all managers and staff involved in the patient care and treatment process, irrespective of department. There also needs to be an emphasis on realistic expectations and orientation of the goals that are an intrinsic part of the task of being a process manager. Generalizations from the results of the qualitative interview studies are limited, but a deeper understanding of the phenomenon was reached, which, in turn, can be transferred to similar settings. This study contributes qualitative descriptions of leading care and treatment processes in a functional, hierarchical health-care organization from process managers' experiences, a subject that has not been investigated earlier.

  9. Integrating palliative care into disease management guidelines.

    PubMed

    Emanuel, Linda; Alexander, Carla; Arnold, Robert M; Bernstein, Richard; Dart, Richard; Dellasantina, Christopher; Dykstra, Lee; Tulsky, James

    2004-12-01

    Palliative care should not be reserved for those who are close to dying; as a comprehensive approach to minimizing illness-related suffering, it is appropriate for patients with significant illness from the time of diagnosis on. The American Hospice Foundation Guidelines Committee's initiative aims to provide a practical approach for guideline writers and others to integrate palliative care into disease management and care services whenever it is relevant. A consensus approach was used to design recommendations for upgrading existing disease management and service guidelines to include palliative care. A template is described for identifying stages in disease management guidelines when integration of palliative care is appropriate: (1) Introductory sections to disease management guidelines should include prognosis and other disease consequences; (2) Diagnostic sections should include recommendations for conducting a whole patient assessment; (3) Treatment sections should include discernment of patient goals for care, continuous goal reassessment, palliative care interventions to reduce suffering as needed, and treatment decisions should include discussion of the type of expected improvement. Service guidelines should note the role of interdisciplinary team care as well as palliative care consultative or care services; (4) Sections that conclude the care provided to incurable patients should not end without recommendations on grief and bereavement care, and care during the last hours of living. The American Hospice Foundation Guidelines Committee recommends integration of relevant aspects of palliative care in introductory, diagnostic, treatment, and closing sections of management guidelines for all significant illnesses.

  10. A biopsychosocial model for the management of patients with sickle-cell disease transitioning to adult medical care.

    PubMed

    Crosby, Lori E; Quinn, Charles T; Kalinyak, Karen A

    2015-04-01

    The lifespan of patients with sickle-cell disease (SCD) continues to increase, and most affected individuals in high-resource countries now live into adulthood. This necessitates a successful transition from pediatric to adult health care. Care for transitioning patients with SCD often falls to primary care providers who may not be fully aware of the many challenges and issues faced by patients and the current management strategies for SCD. In this review, we aim to close the knowledge gap between primary care providers and specialists who treat transitioning patients with SCD. We describe the challenges and issues encountered by these patients, and we propose a biopsychosocial multidisciplinary approach to the management of the identified issues. Examples of this approach, such as transition-focused integrated care models and quality improvement collaboratives, with the potential to improve health outcomes in adulthood are also described.

  11. Nurse-patient communication in primary care diabetes management: an exploratory study

    PubMed Central

    2013-01-01

    Background Diabetes is a major health issue for individuals and for health services. There is a considerable literature on the management of diabetes and also on communication in primary care consultations. However, few studies combine these two topics and specifically in relation to nurse communication. This paper describes the nature of nurse-patient communication in diabetes management. Methods Thirty-five primary health care consultations involving 18 patients and 10 nurses were video-recorded as part of a larger multi-site study tracking health care interactions between health professionals and patients who were newly diagnosed with Type 2 diabetes. Patients and nurses were interviewed separately at the end of the 6-month study period and asked to describe their experience of managing diabetes. The analysis used ethnography and interaction analysis. In addition to analysis of the recorded consultations and interviews, the number of consultations for each patient and total time spent with nurses and other health professionals were quantified and compared. Results This study showed that initial consultations with nurses often incorporated completion of extensive checklists, physical examination, referral to other health professionals and distribution of written material, and were typically longer than consultations with other health professionals. The consultations were driven more by the nurses’ clinical agenda than by what the patient already knew or wanted to know. Interactional analysis showed that protocols and checklists both help and hinder the communication process. This contradictory outcome was also evident at a health systems level: although organisational targets may have been met, the patient did not always feel that their priorities were attended to. Both nurses and patients reported a sense of being overwhelmed arising from the sheer volume of information exchanged along with a mismatch in expectations. Conclusions Conscientious nursing work was

  12. Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial.

    PubMed

    van der Heijden, Amber A W A; de Bruijne, Martine C; Feenstra, Talitha L; Dekker, Jacqueline M; Baan, Caroline A; Bosmans, Judith E; Bot, Sandra D M; Donker, Gé A; Nijpels, Giel

    2014-06-25

    The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). Compared to usual care, managed

  13. Management of patients with Alzheimer's disease in long-term care facilities.

    PubMed

    Maas, M

    1988-03-01

    The care of residents with AD in long-term care facilities presents a number of challenges to nursing staff. The institutionalized person with AD displays a number of behaviors that are difficult to manage on traditional, integrated nursing units. In these units, behaviors such as wandering and falling are often managed by chemical and physical restraints. Multiple, complex stimuli, common on integrated units, contribute to the confusion and disorientation experienced by residents with AD. An alternative setting, the special-care unit designed specifically to meet the needs of residents with AD, has been described. Special-care units modify the environment of the traditional nursing unit to promote the safety of demented residents. The units are an attempt to reduce or control the amount of sensory stimulation in order to prevent catastrophic behaviors in the residents and maximize patient functioning. Staff on special-care units are selected specifically for their commitment to the unique care demands required by residents with AD. Ordinarily, staff in long-term care settings need specialized education to provide this care. A research project designed to evaluate the effectiveness of a special-care unit was also described. This research is valuable to residents with AD, their families, managers, and policy makers of long-term care institutions concerned with the effective use of resources. Considerable costs are involved in the construction and staffing of special-care units. However, the potential costs and threats to quality of care associated with care of residents with AD on traditional units make it imperative to evaluate the effectiveness of special-care units. With the increasing number of persons expected to develop AD, nurses, managers of long-term care facilities, and policy makers are faced with the difficult prospect of determining the most effective means of caring for these residents. Because there have been no definitive, comprehensive studies of

  14. Improving cost-effectiveness of and outcomes from drug therapy in patients with atrial fibrillation in managed care: role of the pharmacist.

    PubMed

    Johnson, Samuel G

    2009-08-01

    The medical care costs for procedures, medications, and testing associated with atrial fibrillation (AF) in the United States are high and projected to increase markedly in the future as the number of Americans affected grows. The burden on patient quality of life, the health care system, and society are pharmacoeconomic considerations in managing AF. To identify key pharmacoeconomic considerations in managing AF and describe ways in which managed care pharmacists can improve the cost-effectiveness of and outcomes from drug therapy for AF. The high medical care costs of AF are largely the result of the high cost of hospitalization and inpatient procedures. Recurrence of AF dramatically increases costs, especially for hospital care. Managed care pharmacists have many opportunities to provide cost-effective care to and improve outcomes in patients with AF. Policy and process review, population management, and case management are key strategies for improving outcomes in patients with AF. Pharmacist input into policy and process review, including pharmacy benefits design, formulary management, and the use of information technology, can help ensure that the use of drug therapy for AF is cost-effective. Population management strategies, such as development of clinical pathways and patient registries, seek to improve the quality, consistency, and cost-effectiveness of care and the likelihood that desired therapeutic outcomes are achieved through targeted interventions. Case management strategies focus on longitudinal care for individuals in order to improve quality. Pharmacist-managed anticoagulation services and antiarrhythmic drug monitoring are the 2 most widely known case management strategies for patients with AF. Managed care pharmacists can screen patients with AF for the use of anticoagulation, which is needed to prevent embolic stroke but is under-used, even though recommended by evidence-based guidelines. The clinical efficacy and cost-effectiveness of

  15. Resource costs for asthma-related care among pediatric patients in managed care.

    PubMed

    Gendo, Karna; Sullivan, Sean D; Lozano, Paula; Finkelstein, Jonathan A; Fuhlbrigge, Anne; Weiss, Kevin B

    2003-09-01

    In 1998, the economic burden of asthma in the United States was estimated to be 12.7 billion dollars. Yet few studies have examined the relationship between the total costs of asthma-related care and measures of asthma morbidity. Understanding the relationship between total costs of asthma-related care and morbidity can assist in designing the most cost-effective asthma care strategies to improve patient outcomes and minimize total costs. To investigate correlates of asthma costs for children with mild-to-moderate persistent asthma and, specifically, to characterize how closely the percentage of predicted forced expiratory volume in 1 second (FEV1) and symptom days were correlated with costs of illness. A total of 638 parents and children with mild-to-moderate persistent asthma in 4 managed care delivery systems in 3 different US geographic regions were enrolled. Symptom burden and annual resource utilization were determined from reports of physician visits, hospitalizations, emergency department visits, medication use, and parental missed workdays. Spirometry was conducted on children who were 5 years and older. To characterize the relationship between symptom days and the percentage of predicted FEV1 with costs, we specified a multivariate regression model. The median total annual asthma-related cost for the group was 564 dollars (interquartile range [IQR], 131 dollars-1602 dollars). Indirect costs represented 54.6% of total costs. Medicines accounted for 52.6% of direct costs. The mean percentage of predicted FEV1 was 101.6% (range, 39.3%-183.5%; IQR, 91.6%-111.3%), with 91.4% of patients with a percentage of predicted FEV1 of more than 80%. Based on multivariate modeling, increasing asthma severity, use of peak expiratory flow rate meters, younger age, low-income status and nonwhite race, and longer duration of asthma were significantly associated with increasing cost. Symptom days (P < 0.001) predicted annual costs better than percentage of predicted FEV1 (P

  16. A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

    PubMed

    Steuten, L M G; Vrijhoef, H J M; Landewé-Cleuren, S; Schaper, N; Van Merode, G G; Spreeuwenberg, C

    2007-10-01

    To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. Single-group, pre-post design with 2-year follow-up in 473 patients. Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

  17. Managed care strategy for mental health services.

    PubMed

    Jones, A

    In the UK, managed care is beginning to be recognized as a cost effective, quality-driven system which can be used to structure patient care. This article examines the potential use of managed care pathways in mental health services, focusing on clients with schizophrenia. The strengths of managed care include the effective coordination of healthcare resources, the clear accountable audit of mental health practice and the re-engineering of mental health practice to improve patient outcomes. Problems in designing representative care pathways and encouraging healthcare providers to implement care pathways are some of the disadvantages of this system.

  18. Involvement of a Case Manager in Palliative Care Reduces Hospitalisations at the End of Life in Cancer Patients; A Mortality Follow-Back Study in Primary Care

    PubMed Central

    van der Plas, Annicka G. M.; Vissers, Kris C.; Francke, Anneke L.; Donker, Gé A.; Jansen, Wim J. J.; Deliens, Luc; Onwuteaka-Philipsen, Bregje D.

    2015-01-01

    Background Case managers have been introduced in primary palliative care in the Netherlands; these are nurses with expertise in palliative care who offer support to patients and informal carers in addition to the care provided by the general practitioner (GP) and home-care nurse. Objectives To compare cancer patients with and without additional support from a case manager on: 1) the patients’ general characteristics, 2) characteristics of care and support given by the GP, 3) palliative care outcomes. Methods This article is based on questionnaire data provided by GPs participating in two different studies: the Sentimelc study (280 cancer patients) and the Capalca study (167 cancer patients). The Sentimelc study is a mortality follow-back study amongst a representative sample of GPs that monitors the care provided via GPs to a general population of end-of-life patients. Data from 2011 and 2012 were analysed. The Capalca study is a prospective study investigating the implementation and outcome of the support provided by case managers in primary palliative care. Data were gathered between March 2011 and December 2013. Results The GP is more likely to know the preferred place of death (OR 7.06; CI 3.47-14.36), the place of death is more likely to be at the home (OR 2.16; CI 1.33-3.51) and less likely to be the hospital (OR 0.26; CI 0.13-0.52), and there are fewer hospitalisations in the last 30 days of life (none: OR 1.99; CI 1.12-3.56 and one: OR 0.54; CI 0.30-0.96), when cancer patients receive additional support from a case manager compared with patients receiving the standard GP care. Conclusions Involvement of a case manager has added value in addition to palliative care provided by the GP, even though the role of the case manager is ‘only’ advisory and he or she does not provide hands-on care or prescribe medication. PMID:26208099

  19. How will computerization revolutionize managed care?

    PubMed

    Trabin, T

    1994-01-01

    Computerization of behavioral health care information systems is revolutionizing how payors, managed care companies, and providers exchange information. In this article, an imaginary scenario is depicted of how patient data will be accessed and communicated to facilitate care management of behavioral health care services in the near future.

  20. A Patient-Centered Transitional Care Case Management Program: Taking Case Management to the Streets and Beyond.

    PubMed

    Lovelace, Derenda; Hancock, Diane; Hughes, Sabrina S; Wyche, Phyllis R; Jenkins, Claire; Logan, Cindy

    In 2011, the Hunter Holmes McGuire Veterans Administration Medical Center (VAMC) in Richmond, VA, had a cumulative readmission rate and emergency department (ED) revisits for discharged Veterans of 1 in 5. In 2012, a transitional care program (TCP) was implemented to improve care coordination and outcomes among Veterans, with an emphasis on geriatric patients with chronic disease. This TCP was created with an interdisciplinary approach using intensive case management interventions, with a goal of reducing Veteran ED and hospital revisits by 30%. To examine the impact of the McGuire VAMC TCP on Veteran ED and hospital utilization and costs. Veterans being discharged to home following an inpatient admission, ED visit, and/or short rehab stay. The primary means of identifying patients for the program is through daily screening of the previous 24-hour admission and ED report, which the inpatient nurse practitioner performs. She completes an extensive review of each Veteran's electronic medical record to determine the number of ED visits and inpatient admissions at the VAMC and in the community. Initial criteria for consideration in the program included the following: more than two hospital admissions and/or ED visits in the past 90 days or at high risk for readmission based on a Care Assessment Need score of greater than 95. Two hundred Veterans participated in the program in fiscal year (FY) 2013, with 146 participating in FY 2014. A retrospective chart review of Veterans participating in the TCP in FYs 2013 and 2014 was conducted, with a focus on number of admissions and ED visits 90 days prior to admission to the TCP and 90 days following TCP admission. Average admission and ED costs for this VA were calculated to determine cost savings from pre- to post-90 days of admission and ED visits. Veterans who obtained TCP services in FYs 2013 and 2014 experienced a 67% decrease in hospital admissions and a 61% decrease in ED visits in the 90 days following participation in

  1. The primary-specialty care interface in chronic diseases: patient and practice characteristics associated with co-management.

    PubMed

    Larochelle, Jean-Louis; Feldman, Debbie Ehrmann; Levesque, Jean-Frederic

    2014-11-01

    Specialist physicians may act either as consultants or co-managers for patients with chronic diseases along with their primary healthcare (PHC) physician. We assessed factors associated with specialist involvement. We used questionnaire and administrative data to measure co-management and patient and PHC practice characteristics in 702 primary care patients with common chronic diseases. Analysis included multilevel logistic regressions. In all, 27% of the participants were co-managed. Persons with more severe chronic diseases and lower health-related quality of life were more likely to be co-managed. Persons who were older, had a lower socioeconomic status, resided in rural regions and who were followed in a PHC practice with an advanced practice nurse were less likely to be co-managed. Co-management of patients with chronic diseases by a specialist is associated with higher clinical needs but demonstrates social inequalities. PHC practices more adapted to chronic care may help optimize specialist resources utilization. Copyright © 2014 Longwoods Publishing.

  2. The Primary-Specialty Care Interface in Chronic Diseases: Patient and Practice Characteristics Associated with Co-Management

    PubMed Central

    Larochelle, Jean-Louis; Feldman, Debbie Ehrmann; Levesque, Jean-Frederic

    2014-01-01

    Objective: Specialist physicians may act either as consultants or co-managers for patients with chronic diseases along with their primary healthcare (PHC) physician. We assessed factors associated with specialist involvement. Methods: We used questionnaire and administrative data to measure co-management and patient and PHC practice characteristics in 702 primary care patients with common chronic diseases. Analysis included multilevel logistic regressions. Results In all, 27% of the participants were co-managed. Persons with more severe chronic diseases and lower health-related quality of life were more likely to be co-managed. Persons who were older, had a lower socioeconomic status, resided in rural regions and who were followed in a PHC practice with an advanced practice nurse were less likely to be co-managed. Discussion: Co-management of patients with chronic diseases by a specialist is associated with higher clinical needs but demonstrates social inequalities. PHC practices more adapted to chronic care may help optimize specialist resources utilization. PMID:25617515

  3. Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service.

    PubMed

    Gillett, K; Lippiett, K; Astles, C; Longstaff, J; Orlando, R; Lin, S X; Powell, A; Roberts, C; Chauhan, A J; Thomas, M; Wilkinson, T M

    2016-01-01

    In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating. To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review. 82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting β 2 -agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86. Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.

  4. The role of the multidisciplinary health care team in the management of patients with Marfan syndrome

    PubMed Central

    von Kodolitsch, Yskert; Rybczynski, Meike; Vogler, Marina; Mir, Thomas S; Schüler, Helke; Kutsche, Kerstin; Rosenberger, Georg; Detter, Christian; Bernhardt, Alexander M; Larena-Avellaneda, Axel; Kölbel, Tilo; Debus, E Sebastian; Schroeder, Malte; Linke, Stephan J; Fuisting, Bettina; Napp, Barbara; Kammal, Anna Lena; Püschel, Klaus; Bannas, Peter; Hoffmann, Boris A; Gessler, Nele; Vahle-Hinz, Eva; Kahl-Nieke, Bärbel; Thomalla, Götz; Weiler-Normann, Christina; Ohm, Gunda; Neumann, Stefan; Benninghoven, Dieter; Blankenberg, Stefan; Pyeritz, Reed E

    2016-01-01

    Marfan syndrome (MFS) is a rare, severe, chronic, life-threatening disease with multiorgan involvement that requires optimal multidisciplinary care to normalize both prognosis and quality of life. In this article, each key team member of all the medical disciplines of a multidisciplinary health care team at the Hamburg Marfan center gives a personal account of his or her contribution in the management of patients with MFS. The authors show how, with the support of health care managers, key team members organize themselves in an organizational structure to create a common meaning, to maximize therapeutic success for patients with MFS. First, we show how the initiative and collaboration of patient representatives, scientists, and physicians resulted in the foundation of Marfan centers, initially in the US and later in Germany, and how and why such centers evolved over time. Then, we elucidate the three main structural elements; a team of coordinators, core disciplines, and auxiliary disciplines of health care. Moreover, we explain how a multidisciplinary health care team integrates into many other health care structures of a university medical center, including external quality assurance; quality management system; clinical risk management; center for rare diseases; aorta center; health care teams for pregnancy, for neonates, and for rehabilitation; and in structures for patient centeredness. We provide accounts of medical goals and standards for each core discipline, including pediatricians, pediatric cardiologists, cardiologists, human geneticists, heart surgeons, vascular surgeons, vascular interventionists, orthopedic surgeons, ophthalmologists, and nurses; and of auxiliary disciplines including forensic pathologists, radiologists, rhythmologists, pulmonologists, sleep specialists, orthodontists, dentists, neurologists, obstetric surgeons, psychiatrist/psychologist, and rehabilitation specialists. We conclude that a multidisciplinary health care team is a means

  5. Strategies for positioning in the managed health care marketplace.

    PubMed

    Cohn, R

    1994-01-01

    Managed health care is becoming increasingly common as the demands of cost containment are placed on providers of care. This article defines managed health care, illustrates its continued growth, demonstrates its effect on clinical decision making and reimbursement issues, and suggests strategies for optimal positioning in the managed care marketplace. The hand therapy specialist, whether based in a hospital, an institution-based ambulatory care setting, or a private practice, must be aware of a managed plan's contractual limitations. Parameters discussed are patient length of stay, documentation, reimbursement, patient responsibility, alternatives to conventional treatment protocols, and the potential effects of utilization review on patient treatment. A heightened awareness of managed health care is critical for the manager and practitioner, especially because national health care reform is on the horizon. A provider must be well prepared to ensure delivery of quality care within the myriad restrictions imposed by managed care regulations.

  6. Formative Evaluation of Care Nexus: a Tool for the Visualization and Management of Care Teams of Complex Pediatric Patients

    PubMed Central

    Ranade-Kharkar, Pallavi; Norlin, Chuck; Del Fiol, Guilherme

    2017-01-01

    Complex and chronic conditions in pediatric patients with special needs often result in large and diverse patient care teams. Having a comprehensive view of the care teams is crucial to achieving effective and efficient care coordination for these vulnerable patients. In this study, we iteratively design and develop two alternative user interfaces (graphical and tabular) of a prototype of a tool for visualizing and managing care teams and conduct a formative assessment of the usability, usefulness, and efficiency of the tool. The median time to task completion for the 21 study participants was less than 7 seconds for 19 out of the 22 usability tasks. While both the prototype formats were well-liked in terms of usability and usefulness, the tabular format was rated higher for usefulness (p=0.02). Inclusion of CareNexus-like tools in electronic and personal health records has the potential to facilitate care coordination in complex pediatric patients. PMID:29854215

  7. Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers.

    PubMed

    Taylor, Erin Fries; Machta, Rachel M; Meyers, David S; Genevro, Janice; Peikes, Deborah N

    2013-01-01

    Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.

  8. Constraints faced by urban poor in managing diabetes care: patients' perspectives from South India.

    PubMed

    Bhojani, Upendra; Mishra, Arima; Amruthavalli, Subramani; Devadasan, Narayanan; Kolsteren, Patrick; De Henauw, Stefaan; Criel, Bart

    2013-10-03

    Four out of five adults with diabetes live in low- and middle-income countries (LMIC). India has the second highest number of diabetes patients in the world. Despite a huge burden, diabetes care remains suboptimal. While patients (and families) play an important role in managing chronic conditions, there is a dearth of studies in LMIC and virtually none in India capturing perspectives and experiences of patients in regard to diabetes care. The objective of this study was to better understand constraints faced by patients from urban slums in managing care for type 2 diabetes in India. We conducted in-depth interviews, using a phenomenological approach, with 16 type 2- diabetes patients from a poor urban neighbourhood in South India. These patients were selected with the help of four community health workers (CHWs) and were interviewed by two trained researchers exploring patients' experiences of living with and seeking care for diabetes. The sampling followed the principle of saturation. Data were initially coded using the NVivo software. Emerging themes were periodically discussed among the researchers and were refined over time through an iterative process using a mind-mapping tool. Despite an abundance of healthcare facilities in the vicinity, diabetes patients faced several constraints in accessing healthcare such as financial hardship, negative attitudes and inadequate communication by healthcare providers and a fragmented healthcare service system offering inadequate care. Strongly defined gender-based family roles disadvantaged women by restricting their mobility and autonomy to access healthcare. The prevailing nuclear family structure and inter-generational conflicts limited support and care for elderly adults. There is a need to strengthen primary care services with a special focus on improving the availability and integration of health services for diabetes at the community level, enhancing patient centredness and continuity in delivery of care. Our

  9. Centralized care management support for "high utilizers" in primary care practices at an academic medical center.

    PubMed

    Williams, Brent C; Paik, Jamie L; Haley, Laura L; Grammatico, Gina M

    2014-01-01

    Although evidence of effectiveness is limited, care management based outside primary care practices or hospitals is receiving increased attention. The University of Michigan (UM) Complex Care Management Program (CCMP) provides care management for uninsured and underinsured, high-utilizing patients in multiple primary care practices. To inform development of optimal care management models, we describe the CCMP model and characteristics and health care utilization patterns of its patients. Of a consecutive series of 49 patients enrolled at CCMP in 2011, the mean (SD) age was 48 (+/- 14); 23 (47%) were women; and 29 (59%) were White. Twenty-eight (57%) had two or more chronic medical conditions, 39 (80%) had one or more psychiatric condition, 28 (57%) had a substance abuse disorder, and 11 (22%) were homeless. Through phone, e-mail, and face-to-face contact with patients and primary care providers (PCPs), care managers coordinated health and social services and facilitated access to medical and mental health care. Patients had a mean (SD) number of hospitalizations and emergency room (ER) visits in 6 months prior to enrollment of2.2 (2.5) and 4.2 (4.3), respectively, with a nonstatistically significant decrease in hospitalizations, hospital days, and emergency room visits in 6 months following enrollment in CCMP. Centralized care management support for primary care practices engages high-utilizing patients with complex medical and behavioral conditions in care management that would be difficult to provide through individual practices and may decrease health care utilization by these patients.

  10. Networking and data management for health care monitoring of mobile patients.

    PubMed

    Amato, Giuseppe; Chessa, Stefano; Conforti, Fabrizio; Macerata, Alberto; Marchesi, Carlo

    2005-01-01

    The problem of medical devices and data integration in health care is discussed and a proposal for remote monitoring of patients based on recent developments in networking and data management is presented. In particular the paper discusses the benefits of the integration of personal medical devices into a Medical Information System and how wireless sensor networks and open protocols could be employed as building blocks of a patient monitoring system.

  11. Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care.

    PubMed

    Rueda-Clausen, C F; Benterud, E; Bond, T; Olszowka, R; Vallis, M T; Sharma, A M

    2014-02-01

    Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity. Obesity counselling is rare, and when it does occur, it is often of low quality because of poor training and/or competency of providers' obesity management, lack of time and economical disincentives, and negative attitude towards obesity and obesity management. 5As frameworks are routinely used for behaviour-change counselling and addiction management (e.g. smoking cessation), but few studies have examined its efficacy for weight management. This study presents pilot data from the implementation and evaluation of an obesity management tool (5As of Obesity Management developed by the Canadian Obesity Network) in a primary care setting. Results show that the tool facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care. Obesity remains poorly managed in primary care. The 5As of Obesity Management is a theory-driven, evidence-based minimal intervention designed to facilitate obesity counselling and management by primary care practitioners. This project tested the impact of implementing this tool in primary care clinics. Electronic self-administered surveys were completed by pre-screened obese subjects at the end of their appointments in four primary care clinics (over 25 healthcare providers [HCPs]). These measurements were performed before (baseline, n = 51) and 1 month after implementing the 5As of Obesity Management (post-intervention, n = 51). Intervention consisted of one online training session (90 min) and distribution of the 5As toolkit to HCPs of participating clinics. Subjects completing the survey before and after the intervention were comparable in terms of age, sex, body mass index, comorbidities, satisfaction and self-reported health status (P > 0.2). Implementing the 5As of Obesity Management resulted in a twofold increase

  12. Eliciting Provider and Patient Perspectives on New Obesity Management Services in a Team-Based Primary Care Organization.

    PubMed

    Royall, Dawna; Brauer, Paula; Atta-Konadu, Edwoba; Dwyer, John J M; Edwards, A Michelle; Hussey, Tracy; Kates, Nick

    2017-09-01

    Both providers and patients may have important insights to inform the development of obesity prevention and management services in Canadian primary care settings. In this formative study, insights for new obesity management services were sought from both providers and patients in 1 progressive citywide organization (150 physicians, team services, separate offices). Seven focus groups with interprofessional health providers (n = 56) and 4 focus groups with patients (n = 34) were conducted. Two clinical vignettes (adult, child) were used to focus discussion. Four analysts coded for descriptive content and interpretative themes on possible tools and care processes using NVivo. Participants identified numerous strategies for care processes, most of which could be categorized into 1 or more of 11 themes: 6 directed at clinical care of patients (raising awareness, screening, clinical care, skill building, ongoing support, and social/peer support) and 5 directed at the organization (coordination/collaboration, creating awareness among health professionals, adding new expertise to the team, marketing, and lobbying/advocacy). The approach was successful in generating an extensive list of diverse activities to be considered for implementation studies. Both patients and providers identified that multiple strategies and systems approaches will be needed to address obesity management in primary care.

  13. Patient contributions during primary care consultations for hypertension after self-reporting via a mobile phone self-management support system.

    PubMed

    Bengtsson, Ulrika; Kjellgren, Karin; Hallberg, Inger; Lundin, Mona; Mäkitalo, Åsa

    2018-03-01

    This paper reports on how the clinical consultation in primary care is performed under the new premises of patients' daily self-reporting and self-generation of data. The aim was to explore and describe the structure, topic initiation and patients' contributions in follow-up consultations after eight weeks of self-reporting through a mobile phone-based hypertension self-management support system. A qualitative, explorative study design was used, examining 20 audio- (n = 10) and video-recorded (n = 10) follow-up consultations in primary care hypertension management, through interaction analysis. Clinical trials registry: ClinicalTrials.gov NCT01510301. Four primary health care centers in Sweden. Patients with hypertension (n = 20) and their health care professional (n = 7). The consultations comprised three phases: opening, examination and closing. The most common topic was blood pressure (BP) put in relation to self-reported variables, for example, physical activity and stress. Topic initiation was distributed symmetrically between parties and BP talk was lifestyle-centered. The patients' contributed to the interpretation of BP values by connecting them to specific occasions, providing insights to the link between BP measurements and everyday life activities. Patients' contribution through interpretations of BP values to specific situations in their own lives brought on consultations where the patient as a person in context became salient. Further, the patients' and health care professionals' equal contribution during the consultations showed actively involved patients. The mobile phone-based self-management support system can thus be used to support patient involvement in consultations with a person-centered approach in primary care hypertension management Key points   The clinical consultation is important to provide opportunities for patients to gain understanding of factors affecting high blood pressure, and for health care professionals to

  14. Partnered research in healthcare delivery redesign for high-need, high-cost patients: development and feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT).

    PubMed

    Zulman, Donna M; Ezeji-Okoye, Stephen C; Shaw, Jonathan G; Hummel, Debra L; Holloway, Katie S; Smither, Sasha F; Breland, Jessica Y; Chardos, John F; Kirsh, Susan; Kahn, James S; Asch, Steven M

    2014-12-01

    We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system. Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients. HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project. Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system. Employing partnered research to redesign care for high-need, high

  15. Respiratory care management information systems.

    PubMed

    Ford, Richard M

    2004-04-01

    Hospital-wide computerized information systems evolved from the need to capture patient information and perform billing and other financial functions. These systems, however, have fallen short of meeting the needs of respiratory care departments regarding work load assessment, productivity management, and the level of outcome reporting required to support programs such as patient-driven protocols. The respiratory care management information systems (RCMIS) of today offer many advantages over paper-based systems and hospital-wide computer systems. RCMIS are designed to facilitate functions specific to respiratory care, including assessing work demand, assigning and tracking resources, charting, billing, and reporting results. RCMIS incorporate mobile, point-of-care charting and are highly configurable to meet the specific needs of individual respiratory care departments. Important and substantial benefits can be realized with an RCMIS and mobile, wireless charting devices. The initial and ongoing costs of an RCMIS are justified by increased charge capture and reduced costs, by way of improved productivity and efficiency. It is not unusual to recover the total cost of an RCMIS within the first year of its operation. In addition, such systems can facilitate and monitor patient-care protocols and help to efficiently manage the vast amounts of information encountered during the practitioner's workday. Respiratory care departments that invest in RCMIS have an advantage in the provision of quality care and in reducing expenses. A centralized respiratory therapy department with an RCMIS is the most efficient and cost-effective way to monitor work demand and manage the hospital-wide allocation of respiratory care services.

  16. [Primary care evaluation of the hypertensive patient management in specialized care after derivation (DERIVA-2 Study)].

    PubMed

    Martell-Claros, Nieves; Galgo Nafría, Alberto; Abad-Cardiel, María; Álvarez-Álvarez, Beatriz; García Donaire, José Antonio; Márquez-Contreras, Emilio; Molino-González, Ángel

    2017-10-13

    To know the opinion/evaluation of the primary care physicians (PCPH) of the received information about patients that were attended in specialized care (SC). Cross-sectional study. Performed nationwide in primary care centers. Researchers from the primary care network. We used the SEH-LELHA derivation criteria guidelines, plus an ad hoc survey that included demographic and anthropometric data, blood pressure levels, and the main reason for derivation to SC at the baseline and final (post-derivation) visit. In addition, time deployed for the study of every patient, changes in diagnosis and treatment, type of follow-up, issues throughout the derivation process and assessment of the medical referred to the PCPH were evaluated. With participation of 578 researchers from primary, the study included 1715 patients aged 60.7±13.3years, 62.7% male. Patients were taking 2.3±1.2 (range 0-10) antihypertensive drugs pre-referral and 2.5±1.2 (0-9) after derivation. Blood pressure levels changed from 166±21.6 /97.7±12.6mmHg to 143±14.4 /85.5±10.5mmHg. The number of controlled patients (BP<140 and <90mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72±64days (median 57days, IQ26-99). The PCPH received a medical report in 80.3% of cases, 76.9% with an explanation of the results of the complementary tests, 75.8% with additional information or a reasoning of treatment and in 71% of cases information about the patient future management. 63% of PCPH were fully agreed with the management of the specialist, 29% agree and 2% strongly disagree. The derivation was evaluated as effective or very effective in 86% of patients and no effective in 9%. Communication between AE and SC in HTA is valued satisfactorily by MAP. However there is still room for improvement in the process. Copyright © 2017. Publicado por Elsevier España, S.L.U.

  17. A managed clinical network for cardiac services: set-up, operation and impact on patient care

    PubMed Central

    E StC Hamilton, Karen; M Sullivan, Frank; T Donnan, Peter; Taylor, Rex; Ikenwilo, Divine; Scott, Anthony; Baker, Chris; Wyke, Sally

    2005-01-01

    Abstract Purpose To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. Methods This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. Results Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and ‘bed down’. Its primary “modus operand” was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were not

  18. Perceived Impact of Care Managers’ Work on Patient and Clinician Outcomes

    PubMed Central

    Carayon, Pascale; Hundt, Ann Schoofs; Hoonakker, Peter; Kianfar, Sarah; Alyousef, Bashar; Salek, Doreen; Cartmill, Randi; Walker, James M.; Tomcavage, Janet

    2015-01-01

    Objectives The aim of this study is to assess the contributions of care management as perceived by care managers themselves. Study Design Focus groups and interviews with care managers who coordinate care for chronic obstructive pulmonary disease and congestive heart failure patients, as well as patients undergoing major surgery. Methods We collected data in focus groups and interviews with 12 care managers working in the Keystone Beacon Community project, including 5 care managers working in hospitals, 2 employed in outpatient clinics and 4 telephoning discharged patients from a Transitions of Care (TOC) call center. Results Inpatient care managers believe that (1) ensuring primary care provider follow-up, (2) coordinating appropriate services, (3) providing patient education, and (4) ensuring accurate medication reconciliation have the greatest impact on patient clinical outcomes. In contrast, outpatient and TOC care managers believe that (1) teaching patients the signs and symptoms of acute exacerbations and (2) building effective relationships with patients improve patient outcomes most. Some care management activities were perceived to have greater impact on patients with certain conditions (e.g., outpatient and TOC care managers saw effective relationships as having more impact on patients with COPD). All care managers believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction. Conclusions These findings may improve best practice for care managers by focusing interventions on the most effective activities for patients with specific medical conditions. PMID:26273476

  19. [Pain management in home hospice care].

    PubMed

    Sakai, T; Sato, A

    1998-12-01

    Among 35 cases with terminal home care cancer patients, 23 (65.7%) cases developed pain. Twenty of these cases (87%) were treated with morphine. MS-contin and Anpec (suppositorium) were given to the patients. The two forms were jointly administered in 20% of them. NSAIDS and other adjuvant analgesics were given to 85% of them. Average dose of morphine were 173.5 +/- 357.5 mg. Adverse morphine side effects were treated with medication. In any case morphine administration was not discontinued due to its adverse effects. Some 82% of the patients died at home. No case dropped out of home care due to unsuccessful pain management. Successful pain management is necessary to implement home terminal care, and both patient and family should fully understand the status and prognosis of the incurable disease. Moreover, medical professionals (home care doctors, home care nurses and hospital doctors) should collaborate to form the temporal, adequate and seamless networking in caring and supporting terminal patients and their families.

  20. Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial

    PubMed Central

    2014-01-01

    Background The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. Methods In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. Results Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not

  1. Managing obesity in primary care.

    PubMed

    Goldie, Christine; Brown, Jenny

    Obesity is a complex problem and often difficult to tackle in primary care. A year-long pilot of a practice nurse-led scheme that used a holistic approach towards self-care in obesity management was set up to reduce the cardiovascular risk of patients who were obese and improve their quality of life. This person-centred approach may offer an important tool in the management of these patients in the GP surgery.

  2. [Contribution of Perioperative Oral Health Care and Management for Patients who Underwent General Thoracic Surgery].

    PubMed

    Saito, Hajime; Minamiya, Yoshihiro

    2016-01-01

    Due to the recent advances in radiological diagnostic technology, the role of video-assisted thoracoscopic surgery in thoracic disease has expanded, surgical indication extended to the elderly patients. Cancer patients receiving surgery, radiation therapy and/or chemotherapy may encounter complications in conjunction with the oral cavity such as aspiration pneumonia, surgical site infection and various type of infection. Recently, it is recognized that oral health care management is effective to prevent the postoperative infectious complications, especially pneumonia. Therefore, oral management should be scheduled before start of therapy to prevent these complications as supportive therapy of the cancer treatment. In this background, perioperative oral function management is highlighted in the remuneration for dental treatment revision of 2012,and the importance of oral care has been recognized in generally. In this manuscript, we introduce the several opinions and evidence based on the recent previous reports about the perioperative oral health care and management on thoracic surgery.

  3. Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore.

    PubMed

    Tan, Lester Teong Jin; Wong, Seng Joung; Kwek, Ernest Beng Kee

    2017-03-01

    The estimated incidence of hip fractures worldwide was 1.26 million in 1990 and is expected to double to 2.6 million by 2025. The cost of care for hip fracture patients is a significant economic burden. This study aimed to look at the inpatient cost of hip fractures among elderly patients placed under a mature orthogeriatric co-managed system. This study was a retrospective analysis of 244 patients who were admitted to the Department of Orthopaedics of Tan Tock Seng Hospital, Singapore, in 2011 for hip fractures under a mature orthogeriatric hip fracture care path. Information regarding costs, surgical procedures performed and patient demographics was collected. The mean cost of hospitalisation was SGD 13,313.81. The mean cost was significantly higher for the patients who were managed surgically than for the patients who were managed non-surgically (SGD 14,815.70 vs. SGD 9,011.38; p < 0.01). Regardless of whether surgery was performed, the presence of complications resulted in a higher average cost (SGD 2,689.99 more than if there were no complications; p = 0.011). Every additional day from admission to time of surgery resulted in an increased cost of SGD 575.89, and the difference between the average cost of surgery within 48 hours and that of surgery > 48 hours was SGD 2,716.63. Reducing the time to surgery and preventing pre- and postoperative complications can help reduce overall costs. A standardised care path that empowers allied health professionals can help to reduce perioperative complications, and a combined orthogeriatric care service can facilitate prompt surgical treatment. Copyright: © Singapore Medical Association

  4. Do critical care units play a role in the management of gynaecological oncology patients? The contribution of gynaecologic oncologist in running critical care units.

    PubMed

    Davidovic-Grigoraki, Miona; Thomakos, Nikolaos; Haidopoulos, Dimitrios; Vlahos, Giorgos; Rodolakis, Alexandros

    2017-03-01

    Routine post-operative care in high dependency unit (HDU), surgical intensive care unit (SICU) and intensive care unit (ICU) after high-risk gynaecological oncology surgical procedures may allow for greater recognition and correct management of post-operative complications, thereby reducing long-term morbidity and mortality. On the other hand, unnecessary admissions to these units lead to increased morbidity - nosocomial infections, increased length of hospital stay and higher hospital costs. Gynaecological oncology surgeons continue to look after their patient in the HDU/SICU and have the final role in decision-making on day-to-day basis, making it important to be well versed in critical care management and ensure the best care for their patients. Post-operative monitoring and the presence of comorbid illnesses are the most common reasons for admission to the HDU/SICU. Elderly and malnutritioned patients, as well as, bowel resection, blood loss or greater fluid resuscitation during the surgery have prolonged HDU/SICU stay. Patients with ovarian cancer have a worse survival outcome than the patients with other types of gynaecological cancer. Dependency care is a part of surgical management and it should be incorporated formally into gynaecologic oncology training programme. © 2016 John Wiley & Sons Ltd.

  5. Patient satisfaction and loyalty among military healthcare beneficiaries enrolled in a managed care program.

    PubMed

    Jennings, B M; Loan, L A

    1999-11-01

    A study was performed to evaluate military beneficiaries' motivation for choosing to change from a civilian managed care system to the military managed care system. Concerns about healthcare cost, quality, and access underpin major reform in military healthcare. The military health system (MHS) is implementing managed care through an initiative known as TRICARE. Patient choice and satisfaction are highly relevant to all healthcare delivery systems; they are being explored aggressively in the MHS as TRICARE evolves. This descriptive study was conducted using a telephone survey consisting of 63 items derived from four pre-existing instruments as well as five facility-specific questions and demographics. The population of interest targeted military beneficiaries on a TRICARE waiting list who, at the time of enrollment, indicated a desire to receive care at the military facility. Consumers were inclined to return to the military system because of loyalty. Also, this study provided evidence that staff courtesy is important to those who seek healthcare. Good quality and accessibility were verified as essential elements in sustaining a consumer's positive view of and attraction to a particular healthcare system. Cost was proven to be a less substantial factor of consumer decision making. Surveys such as this give healthcare providers more information about aspects of care, such as patient loyalty and interpersonal dynamics, that attract people to their healthcare delivery systems. For healthcare systems to thrive, consumer influence and the power of patient dissatisfaction must be understood.

  6. Shared Care: A Quality Improvement Initiative to Optimize Primary Care Management of Constipation

    PubMed Central

    Vernacchio, Louis; Trudell, Emily; Antonelli, Richard; Nurko, Samuel; Leichtner, Alan M.; Lightdale, Jenifer R.

    2015-01-01

    BACKGROUND: Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children’s Hospital and the Pediatric Physician’s Organization at Children’s (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. METHODS: We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children’s Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS: Fewer active patients in the sample were referred after implementation (61/27 365 [0.22%] vs 90/27 792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals. CONCLUSIONS: A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration. PMID:25896837

  7. Managed care: rationing without justice, but not unjustly.

    PubMed

    Buchanan, A

    1998-08-01

    Three ethical criticisms of managed care are often voiced: (1) by "skimming the cream" of the patient population, managed care organizations fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that each of these criticisms is misconceived. The first rests on the false assumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning access to managed care organizations. The second and third criticisms wrongly assume that we in the United States have taken the first step toward assuring equitable access to care for all, articulating a standard for what counts as an "adequate level of care" to which all are entitled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institutional setting within which no connection can be made between the activity of rationing and the basic requirements of justice.

  8. Managing the oncologic patient with suspected pneumonia in the intensive care unit.

    PubMed

    Leoni, D; Encina, B; Rello, J

    2016-10-01

    Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research. This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.

  9. Outcomes of Embedded Care Management in a Family Medicine Residency Patient-Centered Medical Home.

    PubMed

    Newman, Robert J; Bikowski, Richard; Nakayama, Kristy; Cunningham, Tina; Acker, Pam; Bradshaw, Dana

    2017-01-01

    Much attention is devoted nationally to preventing hospital readmissions and emergency department (ED) use, given the high cost of this care. There is a growing body of evidence from the Patient Centered Primary Care Collaborative that a patient-centered medical home (PCMH) model successfully lowers these costs. Our study evaluates a specific intervention in a family medicine residency PCMH to decrease readmissions and ED utilization using an embedded care manager. The Department of Family and Community Medicine at Eastern Virginia Medical School in Norfolk, VA, hired an RN care manager in May of 2013 with a well-defined job description focused on decreasing hospital readmissions and ED usage. Our primary outcomes for the study were number of monthly hospital admissions and readmissions over 23 months and monthly ED visits over 20 months. Readmission rates averaged 22.2% per month in the first year of the intervention and 18.3% in the second year, a statistically significant 3.9% decrease. ED visits averaged 176 per month in the first year and 146 per month in the second year, a statistically significant 17% reduction. Our study adds to the evidence that a PCMH model of care with an embedded RN care manager can favorably lower readmission rates and ED utilization in a family medicine residency practice. Developing a viable business model to support this important work remains a challenge.

  10. Managing hyperkalemia in high-risk patients in long-term care.

    PubMed

    Kumar, Rajeev; Kanev, Leo; Woods, Steven D; Brenner, Melanie; Smith, Bernie

    2017-02-01

    Hyperkalemia is common among elderly patients and is associated with an increase in morbidity and mortality. Patients at highest risk for developing hyperkalemia are those with chronic kidney disease (CKD) and heart failure (HF), particularly those on guideline-recommended inhibitors of the renin-angiotensin-aldosterone system (RAAS). Hyperkalemia remains a challenge for clinicians practicing in the long-term care setting as they are often faced with the difficult decision of down-titrating or discontinuing RAAS inhibitors in response to hyperkalemia in the very patients who derive the greatest benefit from these agents. In the past, options to chronically manage hyperkalemia were limited. Patiromer was approved for the treatment of hyperkalemia in 2015 and has been shown to maintain normokalemia for up to 52 weeks in patients with CKD and/or HF on RAAS inhibitors. With the emergence of a new hyperkalemia treatment, there could be a paradigm shift away from the discontinuation of guideline recommended therapies, allowing the continuation of RAAS inhibitor therapy to effectively manage HF symptoms and reduce the risk of rehospitalization in patients with HF, and slow the progression to end-stage renal disease in patients with CKD.

  11. Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

    PubMed Central

    Stokes, Jonathan; Panagioti, Maria; Alam, Rahul; Checkland, Kath; Cheraghi-Sohi, Sudeh; Bower, Peter

    2015-01-01

    Background An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care ‘at-risk’ of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. Methods and Findings We carried out a systematic review and meta-analysis of the effectiveness of case management for ‘at-risk’ patients in primary care. Six bibliographic databases were searched using terms for ‘case management’, ‘primary care’, and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health – self-assessed health status, mortality; Cost – total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction – patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial ‘strength’ of primary care. Conclusions This was the first meta-analytic review which examined the effects

  12. [Management of heart failure in cardiology and primary care (MICCAP) program: Improving the management of patients with heart failure].

    PubMed

    Barrios, V; Escobar, C; Pallares, V; Egocheaga, M I; Lobos, J M; Bover, R; Gómez Doblas, J J; Cosín, J

    2018-03-26

    Despite current treatments, morbidity and mortality of patients with heart failure remain high. The late diagnosis of heart failure, the insufficient heart failure treatment (i.e. not using the appropriate drugs, prescribing lower doses of drugs than recommended, etc.), and a poor coordination between different health care levels, may explain, at least in part, these figures. The Management of Heart Failure in Cardiology and Primary Care (MICCAP) program has been developed with the aim of optimising the integrated management of patients with heart failure between Primary Care and Cardiology, through the improvement of coordination between both health care levels. This includes continuous medical education to reinforce the diagnostic and therapeutic skills of general practitioners in the field of heart failure. The rationale and objectives of the MICCAP program are summarised in this article. Copyright © 2018 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

  13. Transitions of Care Model Inclusive of Unplanned Care Improves the Patient Experience

    PubMed Central

    Cox, Jon; Teague, Stephanie; Beck, Eric

    2016-01-01

    A major emphasis in health care is creating an experience whereby patients receive the right care at the right time from the right provider in the right setting at the right cost. Over the past several decades, there has been considerable effort in the area of medical management, with prior authorization, gatekeeper utilization management regimens, and other techniques designed to guide patients and caregivers into desired treatment pathways. Alternatively, the concept of demand management may be employed to achieve these desired outcomes by giving patients meaningful, expanded choices beyond traditional acute-care settings. The implementation of a novel, patient-centered, unplanned care delivery model is described along with illustrative case studies. PMID:28725828

  14. Management of Pediatric Delirium in Pediatric Cardiac Intensive Care Patients: An International Survey of Current Practices.

    PubMed

    Staveski, Sandra L; Pickler, Rita H; Lin, Li; Shaw, Richard J; Meinzen-Derr, Jareen; Redington, Andrew; Curley, Martha A Q

    2018-06-01

    The purpose of this study was to describe how pediatric cardiac intensive care clinicians assess and manage delirium in patients following cardiac surgery. Descriptive self-report survey. A web-based survey of pediatric cardiac intensive care clinicians who are members of the Pediatric Cardiac Intensive Care Society. Pediatric cardiac intensive care clinicians (physicians and nurses). None. One-hundred seventy-three clinicians practicing in 71 different institutions located in 13 countries completed the survey. Respondents described their clinical impression of the occurrence of delirium to be approximately 25%. Most respondents (75%) reported that their ICU does not routinely screen for delirium. Over half of the respondents (61%) have never attended a lecture on delirium. The majority of respondents (86%) were not satisfied with current delirium screening, diagnosis, and management practices. Promotion of day/night cycle, exposure to natural light, deintensification of care, sleep hygiene, and reorientation to prevent or manage delirium were among nonpharmacologic interventions reported along with the use of anxiolytic, antipsychotic, and medications for insomnia. Clinicians responding to the survey reported a range of delirium assessment and management practices in postoperative pediatric cardiac surgery patients. Study results highlight the need for improvement in delirium education for pediatric cardiac intensive care clinicians as well as the need for systematic evaluation of current delirium assessment and management practices.

  15. Barriers and facilitators influencing self-management among COPD patients: a mixed methods exploration in primary and affiliated specialist care.

    PubMed

    Hillebregt, Chantal F; Vlonk, Auke J; Bruijnzeels, Marc A; van Schayck, Onno Cp; Chavannes, Niels H

    2017-01-01

    Self-management is becoming increasingly important in COPD health care although it remains difficult to embed self-management into routine clinical care. The implementation of self-management is understood as a complex interaction at the level of patient, health care provider (HCP), and health system. Nonetheless there is still a poor understanding of the barriers and effective facilitators. Comprehension of these determinants can have significant implications in optimizing self-management implementation and give further directions for the development of self-management interventions. Data were collected among COPD patients (N=46) and their HCPs (N=11) in three general practices and their collaborating affiliated hospitals. Mixed methods exploration of the data was conducted and collected by interviews, video-recorded consultations (N=50), and questionnaires on consultation skills. Influencing determinants were monitored by 1) interaction and communication between the patient and HCP, 2) visible and invisible competencies of both the patient and the HCP, and 3) degree of embedding self-management into the health care system. Video observations showed little emphasis on effective behavioral change and follow-up of given lifestyle advice during consultation. A strong presence of COPD assessment and monitoring negatively affects the patient-centered communication. Both patients and HCPs experience difficulties in defining personalized goals. The satisfaction of both patients and HCPs concerning patient centeredness during consultation was measured by the patient feedback questionnaire on consultation skills. The patients scored high (84.3% maximum score) and differed from the HCPs (26.5% maximum score). Although the patient-centered approach accentuating self-management is one of the dominant paradigms in modern medicine, our observations show several influencing determinants causing difficulties in daily practice implementation. This research is a first step

  16. Integrated, automated revenue management for managed care contracts.

    PubMed

    Burckhart, Kent

    2002-04-01

    Faced with increasing managed care penetration and declining net revenue in recent years, healthcare providers increasingly are emphasizing revenue management. To streamline processes and reduce costs in this area, many healthcare providers have implemented or are considering automated contract management systems. When selecting such a system, healthcare financial managers should make certain that the system can interface with both patient-accounting and decision-support systems of the organization. This integration enhances a healthcare provider's financial viability by providing integrated revenue-management capabilities to analyze projected performance of proposed managed care contracts and actual performance of existing contracts.

  17. Critical care nurses' decision making: sedation assessment and management in intensive care.

    PubMed

    Aitken, Leanne M; Marshall, Andrea P; Elliott, Rosalind; McKinley, Sharon

    2009-01-01

    This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients' sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Observational study. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.

  18. Case Management for Patients with Complex Multimorbidity: Development and Validation of a Coordinated Intervention between Primary and Hospital Care

    PubMed Central

    Giménez-Campos, María Soledad; Villar-López, Julia; Faubel-Cava, Raquel; Donat-Castelló, Lucas; Valdivieso-Martínez, Bernardo; Soriano-Melchor, Elisa; Bahamontes-Mulió, Amparo; García-Gómez, Juan M.

    2017-01-01

    In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation. We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity. A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity. PMID:28970745

  19. RCT of a care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints.

    PubMed

    Dickinson, L Miriam; Rost, Kathryn; Nutting, Paul A; Elliott, Carl E; Keeley, Robert D; Pincus, Harold

    2005-01-01

    Depression care management for primary care patients results in sustained improvement in clinical outcomes with diminishing costs over time. Clinical benefits, however, are concentrated primarily in patients who report to their primary care clinicians psychological rather than exclusively physical symptoms. This study proposes to determine whether the intervention affects outpatient costs differentially when comparing patients who have psychological with patients who have physical complaints. We undertook a group-randomized controlled trial (RCT) of depression comparing intervention with usual care in 12 primary care practices. Intervention practices encouraged depressed patients to engage in active treatment, using nurses to provide regularly scheduled care management for 24 months. The study sample included 200 adults beginning a new depression treatment episode where patient presentation style could be identified. Outpatient costs were defined as intervention plus outpatient treatment costs for the 2 years. Cost-offset analysis used general linear mixed models, 2-part models, and bootstrapping to test hypotheses regarding a differential intervention effect by patients' style, and to obtain 95% confidence intervals for costs. Intervention effects on outpatient costs over time differed by patient style (P <.05), resulting in a $980 cost decrease for depressed patients who complain of psychological symptoms and a 1,378 dollars cost increase for depressed patients who complain of physical symptoms only. Depression intervention for a 2-year period produced observable clinical benefit with decreased outpatient costs for depressed patients who complain of psychological symptoms. It produced limited clinical benefit with increased costs, however, for depressed patients who complain exclusively of physical symptoms, suggesting the need for developing new intervention approaches for this group.

  20. 'The onus is on me': primary care patient views of Medicare-funded team care in chronic disease management in Australia.

    PubMed

    Foster, Michele M; Mitchell, Geoffrey K

    2015-10-01

    This study investigated the views of primary care patients in receipt of Medicare-funded team care for chronic disease management (CDM) in Australia. A qualitative study using a repeat in-depth interview design. Twenty-three patients (17 female), aged 32-89, were recruited over a six-month period from two purposively selected general practices: one urban and one regional practice in Queensland, Australia. Semi-structured interviews were conducted with participants 6 months apart. An interview guide was used to ensure consistency of topics explored. Interviews were recorded and transcribed, and a thematic analysis was conducted. Patients in this study viewed the combined contributions of a GP and other health professionals in team care as thorough and reassuring. In this case of Medicare-funded team care, patients also saw obligations within the structured care routine which cultivated a personal ethics of CDM. This was further influenced by how patients viewed their role in the health-care relationship. Aside from personal obligations, Medicare funding got patients engaged in team care by providing financial incentives. Indeed, this was a defining factor in seeing allied health professionals. However, team care was also preferential due to patients' valuations of costs and benefits. Patients are likely to engage with a structured team care approach to CDM if there is a sense of personal obligation and sufficient financial incentive. The level of engagement in team care is likely to be optimized if patient expectations and preferences are considered in decisions. © 2013 Blackwell Publishing Ltd.

  1. A management, leadership, and board road map to transforming care for patients.

    PubMed

    Toussaint, John

    2013-01-01

    Over the last decade I have studied 115 healthcare organizations in II countries, examining them from the boardroom to the patient bedside. In that time, I have observed one critical element missing from just about every facility: a set of standards that could reliably produce zero-defect care for patients. This lack of standards is largely rooted in the Sloan management approach, a top-down management and leadership structure that is void of standardized accountability. This article offers an alternative approach: management by process--an operating system that engages frontline staff in decisions and imposes standards and processes on the act of managing. Organizations that have adopted management by process have seen quality improve and costs decrease because the people closest to the work are expected to identify problems and solve them. Also detailed are the leadership behaviors required for an organization to successfully implement the management-by-process operating system and the board of trustees' role in supporting the transformation.

  2. Physicians' perceptions of managed care.

    PubMed

    Levine, R A; Lieberson, A

    1998-02-01

    We wished to determine physicians' views and knowledge of managed care, particularly their beliefs about the provisions of managed care contracts in terms of legality and ethics. A questionnaire was sent to the 315 physicians of the medical staff of Norwalk Hospital in Connecticut regarding managed care and managed care contracts. Sixty-six responses were received within a 45-day period (20.9% return). Although only 1 of 11 contract provisions presented in one section of the questionnaire was illegal in Connecticut, a majority of physicians believed 7 of the 11 were illegal. On average, 50% of physicians polled thought each of the provisions was illegal, and a varying majority of physicians (53% to 95.4%) felt the various provisions were unethical. The majority of respondents (84.8% to 92.4%) believed that nondisclosure provisions were unethical. Ninety-seven percent thought managed care interferes with quality of care, and 72.7% of physicians felt that the managed care industry should be held legally responsible for ensuring quality of care. However, 92.4% of physicians considered themselves to be ethically responsible for ensuring quality of care. Physicians have a poor understanding of the legal aspects of managed care contracts but feel strongly that many provisions of these contracts are unethical. Physicians also believe that managed care is causing medicine to be practiced in a manner that is contrary to patients' interests and that legal recourse is needed to prevent this.

  3. The impact of managed care in dentistry.

    PubMed

    Clouse, H R

    1999-01-01

    Managed care plans attempt to control health care expenditures aggressively. These plans directly influence access to medical care and the type, level, and frequency of care rendered. As a result, hospital stays are reduced, focus shifts from inpatient to outpatient care, and patients are responsible for a larger share of health care costs. Dentistry is not immune from the impact of managed care. The attractiveness of the dental market has drawn many managed care organizations, insurers, and entrepreneurs to encourage dentists to participate in a wide variety of managed care programs. However, the delivery of dental care differs markedly in many respects from that of medical care. Therefore, many of the cost saving aspects of managed care that have been so successful in medicine may not result in similar cost savings in dentistry.

  4. Implementing a hybrid approach to select patients for care management: variations across practices.

    PubMed

    Vogeli, Christine; Spirt, Jenna; Brand, Richard; Hsu, John; Mohta, Namita; Hong, Clemens; Weil, Eric; Ferris, Timothy G

    2016-05-01

    Appropriate selection of patients is key to the success of care management programs (CMPs). Hybrid patient selection approaches, in which large data assets are culled to develop a list of patients for more targeted clinical review, are increasingly common. We sought to describe the patient and practice characteristics associated with high-risk patient identification and selection for a CMP during clinical review, and to explore variation across primary care practices. Retrospective cohort study. Standardized estimates of Medicare beneficiaries identified as high risk for poor outcomes and high medical expense, and appropriate for a CMP within a large Pioneer Accountable Care Organization, were developed using mixed effects logistic models. Study subjects were 2685 Medicare beneficiaries aged over 18 (includes individuals eligible for Medicare due to a disability) aligned to 35 primary care practices in 2013. Independent predictors of patient identification as high risk include older age; higher risk score; recent increases in medical conditions; higher numbers of medical hospitalizations, skilled nursing facility days, and primary care physician visits; and shorter relationships with the primary care physician. Older age, and lower income, but no prior hospice use were independently associated with patient selection for a CMP among the subset of patients identified as being high risk. Adjusted predicted percents of high-risk patients varied significantly across practices overall and for 5 of the 6 patient characteristics that were independently associated with identification as high risk. Inconsistency in high-risk patient identification and selection for a CMP may reflect differences in practice resources, but also highlight the need for continual training and feedback in order to protect against unintentional biases.

  5. Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes.

    PubMed

    Fromer, Len

    2011-01-01

    Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient's health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.

  6. Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study.

    PubMed

    Hudon, Catherine; Chouinard, Maud-Christine; Dubois, Marie-France; Roberge, Pasquale; Loignon, Christine; Tchouaket, Éric; Lambert, Mireille; Hudon, Émilie; Diadiou, Fatoumata; Bouliane, Danielle

    2018-05-01

    This study aimed to evaluate the effects of the V1SAGES case management intervention (Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support) for frequent users of health care services with chronic disease and complex care needs on psychological distress and patient activation. We used a 2-phase sequential mixed methods design. The first phase was a pragmatic randomized controlled trial with intention-to-treat analysis that measured the effects of the intervention compared with usual care on psychological distress and patient activation before and after 6 months. The second phase had a qualitative descriptive design and entailed thematic analysis of in-depth interviews (25 patients, 6 case management nurses, 9 health managers) and focus groups (8 patients' spouses, 21 family physicians) to understand stakeholders' perceived effects of the intervention on patients. A total of 247 patients were randomized into the intervention group (n = 126) or the control group (n = 121). Compared with usual care, the intervention reduced psychological distress (odds ratio = 0.43; 95% CI, 0.19-0.95, P = .04), but did not have any significant effect on patient activation ( P = .43). Qualitative results suggested that patients and their spouses benefitted from the case management intervention, gaining a sense of security, and stakeholders noted better patient self-management of health. Together, our study's quantitative and qualitative results suggest that case management reduces psychological distress, making patients and caregivers feel more secure, whereas impact on self-management is unclear. Case management is a promising avenue to improve outcomes among frequent users of health care with complex needs. © 2018 Annals of Family Medicine, Inc.

  7. Information Needs of Nurse Care Managers

    PubMed Central

    Dorr, David A.; Tran, Hanh; Gorman, Paul; Wilcox, Adam B.

    2006-01-01

    Unmet information needs of physicians and patients are common, but those of nurse care managers – defined as collaborative care planners for with chronic conditions – are less well understood. We taped and transcribed daily activities and conducted semi-structured interviews of 7 care managers, and analyzed questions elicited through this work through a variety of frameworks. PMID:17238532

  8. Integrated care management: aligning medical call centers and nurse triage services.

    PubMed

    Kastens, J M

    1998-01-01

    Successful integrated delivery systems must aggressively design new approaches to managing patient care. Implementing a comprehensive care management model to coordinate patient care across the continuum is essential to improving patient care and reducing costs. The practice of telephone nursing and the need for experienced registered nurses to staff medical call centers, nurse triage centers, and outbound telemanagement is expanding as the penetration of full-risk capitated managed care contracts are signed. As health systems design their new care delivery approaches and care management models, medical call centers will be an integral approach to managing demand for services, chronic illnesses, and prevention strategies.

  9. Managed care and inpatient mortality in adults: effect of primary payer.

    PubMed

    Hines, Anika L; Raetzman, Susan O; Barrett, Marguerite L; Moy, Ernest; Andrews, Roxanne M

    2017-02-08

    Because managed care is increasingly prevalent in health care finance and delivery, it is important to ascertain its effects on health care quality relative to that of fee-for-service plans. Some stakeholders are concerned that basing gatekeeping, provider selection, and utilization management on cost may lower quality of care. To date, research on this topic has been inconclusive, largely because of variation in research methods and covariates. Patient age has been the only consistently evaluated outcome predictor. This study provides a comprehensive assessment of the association between managed care and inpatient mortality for Medicare and privately insured patients. A cross-sectional design was used to examine the association between managed care and inpatient mortality for four common inpatient conditions. Data from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases for 11 states were linked to data from the American Hospital Association Annual Survey Database. Hospital discharges were categorized as managed care or fee for service. A phased approach to multivariate logistic modeling examined the likelihood of inpatient mortality when adjusting for individual patient and hospital characteristics and for county fixed effects. Results showed different effects of managed care for Medicare and privately insured patients. Privately insured patients in managed care had an advantage over their fee-for-service counterparts in inpatient mortality for acute myocardial infarction, stroke, pneumonia, and congestive heart failure; no such advantage was found for the Medicare managed care population. To the extent that the study showed a protective effect of privately insured managed care, it was driven by individuals aged 65 years and older, who had consistently better outcomes than their non-managed care counterparts. Privately insured patients in managed care plans, especially older adults, had better outcomes than those in fee-for-service plans

  10. Integrating disease management into the outpatient delivery system during and after managed care.

    PubMed

    Villagra, Victor G

    2004-01-01

    Managed care introduced disease management as a replacement strategy to utilization management. The focus changed from influencing treatment decisions to supporting self-care and compliance. Disease management rendered operational many elements of the chronic care model, but it did so outside the delivery system, thus escaping the financial limitations, cultural barriers, and inertia inherent in effecting radical change from within. Medical management "after managed care" should include the functional and structural integration of disease management with primary care clinics. Such integration would supply the infrastructure that primary care physicians need to coordinate the care of chronically ill patients more effectively.

  11. Using health information technology to manage a patient population in accountable care organizations.

    PubMed

    Wu, Frances M; Rundall, Thomas G; Shortell, Stephen M; Bloom, Joan R

    2016-06-20

    Purpose - The purpose of this paper is to describe the current landscape of health information technology (HIT) in early accountable care organizations (ACOs), the different strategies ACOs are using to develop HIT-based capabilities, and how ACOs are using these capabilities within their care management processes to advance health outcomes for their patient population. Design/methodology/approach - Mixed methods study pairing data from a cross-sectional National Survey of ACOs with in-depth, semi-structured interviews with leaders from 11 ACOs (both completed in 2013). Findings - Early ACOs vary widely in their electronic health record, data integration, and analytic capabilities. The most common HIT capability was drug-drug and drug-allergy interaction checks, with 53.2 percent of respondents reporting that the ACO possessed the capability to a high degree. Outpatient and inpatient data integration was the least common HIT capability (8.1 percent). In the interviews, ACO leaders commented on different HIT development strategies to gain a more comprehensive picture of patient needs and service utilization. ACOs realize the necessity for robust data analytics, and are exploring a variety of approaches to achieve it. Research limitations/implications - Data are self-reported. The qualitative portion was based on interviews with 11 ACOs, limiting generalizability to the universe of ACOs but allowing for a range of responses. Practical implications - ACOs are challenged with the development of sophisticated HIT infrastructure. They may benefit from targeted assistance and incentives to implement health information exchanges with other providers to promote more coordinated care management for their patient population. Originality/value - Using new empirical data, this study increases understanding of the extent of ACOs' current and developing HIT capabilities to support ongoing care management.

  12. Management of the patient with a total joint replacement: the primary care practitioner's role.

    PubMed

    Palmer, L M

    1999-01-01

    The primary care practitioner assumes chief responsibility for patients with arthritis. More than 40 million Americans experience some form of arthritis. Management of the patient with arthritis may include a referral to an orthopedic surgeon for surgical intervention. As estimated, up to 500,000 total joint replacement procedures are performed by orthopedic surgeons each year in the United States. Presurgical evaluation for a total joint replacement is imperative to ensure that the patient can safely undergo this surgical procedure. Postsurgical care of a patient with total joint replacement involves coordinating care with the physical therapist and orthopedic surgeon to ensure adequate follow-through with the recommended rehabilitation program, prophylactic antibiotic coverage, and observation for any complications including infection, deep-vein thrombosis, or loosening of the total-joint prosthesis.

  13. Self-Care Management among Patients with Type 2 Diabetes in East Jerusalem

    ERIC Educational Resources Information Center

    Daoud, Nihaya; Osman, Amira; Hart, Trevor A.; Berry, Elliott M.; Adler, Bella

    2015-01-01

    Objective: Little research exists on diabetes self-care management (DSCM) in Arab populations. We examined the contribution of health belief constructs, socioeconomic position (SEP) and clinical factors (glycated haemoglobin [HbA1C] level, type of diabetes treatments, and receiving professional guidance) to DSCM among Arab patients in East…

  14. [Palliative care pathways of older patients].

    PubMed

    Zubieta, Lourdes; Hébert, Réjean; Raîche, Michel

    To determine the palliative care pathways of older patients in Sherbrooke, Qc by examining their transfers to other facilities. This analysis was conducted by linking 3 databases: emergency department, hospitalizations and nursing homes. The study period ranged from January 2011 to December 2015. SPSS was used for statistical analysis. The study only included palliative care patients. 25% of patients waited less than 7 days for transfer, and 74% waited less than 3 weeks. 64.9% of patients were transferred to a long-term facility for dependent adults (LTF), 15.2% returned home or were transferred to private accommodation, and 15.9% were transferred to an intermediate care facility. One-half of patients subsequently changed facility, mainly those in homes or intermediate care. Palliative care patient bed occupation rates represented 1% of available bed-days and less than 2% of total beds for 86.4% of days. Only 12% of patients returned to hospital within 90 days after discharge. The number of beds occupied by palliative care patients does not seem to disrupt the hospital capacity. The majority of the palliative care patients were well managed, as reflected by the low readmission rate. Our results indicate good management of transfers and an adequate supply of long-term care facilities and home services.

  15. The politics of patient-centred care.

    PubMed

    Kreindler, Sara A

    2015-10-01

    Despite widespread belief in the importance of patient-centred care, it remains difficult to create a system in which all groups work together for the good of the patient. Part of the problem may be that the issue of patient-centred care itself can be used to prosecute intergroup conflict. This qualitative study of texts examined the presence and nature of intergroup language within the discourse on patient-centred care. A systematic SCOPUS and Google search identified 85 peer-reviewed and grey literature reports that engaged with the concept of patient-centred care. Discourse analysis, informed by the social identity approach, examined how writers defined and portrayed various groups. Managers, physicians and nurses all used the discourse of patient-centred care to imply that their own group was patient centred while other group(s) were not. Patient organizations tended to downplay or even deny the role of managers and providers in promoting patient centredness, and some used the concept to advocate for controversial health policies. Intergroup themes were even more obvious in the rhetoric of political groups across the ideological spectrum. In contrast to accounts that juxtaposed in-groups and out-groups, those from reportedly patient-centred organizations defined a 'mosaic' in-group that encompassed managers, providers and patients. The seemingly benign concept of patient-centred care can easily become a weapon on an intergroup battlefield. Understanding this dimension may help organizations resolve the intergroup tensions that prevent collective achievement of a patient-centred system. © 2013 John Wiley & Sons Ltd.

  16. Medication management for community palliative care patients and the role of a specialist palliative care pharmacist: A qualitative exploration of consumer and health care professional perspectives.

    PubMed

    Kuruvilla, Lisha; Weeks, Greg; Eastman, Peter; George, Johnson

    2018-05-01

    Pharmacists have a key role to play in optimisation of medication regimens and promotion of medication safety. The role of specialist pharmacists as part of the multidisciplinary palliative care team, especially in the primary care setting, is not widely recognised. To explore the perspectives of stakeholders about the gaps in the current model of community palliative care services in relation to medication management and to assess their opinions pertaining to the role of a specialist palliative care pharmacist in addressing some of those gaps. Qualitative study utilising three focus groups involving 20 stakeholders. Thematic analysis was carried out using a framework approach and interpreted in the context of the Chronic Care Model for improving primary care for patients with chronic illness. Setting was a large regional Australian palliative care service. Participants included palliative care consumers and clinicians specifically patients, caregivers, physicians, nurses and pharmacists. Five major themes emerged from the focus groups: access to resources, medicines and information; shared care; challenges of polypharmacy; informal caregiver needs and potential roles of a palliative care pharmacist. Gaps in access to medicines/resources, training for generalist practitioners, communication between treating teams and lack of support for patients and carers were cited as factors adversely impacting medication management in community-based palliative care. While community-based palliative care is an essential aspect of meeting the health care demands of an ageing society, the current model has several gaps and limitations. An appropriately qualified and skilled pharmacist within the palliative care team may help to address some of the gaps in relation to medication access and appropriateness.

  17. Managed care in obstetrics.

    PubMed

    Devoe, L D

    1997-08-01

    Managed care has marched relentlessly through all fields of obstetric care: individual and group practices, proprietary hospitals and academic medical centers, and public health systems. Emphasis on cost containment while preserving high quality has driven the redesign of healthcare delivery. A number of models for providing effective and less expensive obstetric care are now being examined in the USA and abroad. Increased market penetration by managed care will also exert profound and possibly harmful effects on traditional academic teaching institutions. These organizations must adapt to this new environment or face the erosion of physician support and training bases. Ultimately, significant moral and ethical dilemmas will arise when patients' best interests for care are being continually brought into conflict with the physician's need to earn a living.

  18. Cost-Utility Analysis of Pharmaceutical Care Intervention Versus Usual Care in Management of Nigerian Patients with Type 2 Diabetes.

    PubMed

    Adibe, Maxwell O; Aguwa, Cletus N; Ukwe, Chinwe V

    To assess the cost-effectiveness of pharmaceutical care (PC) intervention versus usual care (UC) in the management of type 2 diabetes. This study was a randomized, controlled study with a 12-month patient follow-up in two Nigerian tertiary hospitals. One hundred and ten patients were randomly assigned to each of the "intervention" (PC) and the "control" (UC) groups. Patients in the UC group received the usual/conventional care offered by the hospitals. Patients in the PC group received UC and PC in the form of structural self-care education and training for 12 months. The economic evaluation was based on patients' perspective. Costs of management of individual complications were calculated from activities involved in their management by using activity-based costing. The impact of the interventions on quality of life was estimated by using the HUI23S4EN.40Q (Mark index 3) questionnaire. The primary outcomes were incremental cost-utility ratio and net monetary benefit. An intention-to-treat approach was used. Two-sample comparisons were made by using Student's t tests for normally distributed variables data at baseline, 6 months, and 12 months. Comparisons of proportions were done by using the chi-square test. The PC intervention led to incremental cost and effect of Nigerian naira (NGN) 10,623 ($69) and 0.12 quality-adjusted life-year (QALY) gained, respectively, with an associated incremental cost-utility ratio of NGN 88,525 ($571) per QALY gained. In the cost-effectiveness acceptability curve, the probability that PC was more cost-effective than UC was 95% at the NGN 250,000 ($1613) per QALY gained threshold and 52% at the NGN 88,600 ($572) per QALY gained threshold. The PC intervention was very cost-effective among patients with type 2 diabetes at the NGN 88,525 ($571.13) per QALY gained threshold, although considerable uncertainty surrounds these estimates. Copyright © 2013, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by

  19. Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care: A Cluster Randomized Trial.

    PubMed

    Allen, Kelli D; Oddone, Eugene Z; Coffman, Cynthia J; Jeffreys, Amy S; Bosworth, Hayden B; Chatterjee, Ranee; McDuffie, Jennifer; Strauss, Jennifer L; Yancy, William S; Datta, Santanu K; Corsino, Leonor; Dolor, Rowena J

    2017-03-21

    A single-site study showed that a combined patient and provider intervention improved outcomes for patients with knee osteoarthritis, but it did not assess separate effects of the interventions. To examine whether patient-based, provider-based, and patient-provider interventions improve osteoarthritis outcomes. Cluster randomized trial with assignment to patient, provider, and patient-provider interventions or usual care. (ClinicalTrials.gov: NCT01435109). 10 Duke University Health System community-based primary care clinics. 537 outpatients with symptomatic hip or knee osteoarthritis. The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved electronic delivery of patient-specific osteoarthritis treatment recommendations to providers. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months. Secondary outcomes were objective physical function (Short Physical Performance Battery) and depressive symptoms (Patient Health Questionnaire). Linear mixed models assessed the difference in improvement among groups. No difference was observed in WOMAC score changes from baseline to 12 months in the patient (-1.5 [95% CI, -5.1 to 2.0]; P = 0.40), provider (2.5 [CI, -0.9 to 5.9]; P = 0.152), or patient-provider (-0.7 [CI, -4.2 to 2.8]; P = 0.69) intervention groups compared with usual care. All groups had improvements in WOMAC scores at 12 months (range, -3.7 to -7.7). In addition, no differences were seen in objective physical function or depressive symptoms at 12 months in any of the intervention groups compared with usual care. The study involved 1 health care network. Data on provider referrals were not collected. Contrary to a previous study of a combined patient and provider intervention for osteoarthritis in a Department of Veterans Affairs medical center, this study found no statistically

  20. Palliative care case managers in primary care: a descriptive study of referrals in relation to treatment aims.

    PubMed

    van der Plas, Annicka G M; Onwuteaka-Philipsen, Bregje D; Francke, Anneke L; Jansen, Wim J J; Vissers, Kris C; Deliens, Luc

    2015-04-01

    Three important elements of the World Health Organization (WHO) definition of palliative care are: 1) it includes patients who may have cure or life prolongation as treatment aims besides palliative care; 2) it is not exclusively for cancer patients; and 3) it includes attention to the medical, psychological, social, and spiritual needs of the patients and their families. Case managers (nurses with expertise in palliative care) may assist generalist primary care providers in delivery of good palliative care. This study investigates the referral of patients to case managers in primary care with regard to the three elements mentioned: diagnosis, treatment aims, and needs as reflected in reasons given for referral. In this cross-sectional survey in primary care among case managers and referrers to case management, case managers completed questionnaires for 687 patients; referrers completed 448 (65%). Most patients referred have a combination of treatment aims (69%). Life expectancy and functional status of patients are lower for those with a treatment aim of palliation. Almost all (96%) of those referred are cancer patients. A need for psychosocial support is frequently given as a reason for referral (66%) regardless of treatment aim. Referrals to case managers reflect two of three elements of the WHO definition. Mainly, patients are referred for support complementary to medical care, and relatively early in their disease trajectory. However, most of those referred are cancer patients. Thus, to fully reflect the definition, broadening the scope to reach other patient groups is important.

  1. Open source electronic health record and patient data management system for intensive care.

    PubMed

    Massaut, Jacques; Reper, Pascal

    2008-01-01

    In Intensive Care Units, the amount of data to be processed for patients care, the turn over of the patients, the necessity for reliability and for review processes indicate the use of Patient Data Management Systems (PDMS) and electronic health records (EHR). To respond to the needs of an Intensive Care Unit and not to be locked with proprietary software, we developed a PDMS and EHR based on open source software and components. The software was designed as a client-server architecture running on the Linux operating system and powered by the PostgreSQL data base system. The client software was developed in C using GTK interface library. The application offers to the users the following functions: medical notes captures, observations and treatments, nursing charts with administration of medications, scoring systems for classification, and possibilities to encode medical activities for billing processes. Since his deployment in February 2004, the PDMS was used to care more than three thousands patients with the expected software reliability and facilitated data management and review processes. Communications with other medical software were not developed from the start, and are realized by the use of the Mirth HL7 communication engine. Further upgrade of the system will include multi-platform support, use of typed language with static analysis, and configurable interface. The developed system based on open source software components was able to respond to the medical needs of the local ICU environment. The use of OSS for development allowed us to customize the software to the preexisting organization and contributed to the acceptability of the whole system.

  2. Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care.

    PubMed

    Levinson, W; Gorawara-Bhat, R; Dueck, R; Egener, B; Kao, A; Kerr, C; Lo, B; Perry, D; Pollitz, K; Reifsteck, S; Stein, T; Santa, J; Kemp-White, M

    1999-10-20

    Managed care uses financial incentives and restrictions on tests and procedures to attempt to influence physician decision making and limit costs. Increasingly, the public is questioning whether physicians are truly making decisions based on the patient's best interest or are unduly influenced by economic incentives. These circumstances lead to the potential for disagreements and conflict in the patient-physician relationship. We convened a group of individuals in October 1998, including patient representatives, leaders from health care organizations, practicing physicians, communication experts, and medical ethicists, to articulate the types of disagreements emerging in the patient-physician relationship as a result of managed care. We addressed 3 specific scenarios physicians may encounter, including allocation, illustrated by a patient who is referred to a different ophthalmologist based on a new arrangement in the physician's group; access, illustrated by a patient who wishes to see his own physician for a same-day visit rather than a nurse specialist; and financial incentives, illustrated by a patient who expects to have a test performed and a physician who does not believe the test is necessary but is afraid the patient will think the physician is not ordering the test because of financial incentives. Using these scenarios, we suggest communication strategies that physicians can use to decrease the potential for disagreements. In addition, we propose strategies that health plans or physician groups can use to alleviate or resolve these disagreements.

  3. Telephone Care Management of Fall Risk:: A Feasibility Study.

    PubMed

    Phelan, Elizabeth A; Pence, Maureen; Williams, Barbara; MacCornack, Frederick A

    2017-03-01

    Care management has been found to be more effective than usual care for some chronic conditions, but few studies have tested care management for prevention of elder falls. This study aimed to assess the feasibility and preliminary efficacy of telephone care management of older adults presenting for medical attention due to a fall. The setting was an independent practice association in western Washington serving 1,300 Medicare Advantage-insured patients. Patients aged ≥65 years treated for a fall in an emergency department or their primary care provider's office were contacted via telephone by a care manager within 48 hours of their fall-related visit and invited to participate in a telephone-administered interview to identify modifiable fall risk factors and receive recommendations and follow-up to address identified risk factors. Data from care manager records, patient medical records, and healthcare claims for the first 6 months (November 2009-April 2010) of program implementation were analyzed in 2011. The feasibility of screening and management of fall risk factors over the telephone and the effect on medically attended falls were assessed. Twenty-two patients eligible for fall care management were reached and administered the protocol. Administration took 15-20 minutes and integrated easily with the care manager's other responsibilities. Follow-through on recommendations varied, from 45% for those for whom exercise participation was recommended to 100% for other recommendations. No medically attended falls occurred over 6 months of follow-up. Telephone care management of fall risk appears feasible and may reduce falls requiring medical attention. Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

  4. Medicare Managed Care Spillovers and Treatment Intensity.

    PubMed

    Callison, Kevin

    2016-07-01

    Evidence suggests that the share of Medicare managed care enrollees in a region affects the costs of treating traditional fee-for-service (FFS) Medicare beneficiaries; however, little is known about the mechanisms through which these 'spillover effects' operate. This paper examines the relationship between Medicare managed care penetration and treatment intensity for FFS enrollees hospitalized with a primary diagnosis of AMI. I find that increased Medicare managed care penetration is associated with a reduction in both the costs and the treatment intensity of FFS AMI patients. Specifically, as Medicare managed care penetration increases, FFS AMI patients are less likely to receive surgical reperfusion and mechanical ventilation and to experience an overall reduction in the number of inpatient procedures. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

  5. Disease management in the treatment of patients with chronic heart failure who have universal access to health care: a randomized controlled trial.

    PubMed

    Kalter-Leibovici, Ofra; Freimark, Dov; Freedman, Laurence S; Kaufman, Galit; Ziv, Arnona; Murad, Havi; Benderly, Michal; Silverman, Barbara G; Friedman, Nurit; Cukierman-Yaffe, Tali; Asher, Elad; Grupper, Avishay; Goldman, Dorit; Amitai, Miriam; Matetzky, Shlomi; Shani, Mordechai; Silber, Haim

    2017-05-01

    The efficacy of disease management programs in improving the outcome of heart failure patients remains uncertain and may vary across health systems. This study explores whether a countrywide disease management program is superior to usual care in reducing adverse health outcomes and improving well-being among community-dwelling adult patients with moderate-to-severe chronic heart failure who have universal access to advanced health-care services and technologies. In this multicenter open-label trial, 1,360 patients recruited after hospitalization for heart failure exacerbation (38%) or from the community (62%) were randomly assigned to either disease management or usual care. Disease management, delivered by multi-disciplinary teams, included coordination of care, patient education, monitoring disease symptoms and patient adherence to medication regimen, titration of drug therapy, and home tele-monitoring of body weight, blood pressure and heart rate. Patients assigned to usual care were treated by primary care practitioners and consultant cardiologists. The primary composite endpoint was the time elapsed till first hospital admission for heart failure exacerbation or death from any cause. Secondary endpoints included the number of all hospital admissions, health-related quality of life and depression during follow-up. Intention-to-treat comparisons between treatments were adjusted for baseline patient data and study center. During the follow-up, 388 (56.9%) patients assigned to disease management and 387 (57.1%) assigned to usual care had a primary endpoint event. The median (range) time elapsed until the primary endpoint event or end of study was 2.0 (0-5.0) years among patients assigned to disease management, and 1.8 (0-5.0) years among patients assigned to usual care (adjusted hazard ratio, 0.908; 95% confidence interval, 0.788 to 1.047). Hospital admissions were mostly (70%) unrelated to heart failure. Patients assigned to disease management had a better

  6. Managing pediatric dental patients: issues raised by the law and changing views of proper child care.

    PubMed

    Bross, Donald C

    2004-01-01

    The purpose of this paper was to examine legal issues regarding the management of pediatric dental patients and changing views of proper child care. Standards of care in pediatric dentistry are not static. They change in response to research, patterns of reimbursement, patient and parental expectations of reasonable care, and consensus among practitioners. The law pertaining to accountability for pediatric dental patient treatment largely reflects standards of care established by the pediatric dentistry profession. However, the law can also reflect changes in public expectations of reasonable care that can effectively outrun the discipline's efforts to reflect new knowledge or changing public concerns. A major impetus for considering the care of children in all settings has been the increasing recognition of suboptimal children's care, as well as concerns that children have either been abused or neglected in a number of settings. Too often, practices towards children have been untested and based only on the assumption that what is done is "for the child's own good." Pediatric dentists can respond to changing standards of reasonable care for pediatric dental patients, as expressed in legal decisions. They can also usefully consider how attention to child maltreatment has sensitized parents to be better consumers of services on their children's behalf. Rather than reacting only to public pressures for better means of behavior management, the challenge is to exceed expectations via new research and thoughtful anticipation of improvements that can be made.

  7. A guide to wound managment in palliative care.

    PubMed

    Naylor, Wayne A

    2005-11-01

    Wound management in palliative patients is often a very challenging area of care. There are many unique issues that can combine to produce complicated wound management scenarios, including the types of wounds and wound symptoms most commonly affecting palliative care patients, as well as the presence of concurrent disease and associated treatment. Problems exist with the availability of suitable dressings and balancing life expectancy with the goals of wound care. A significant, and possibly under-recognized, issue is the emotional and social distress experienced by these patients, which can be directly attributed to their wound. These problems must all be recognized and addressed in order to manage wounds effectively in this patient population. This article aims to explore these issues and offer advice on the management of wound-related symptoms, with the ultimate goal of improving patients' quality of life.

  8. [Endorsement of risk management and patient safety by certification of conformity in health care quality assessment].

    PubMed

    Waßmuth, Ralf

    2015-01-01

    Certification of conformity in health care should provide assurance of compliance with quality standards. This also includes risk management and patient safety. Based on a comprehensive definition of quality, beneficial effects on the management of risks and the enhancement of patient safety can be expected from certification of conformity. While these effects have strong face validity, they are currently not sufficiently supported by evidence from health care research. Whether this relates to a lack of evidence or a lack of investigation remains open. Advancing safety culture and "climate", as well as learning from adverse events rely in part on quality management and are at least in part reflected in the certification of healthcare quality. However, again, evidence of the effectiveness of such measures is limited. Moreover, additional factors related to personality, attitude and proactive action of healthcare professionals are crucial factors in advancing risk management and patient safety which are currently not adequately reflected in certification of conformity programs.

  9. Managing depression in primary care

    PubMed Central

    Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping

    2017-01-01

    Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient. PMID:28848991

  10. Care of Patients at the End of Life: Management of Nonpain Symptoms.

    PubMed

    Baralatei, Florence T; Ackermann, Richard J

    2016-08-01

    Management of nonpain symptoms can improve quality of life for patients at the end of life and their family members. Constipation is the most common nonpain symptom. It can be related to opioid therapy and/or medical conditions. After abdominal examination to detect masses or evidence of bowel obstruction and rectal examination to exclude fecal impaction, constipation should be managed with a stimulant laxative (eg, senna) or an osmotic laxative (eg, sorbitol). Dyspnea also is common, and often improves with use of a fan to blow air into the face, as well with breathing and relaxation exercises. However, many patients require titrated doses of opioids to address respiratory depression, and anxiolytics such as haloperidol may be needed to manage dyspnea-related anxiety. Oxygen typically is not effective in dyspnea management in nonhypoxemic patients at the end of life. Cough is managed with antitussives. Nausea and vomiting occur in 70% of patients in palliative care units. If no reversible etiology can be identified, dopamine antagonists and motility-enhancing drugs can be used. There are no clearly effective treatments to manage noisy respiratory secretions, but position change, decrease in fluid intake, and drugs such as scopolamine or glycopyrrolate may be effective. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

  11. Effectiveness of integrated disease management for primary care chronic obstructive pulmonary disease patients: results of cluster randomised trial.

    PubMed

    Kruis, Annemarije L; Boland, Melinde R S; Assendelft, Willem J J; Gussekloo, Jacobijn; Tsiachristas, Apostolos; Stijnen, Theo; Blom, Coert; Sont, Jacob K; Rutten-van Mölken, Maureen P H M; Chavannes, Niels H

    2014-09-10

    To investigate the long term effectiveness of integrated disease management delivered in primary care on quality of life in patients with chronic obstructive pulmonary disease (COPD) compared with usual care. 24 month, multicentre, pragmatic cluster randomised controlled trial 40 general practices in the western part of the Netherlands Patients with COPD according to GOLD (Global Initiative for COPD) criteria. Exclusion criteria were terminal illness, cognitive impairment, alcohol or drug misuse, and inability to fill in Dutch questionnaires. Practices were included if they were willing to create a multidisciplinary COPD team. General practitioners, practice nurses, and specialised physiotherapists in the intervention group received a two day training course on incorporating integrated disease management in practice, including early recognition of exacerbations and self management, smoking cessation, physiotherapeutic reactivation, optimal diagnosis, and drug adherence. Additionally, the course served as a network platform and collaborating healthcare providers designed an individual practice plan to integrate integrated disease management into daily practice. The control group continued usual care (based on international guidelines). The primary outcome was difference in health status at 12 months, measured by the Clinical COPD Questionnaire (CCQ); quality of life, Medical Research Council dyspnoea, exacerbation related outcomes, self management, physical activity, and level of integrated care (PACIC) were also assessed as secondary outcomes. Of a total of 1086 patients from 40 clusters, 20 practices (554 patients) were randomly assigned to the intervention group and 20 clusters (532 patients) to the usual care group. No difference was seen between groups in the CCQ at 12 months (mean difference -0.01, 95% confidence interval -0.10 to 0.08; P=0.8). After 12 months, no differences were seen in secondary outcomes between groups, except for the PACIC domain "follow

  12. Documentation of pain care processes does not accurately reflect pain management delivered in primary care.

    PubMed

    Krebs, Erin E; Bair, Matthew J; Carey, Timothy S; Weinberger, Morris

    2010-03-01

    Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management. To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered. Prospective observational study. 237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week. Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month. Participants' mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k = 0.50) and slight for receiving pain management advice (k = 0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p = 0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p = 0.005). Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately

  13. The impact of managed care and current governmental policies on an urban academic health care center.

    PubMed

    Rodriguez, J L; Peterson, D J; Muehlstedt, S G; Zera, R T; West, M A; Bubrick, M P

    2001-10-01

    Managed care and governmental policies have restructured hospital reimbursement. We examined reimbursement trends in trauma care to assess the impact of this market driven change on an urban academic health center. Patients injured between January 1997 and December 1999 were analyzed for Injury Severity Score (ISS), length of hospital stay, hospital cost, payer, and reimbursement. Between 1997 and 1999, the volume of patients with an ISS less than 9 increased and length of stay decreased. In addition, overall cost, payment, and profit margin increased. Commercially insured patients accounted for this margin increase, because the margins of managed care and government insured patients experienced double-digit decreases. Patients with ISS of 9 or greater also experienced a volume increase and a reduction in length of stay; however, costs within this group increased greater than payments, thereby reducing profit margin. Whereas commercially insured patients maintained their margin, managed care and government insured patients did not (double- and triple-digit decreases). Managed care and current governmental policies have a negative impact on urban academic health center reimbursement. Commercial insurers subsidize not only the uninsured but also the government insured and managed care patients as well. National awareness of this issue and policy action are paramount to urban academic health centers and may also benefit commercial insurers.

  14. Impact of Managed Care Health Insurance System for Indigent Patients with Rheumatoid Arthritis in Puerto Rico

    PubMed Central

    Santiago-Casas, Yesenia; González-Rivera, Tania; Castro-Santana, Lesliane; Ríos, Grissel; Martínez, David; Rodríguez, Vanessa; González-Alcover, Rafael; Mayor, Ángel M.; Vilá, Luis M.

    2013-01-01

    The aim of this study was to determine the clinical outcome among indigent patients with rheumatoid arthritis (RA) in Puerto Rico receiving their healthcare in a managed care system, as compared to non-indigent patients treated in fee-for-service settings. A cross-sectional study was conducted in 214 Puerto Ricans with RA (per American College of Rheumatology classification criteria). Demographic features, health-related behaviors, cumulative clinical manifestations, disease activity (per Disease Activity Score 28), comorbid conditions, functional status (per Health Assessment Questionnaire, HAQ), and pharmacologic profile were determined. Data were examined using univariable and multivariable (logistic regression) analyses. The mean (standard deviation [SD]) age of the study population was 56.6 (13.5) years; 180 (84.1%) were women. The mean (SD) disease duration was 10.8 (9.6) years. Sixty-seven patients were treated in the managed care setting and 147 patients received their healthcare in fee-for-service settings. In the multivariable analyses RA patients treated in the managed care setting had more joint deformities, extra-articular manifestations, arterial hypertension, type 2 diabetes mellitus, cardiovascular events, fibromyalgia syndrome, and poorer functional status, while having a lower exposure to biologic agents than those treated in fee-for-service settings. Efforts should be undertaken to curtail the gap of health disparities among these Hispanic patients in order to improve their long term outcomes. PMID:23314687

  15. Impact of managed care health insurance system for indigent patients with rheumatoid arthritis in Puerto Rico.

    PubMed

    Santiago-Casas, Yesenia; González-Rivera, Tania; Castro-Santana, Lesliane; Ríos, Grissel; Martínez, David; Rodríguez, Vanessa; González-Alcover, Rafael; Mayor, Angel M; Vilá, Luis M

    2013-06-01

    The aim of this study was to determine the clinical outcome among indigent patients with rheumatoid arthritis (RA) in Puerto Rico receiving their healthcare in a managed care system, as compared with non-indigent patients treated in fee-for-service settings. A cross-sectional study was conducted in 214 Puerto Ricans with RA (per American College of Rheumatology classification criteria). Demographic features, health-related behaviors, cumulative clinical manifestations, disease activity (per disease activity score 28), comorbid conditions, functional status (per Health Assessment Questionnaire), and pharmacologic profile were determined. Data were examined using uni- and multivariable (logistic regression) analyses. The mean (standard deviation (SD)) age of the study population was 56.6 (13.5) years; 180 (84.1 %) were women. The mean (SD) disease duration was 10.8 (9.6) years. Sixty-seven patients were treated in the managed care setting, and 147 patients received their healthcare in fee-for-service settings. In the multivariable analyses, RA patients treated in the managed care setting had more joint deformities, extra-articular manifestations, arterial hypertension, type 2 diabetes mellitus, cardiovascular events, fibromyalgia syndrome, and poorer functional status while having a lower exposure to biological agents than those treated in fee-for-service settings. Efforts should be undertaken to curtail the gap of health disparities among these Hispanic patients in order to improve their long-term outcomes.

  16. Length of Stay and Inpatient Costs Under Medicaid Managed Care in Florida

    PubMed Central

    Park, Jungwon

    2015-01-01

    This study examines the patterns of length of stay (LOS) and inpatient costs for both Medicaid managed care and nonmanaged care patients using data from Medicaid patients aged 18 to 64 years who were discharged from hospitals in Florida between 2006 and 2012. This study used pooled cross-sectional multilevel modeling. The results show that the type of Medicaid program in which patients were enrolled was significantly related to the hospital LOS and inpatient costs. Medicaid managed care patients had 7% shorter LOSs and a 1.9% lower inpatient cost than did Medicaid fee-for-service (FFS) patients. Medicaid managed care patients had shorter LOSs in the Medicaid managed care market with high competition. High managed care penetration generates a cost-decreasing spillover to Medicaid FFS patients. PMID:26472718

  17. Length of Stay and Inpatient Costs Under Medicaid Managed Care in Florida.

    PubMed

    Park, Jungwon

    2015-01-01

    This study examines the patterns of length of stay (LOS) and inpatient costs for both Medicaid managed care and nonmanaged care patients using data from Medicaid patients aged 18 to 64 years who were discharged from hospitals in Florida between 2006 and 2012. This study used pooled cross-sectional multilevel modeling. The results show that the type of Medicaid program in which patients were enrolled was significantly related to the hospital LOS and inpatient costs. Medicaid managed care patients had 7% shorter LOSs and a 1.9% lower inpatient cost than did Medicaid fee-for-service (FFS) patients. Medicaid managed care patients had shorter LOSs in the Medicaid managed care market with high competition. High managed care penetration generates a cost-decreasing spillover to Medicaid FFS patients. © The Author(s) 2015.

  18. Impact of a telehealth and care management program for patients with chronic obstructive pulmonary disease.

    PubMed

    Au, David H; Macaulay, Dendy S; Jarvis, John L; Desai, Urvi S; Birnbaum, Howard G

    2015-03-01

    Improving outcomes and health resource use for patients with chronic obstructive pulmonary disease (COPD) care is a priority for health systems. The Health Buddy Program, a content-driven telehealth system coupled with care management, is designed to enhance patient education, self-management, and timely access to care. To examine the effects of the Health Buddy Program on resource use among Medicare patients with COPD who participated in a Centers for Medicare and Medicaid Services demonstration project from 2006 to 2010. Medicare fee-for-service beneficiaries with COPD who enrolled in the intervention at two participating clinics were propensity-score matched to similar patients with COPD identified from a 5% random sample of Medicare patients. Difference-in-difference analyses descriptively compared the program's effect on quarterly healthcare resource use over the 3-year study period compared with baseline. Negative binomial models estimated the association of the program with healthcare resource outcomes adjusting for significant (P<0.05) baseline differences post matching. The effect of the Health Buddy Program on quarterly all-cause and respiratory-related hospital admissions, hospital admissions for COPD exacerbations, and all-cause emergency department use was assessed after matching. Intervention (n=619) and matched control subjects (n=619) had similar baseline characteristics after matching. The Health Buddy Program was associated with 23% lower quarterly all-cause hospital admissions and 40% lower quarterly respiratory-related hospital admissions compared with baseline for intervention beneficiaries versus control subjects. In subgroup analyses, patients who engaged in the intervention during the study period (n=247) demonstrated significantly lower quarterly hospital admissions for COPD exacerbations. The Health Buddy Program was not associated with reductions in quarterly emergency department use. Results were robust in analyses that adjusted for

  19. Chronically ill patients' self-management abilities to maintain overall well-being: what is needed to take the next step in the primary care setting?

    PubMed

    Cramm, Jane Murray; Nieboer, Anna Petra

    2015-09-15

    Although widespread problems in patient-professional interaction and insufficient support of patients' self-management abilities have been recognized, research investigating the relationships among care quality, productive interaction, and self-management abilities to maintain overall well-being is lacking. Furthermore, studies have revealed differences in these characteristics among certain groups (e.g., less-educated and older patients). This longitudinal study thus aimed to identify relationships among background characteristics, quality of care, productivity of patient-professional interaction, and self-management abilities to maintain overall well-being in chronically ill patients participating in 18 Dutch disease management programs. This longitudinal study included patients participating in 18 Dutch disease management programs. Surveys were administered in 2011 (T1; n = 2191 (out of 4693), 47 % response rate) and 2012 (T2: n = 1722 (out of 4350), 40 % response rate). A total of 1279 patients completed questionnaires at both timepoints (T1 and T2) (27 % response rate). Self-management abilities to maintain well-being were measured using the short (18-item) version of the Self-Management Ability Scale (SMAS-S), patients' perceptions of the productivity of interactions with health care professionals were assessed with the relational coordination instrument and the short (11-item) version of the Patient Assessment of Chronic Illness Care (PACIC-S) was used to assess patients' perceptions of the quality of chronic care delivery. Perceived and objective quality of care and the productivity of patient-professional interaction were found to be related to patients' self-management abilities to maintain overall well-being. These abilities were related negatively to and significantly predicted by low educational level, single status, and older age, despite the mediating role of productive interaction in their relationship with patients' perceptions of care quality

  20. Diabetes Care Management Teams Did Not Reduce Utilization When Compared With Traditional Care: A Randomized Cluster Trial.

    PubMed

    Kearns, Patrick

    2017-10-01

    PURPOSE: Health services research evaluates redesign models for primary care. Care management is one alternative. Evaluation includes resource utilization as a criterion. Compare the impact of care-manager teams on resource utilization. The comparison includes entire panes of patients and the subset of patients with diabetes. DESIGN: Randomized, prospective, cohort study comparing change in utilization rates between groups, pre- and post-intervention. METHODOLOGY: Ten primary care physician panels in a safety-net setting. Ten physicians were randomized to either a care-management approach (Group 1) or a traditional approach (Group 2). Care managers focused on diabetes and the cardiovascular cluster of diseases. Analysis compared rates of hospitalization, 30-day readmission, emergency room visits, and urgent care visits. Analysis compared baseline rates to annual rates after a yearlong run-in for entire panels and the subset of patients with diabetes. RESULTS: Resource utilization showed no statistically significant change between baseline and Year 3 (P=.79). Emergency room visits and hospital readmission increased for both groups (P=.90), while hospital admissions and urgent care visits decreased (P=.73). Similarly, utilization was not significantly different for patients with diabetes (P=.69). CONCLUSIONS: A care-management team approach failed to improve resource utilization rates by entire panels and the subset of diabetic patients compared to traditional care. This reinforces the need for further evidentiary support for the care-management model's hypothesis in the safety net.

  1. Low literacy self-care management patient education for a multi-lingual heart failure population: Results of a pilot study.

    PubMed

    Dickson, Victoria Vaughan; Chyun, Deborah; Caridi, Cristina; Gregory, Jill K; Katz, Stuart

    2016-02-01

    The purpose of this pilot study was to test the impact of language-free, low literacy self-care management patient education materials in an ethnically diverse multilingual heart failure (HF) population. A one group pre-test-post-test design measured changes in self-care, knowledge and health-related quality of life (HRQL) after a 1 month intervention using language-free, low literacy self-care management patient education materials and delivered by a health educator. The ethnically diverse sample (n=21) was predominately male (72%), 48% Black, 42% Hispanic, and 28% marginal/inadequate literacy. There were significant improvements in self-care and knowledge but not HRQL. Language-free, low literacy self-care patient education may facilitate improved self-care and knowledge in diverse populations who are at risk for poor HF outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

  2. The costs of caring: medical costs of Alzheimer's disease and the managed care environment.

    PubMed

    Murman, D L

    2001-01-01

    This review summarizes the medical costs associated with Alzheimer's disease (AD) and related dementias, as well as the payers responsible for these medical costs in the US health care system. It is clear from this review that AD and related dementias are associated with substantial medical costs. The payers responsible for a majority of these costs are families of patients with AD and the US government through the Medicare and Medicaid programs. In an attempt to control expenditures, Medicare and Medicaid have turned to managed care principles and managed care organizations. The increase in "managed" dementia care gives rise to several potential problems for patients with AD, along with many opportunities for systematic improvement in the quality of dementia care. Evidence-based disease management programs provide the greatest opportunities for improving managed dementia care but will require the development of dementia-specific quality of care measures to evaluate and continually improve them.

  3. The mapping competences of the nurse Case/Care Manager in the context of Intensive Care.

    PubMed

    Alfieri, Emanuela; Ferrini, Anna Chiara; Gianfrancesco, Francesca; Lise, Gianluca; Messana, Giovanni; Tirelli, Lorenzo; Lorenzo, Ana; Sarli, Leopoldo

    2017-03-15

    Since the recent introduction of the Case/Care Manager's professional figure, it is quite difficult to identify properly his/her own particular features, which could be mainly be found revising mainly in American studies. Therefore, the present study intended to identify the Case/Care Manager's skills and professional profile in an Intensive Care Unit experience, taking into consideration the staff's activities, perception and expectations towards the Case/Care Manager. In particular, it has been compared the experience of an Intensive Care Units where the Case/Care Manager's profile is operational to a different Unit where a Case/Care Manager is not yet in force. a Levati's model was used to map the Case/Care Manager's skills, involving each unit whole working staff, executives and caregivers through semi-structured interviews. It has been taken into consideration the Anaesthesia Unit and Emergency Unit of Cesena's healthcare organisation (AUSL of Romagna) and a Cardiology Intensive Care Unit of Piacenza's healthcare organisation, where the Case/Care Manager's profile has not been experimented yet. Firstly, it a data collection in each healthcare organization has been organised. Subsequently, semi-structured interviews to doctors, unit nurses, caregivers, nurses' coordinators and medical staff have been used to compare each healthcare system. The interviewees' described their expectations in relation to the Case/Care Manager working in a critical area. Then, every data collected during interviews has been organised to map a Case/Care Manager's essential professional profile to work in a critical area together with medical staff. Piacenza's O.U. critical area experience reported a major demand for patients' and patient's families' assistance. On the other hand, the very same aspects seem to have been better achieved in Cesena's O.U., where a Case/Care Manager's recent introduction has actually helped to overcome the void in organising systems. a Case/Care Manager

  4. Cost-Effectiveness of a Technology-Facilitated Depression Care Management Adoption Model in Safety-Net Primary Care Patients with Type 2 Diabetes.

    PubMed

    Hay, Joel W; Lee, Pey-Jiuan; Jin, Haomiao; Guterman, Jeffrey J; Gross-Schulman, Sandra; Ell, Kathleen; Wu, Shinyi

    2018-05-01

    The Diabetes-Depression Care-Management Adoption Trial is a translational study of safety-net primary care predominantly Hispanic/Latino patients with type 2 diabetes in collaboration with the Los Angeles County Department of Health Services. To evaluate the cost-effectiveness of an information and communication technology (ICT)-facilitated depression care management program. Cost-effectiveness of the ICT-facilitated care (TC) delivery model was evaluated relative to a usual care (UC) and a supported care (SC) model. TC added automated low-intensity periodic depression assessment calls to patients. Patient-reported outcomes included the 12-Item Short Form Health Survey converted into quality-adjusted life-years (QALYs) and the 9-Item Patient Health Questionnaire-calculated depression-free days (DFDs). Costs and outcomes data were collected over a 24-month period (-6 to 0 months baseline, 0 to 18 months study intervention). A sample of 1406 patients (484 in UC, 480 in SC, and 442 in TC) was enrolled in the nonrandomized trial. TC had a significant improvement in DFDs (17.3; P = 0.011) and significantly greater 12-Item Short Form Health Survey utility improvement (2.1%; P = 0.031) compared with UC. Medical costs were statistically significantly lower for TC (-$2328; P = 0.001) relative to UC but not significantly lower than for SC. TC had more than a 50% probability of being cost-effective relative to SC at willingness-to-pay thresholds of more than $50,000/QALY. An ICT-facilitated depression care (TC) delivery model improved QALYs, DFDs, and medical costs. It was cost-effective compared with SC and dominant compared with UC. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

  5. A new model for care population management.

    PubMed

    Williams, Jeni

    2013-03-01

    Steps toward building a population management model of care should include: Identifying the population that would be cared for through a population management initiative. Conducting an actuarial analysis for this population, reviewing historical utilization and cost data and projecting changes in utilization. Investing in data infrastructure that supports the exchange of data among providers and with payers. Determining potential exposure to downside risk and organizational capacity to assume this risk. Experimenting with payment models and care delivery approaches Hiring care coordinators to manage care for high-risk patients.

  6. Managing depression in primary care.

    PubMed

    Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping

    2017-08-01

    Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient. Copyright: © Singapore Medical Association.

  7. Managed care and its impact on American urology.

    PubMed

    Holtgrewe, H L

    1998-05-01

    America's health care is undergoing a revolution. A previous private, fee-for-service, delivery system chiefly centered around hospital specialty care is rapidly being replaced by a commercialized system of managed care, controlled by businessmen whose prime motive is profit. Increasing emphasis of these managed care organizations is upon primary physicians who function as gatekeepers. While this new commercialized method of health care has been attended with reductions in the previous omnipresent health care inflation our country has experienced for the past several decades, its impact on quality of care and patient choice of physician remain a great concern. Especially vulnerable in this new system are our nation's academic centers, which, burdened with responsibility for education and research, are at a disadvantage in the competitive cost-based bidding for managed care contracts. Urology work force issues and the number of urologists in our nation remain another concern for urologists as they compete for access to patients in this new highly competitive environment. In a 1995 survey of a cohort of urologists in seven states, the respondents reported 35.8% of gross income came from managed care contracts, 86% reported the need for preservice approval for many diagnostic and therapeutic undertakings, 87% reported an inability to refer complex cases outside the Managed Care Organization (MCO) network, and 23% reported they were required to retain patients for treatment who they would have otherwise referred to a more qualified urologist. The majority of American urologists are reporting dropping gross revenues and increasing overhead in their dealings with managed care contracts. The advent of managed care is being attended with dropping gross revenues, increasing overhead costs and interference with the practice patterns of American urologists.

  8. A family involvement and patient-tailored health management program in elderly Korean stroke patients' day care centers.

    PubMed

    Chang, Ae Kyung; Park, Yeon-Hwan; Fritschi, Cynthia; Kim, Mi Ja

    2015-01-01

    This study aimed to examine the effects of a family involvement and functional rehabilitation program in an adult day care center on elderly Korean stroke patients' perceived health, activities of daily living, instrumental activities of daily living, and cost of health services, and on family caregivers' satisfaction. Using one-group pre- and posttest design, dyads consisting of 19 elderly stroke patients and family caregivers participated in 12-week intervention, including involvement of family caregivers in day care services and patient-tailored health management. Outcomes of patients and caregivers were significantly improved (all p < .001). However, the cost of health services did not decrease significantly. This program improved functional levels and health perception of elderly stroke patients and caregivers' satisfaction. However, results must be interpreted with caution, because this was only a small, single-group pilot study. This program may be effective for elderly stroke patients and their caregivers. © 2013 Association of Rehabilitation Nurses.

  9. Person-centred pain management for the patient with acute abdominal pain: an ethnography informed by the Fundamentals of Care framework.

    PubMed

    Avallin, Therese; Muntlin Athlin, Åsa; Sorensen, Erik Elgaard; Kitson, Alison; Björck, Martin; Jangland, Eva

    2018-06-12

    To explore and describe the impact of the organizational culture on and the patient-practitioner patterns of actions that contribute to or detract from successful pain management for the patient with acute abdominal pain across the acute care pathway. Although pain management is a recognised human right, unmanaged pain continues to cause suffering and prolong hospital care. Unanswered questions about how to successfully manage pain relate to both organizational culture and individual practitioners' performance. Focused ethnography, applying the Developmental Research Sequence and the Fundamentals of Care framework. Participant observation and informal interviews (92 hours) were performed at one emergency department and two surgical wards at a University Hospital during April - November 2015. Data includes 261 interactions between patients, aged ≥18 years seeking care for acute abdominal pain at the emergency department and admitted to a surgical ward (N = 31; aged 20-90 years; 14 men, 17 women; 9 with communicative disabilities) and healthcare practitioners (N =198). The observations revealed an organizational culture with considerable impact on how well pain was managed. Well managed pain presupposed the patient and practitioners to connect in a holistic pain management including a trustful relationship, communication to share knowledge and individualized analgesics. Person-centred pain management requires an organization where patients and practitioners share their knowledge of pain and pain management as true partners. Leaders and practitioners should make small behavioural changes to enable the crucial positive experience of pain management. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

  10. Safe patient care - safety culture and risk management in otorhinolaryngology.

    PubMed

    St Pierre, Michael

    2013-12-13

    Safety culture is positioned at the heart of an organization's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organization's maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organization's safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality. Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate stimulation based team trainings into their

  11. [Safe patient care: safety culture and risk management in otorhinolaryngology].

    PubMed

    St Pierre, M

    2013-04-01

    Safety culture is positioned at the heart of an organisation's vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture ("top-down process"). A type marker for organizational culture and thus a predictor for an organizations maturity in respect to safety is information flow and in particular an organization's general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed "informed culture". An informed culture is free of blame and open for information provided by incidents. "Incident reporting systems" are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organisation's "safe surgery checklist" is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate simulation based team trainings into their curriculum

  12. International Primary Care Respiratory Group (IPCRG) Guidelines: management of asthma.

    PubMed

    van der Molen, Thys; Østrem, Anders; Stallberg, Bjorn; Østergaard, Marianne Stubbe; Singh, Raj B

    2006-02-01

    Worldwide, most patients with asthma are treated in primary care. Optimal primary care management of asthma is therefore of considerable importance. This IPCRG Guideline paper on the management of asthma in primary care is fully consistent with GINA guidelines. It is split into two sections, the first on the management of adults and schoolchildren, and the second on the management of pre-school children. It highlights the treatment goals for asthma and gives an overview of optimal management including the topics which should be covered by the primary care health professional when educating a patient about asthma. It covers the classification of the disease, the stepwise approach to pharmacologic therapy, disease monitoring, the management of exacerbations, and the identification of patients at risk of asthma death.

  13. Care management in amyotrophic lateral sclerosis.

    PubMed

    Soriani, M-H; Desnuelle, C

    2017-05-01

    Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive and fatal neurodegenerative disease characterized by progressive weakness of voluntary muscles of movement as well as those for swallowing, speech and respiration. In the absence of curative treatment, care can improve quality of life, prolong survival, and support ALS patients and their families, and also help them to anticipate and prepare for the end of life. Multidisciplinary management in tertiary centers is recommended in close collaboration with general practitioners, home carers and a dedicated health network. Patients' follow-up deals mainly with motor impairment and physical disability, adaptation, nutrition and respiratory function. Involvement of palliative care as part of the multidisciplinary team management offers patients the possibility of discussing their end of life issues. This review summarizes the different aspects of ALS care, from delivering the diagnosis to the end of life, and the organization of its management. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

  14. Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient.

    PubMed

    Wiznia, Daniel H; Zaki, Theodore; Maisano, Julianna; Kim, Chang-Yeon; Halaszynski, Thomas M; Leslie, Michael P

    The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.

  15. Identifying patients with gastroesophageal reflux disease in a managed care organization.

    PubMed

    Ofman, J J; Ryu, S; Borenstein, J; Kania, S; Lee, J; Grogg, A; Farup, C; Weingarten, S

    2001-09-01

    The ability of various strategies to identify patients with gastroesophageal reflux disease (GERD) and the relative economic impact on disease management programs for GERD were studied. A telephone interview was conducted of a random sample of patients enrolled in any of three health plans in a 100,000-member managed care organization who had either a pharmacy claim or an encounter claim during 1997. The telephone interview identified patients with GERD and served as the standard by which the sensitivity, specificity, and predictive values of the following patient-identification strategies were compared: (1) telephone interview, (2) chart review, (3) use of encounter claims, (4) use of pharmacy claims, (5) use of both encounter claims, and pharmacy claims, and (6) use of encounter claims or pharmacy claims. Conservative estimates of costs and projected savings were then used to model the potential return on investment of the strategies. A total of 1186 patients completed the telephone interview, of whom 390 (33%) met the case definition of GERD. The most sensitive method for identifying patients with GERD was using either pharmacy or encounter claims (26%). The most specific strategy with the highest positive predictive value (PPV) (87%) was using both pharmacy and encounter claims, but this approach had a case-detection rate of only 3%. Encounter claims were significantly more sensitive than pharmacy claims and yielded a higher estimate of prevalence. The telephone interview identified the most subjects who could have benefited from a disease management program and cost 84% less than chart review. While use of administrative data (pharmacy and encounter claims) was the least costly strategy, it identified 74% fewer patients expected to benefit from disease management. The efficiency of disease management programs for GERD may depend on the method of patient identification, which in turn may depend on whether PPV or negative predictive value (NPV) should be

  16. Patient Safety Policy in Long-Term Care: A Research Protocol to Assess Executive WalkRounds to Improve Management of Early Warning Signs for Patient Safety.

    PubMed

    van Dusseldorp, Loes; Hamers, Hub; van Achterberg, Theo; Schoonhoven, Lisette

    2014-07-15

    At many hospitals and long-term care organizations (such as nursing homes), executive board members have a responsibility to manage patient safety. Executive WalkRounds offer an opportunity for boards to build a trusting relationship with professionals and seem useful as a leadership tool to pick up on soft signals, which are indirect signals or early warnings that something is wrong. Because the majority of the research on WalkRounds has been performed in hospitals, it is unknown how board members of long-term care organizations develop their patient safety policy. Also, it is not clear if these board members use soft signals as a leadership tool and, if so, how this influences their patient safety policies. The objective of this study is to explore the added value and the feasibility of WalkRounds for patient safety management in long-term care. This study also aims to identify how executive board members of long-term care organizations manage patient safety and to describe the characteristics of boards. An explorative before-and-after study was conducted between April 2012 and February 2014 in 13 long-term care organizations in the Netherlands. After implementing the intervention in 6 organizations, data from 72 WalkRounds were gathered by observation and a reporting form. Before and after the intervention period, data collection included interviews, questionnaires, and studying reports of the executive boards. A mixed-method analysis is performed using descriptive statistics, t tests, and content analysis. Results are expected to be ready in mid 2014. It is a challenge to keep track of ongoing development and implementation of patient safety management tools in long-term care. By performing this study in cooperation with the participating long-term care organizations, insight into the potential added value and the feasibility of this method will increase.

  17. Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9.

    PubMed

    Bauer, Amy M; Chan, Ya-Fen; Huang, Hsiang; Vannoy, Steven; Unützer, Jürgen

    2013-03-01

    With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. Observational analysis of data collected from a patient registry. Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10). SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily

  18. Intensive care unit versus hospital floor: a comparative study of postoperative management of patients with adolescent idiopathic scoliosis.

    PubMed

    Shan, Le-Qun; Skaggs, David L; Lee, Christopher; Kissinger, Catherine; Myung, Karen S

    2013-04-03

    Patients undergoing posterior spinal instrumentation and fusion surgery for adolescent idiopathic scoliosis were admitted to the intensive care unit until two years ago, at which time we changed our protocol to admit these patients to the general hospital floor following a brief stay in a postanesthesia care unit. This study compared postoperative management on a hospital floor with that in the intensive care unit for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. A retrospective review of 124 consecutive patients with adolescent idiopathic scoliosis treated with spinal fusion from August 2007 to August 2010 was performed. Inclusion criteria were a diagnosis of adolescent idiopathic scoliosis and posterior spinal instrumentation and fusion surgery. Of 124 patients, sixty-six were managed postoperatively in the intensive care unit and fifty-eight, on the hospital floor. The mean age at the time of surgery was fourteen years. A mean of eleven vertebral levels (range, six to fifteen levels) were fused. No significant difference between the groups was found with respect to the mean age at the time of surgery, mean weight, mean preoperative and postoperative Cobb angles, and mean number of levels fused (p ≥ 0.12). However, the use of analgesic and antianxiety medication, number of postoperative blood tests, days of hospital stay, and number of physical therapy sessions were significantly decreased in the floor group compared with the intensive care unit group (p ≤ 0.05). No patient from the floor group had to be admitted to the intensive care unit. The mean charge was $33,121 for the floor group and $39,252 for the intensive care unit group (p < 0.001). Initial postoperative management of patients with adolescent idiopathic scoliosis following a posterior spinal instrumentation and fusion surgery on a general hospital floor, rather than in an intensive care unit, was associated with a shorter hospital stay, fewer blood tests, less

  19. [Quality management in intensive care medicine].

    PubMed

    Martin, J; Braun, J-P

    2014-02-01

    Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to external quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

  20. [Quality management in intensive care medicine].

    PubMed

    Martin, J; Braun, J-P

    2013-09-01

    Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to extern quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

  1. Liability issues in managed care.

    PubMed

    Ellis, M S

    1997-05-01

    The explosive growth in Managed Care Organizations as a mechanism for providing health care in the United States has generated an equal explosion in litigation and new legislation related to problems within this delivery system. Abuses have included the "gagging" of physicians from providing full disclosure of medical options for their patients, inappropriate denial of care, denial of specialty referral, false claims data, insurer insolvency, economic credentialling, deselection, financial disincentives to render care, and lack of appeal or grievance mechanisms. These issues and others have resulted in injuries to patients and damage to the patient/physician relationship. This article discusses some of the more dramatic litigated cases and endeavors to alert both physicians and patients to potential legal matters that should be considered before becoming involved within this structure.

  2. Understanding effective care management implementation in primary care: a macrocognition perspective analysis.

    PubMed

    Holtrop, Jodi Summers; Potworowski, Georges; Fitzpatrick, Laurie; Kowalk, Amy; Green, Lee A

    2015-08-21

    Care management in primary care can be effective in helping patients with chronic disease improve their health status. Primary care practices, however, are often challenged with its implementation. Incorporating care management involves more than a simple physical process redesign to existing clinical care routines. It involves changes to who is working with patients, and consequently such things as who is making decisions, who is sharing patient information, and how. Studying the range of such changes in "knowledge work" during implementation requires a perspective and tools designed to do so. We used the macrocognition perspective, which is designed to understand how individuals think in dynamic, messy real-world environments such as care management implementation. To do so, we used cognitive task analysis to understand implementation in terms of such thinking as decision making, knowledge, and communication. Data collection involved semi-structured interviews and observations at baseline and at approximately 9 months into implementation at five practices in one physician-owned administratively connected group of practices in the state of Michigan, USA. Practices were intervention participants in a larger trial of chronic care model implementation. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with macrocognition as a guiding framework. Seventy-four interviews and five observations were completed. There were differences in implementation success across the practices, and these differences in implementation success were well explained by macrocognition. Practices that used more macrocognition functions and used them more often were also more successful in care management implementation. Although care management can introduce many new changes into the delivery of primary care clinical practice, implementing it successfully as a new complex intervention is possible. Macrocognition is a

  3. Promoting self-management in diabetes: efficacy of a collaborative care approach.

    PubMed

    Sieber, William; Newsome, Alita; Lillie, Dustin

    2012-12-01

    Diabetes is a leading cause of death and is estimated to cost the United States 90 billion dollars annually. Increasing patient self-management skills has been shown to improve outcomes in patients with Type II diabetes. Promotion of shared decision-making between patient and provider is a core element of collaborative care and is especially well suited for increasing patient self-management. Research trials to date have been limited in demonstrating how self-management promotion can be fully integrated into primary care practices. Demonstration of the impact of this approach is needed. This study involves 22 randomly assigned physicians across three family medicine clinics to either provide usual care or work with a part-time collaborative care therapist in their clinic serving as an outreach health coach for their diabetic patients. Each outreach health coach met with each physician in the intervention group to identify patients most in need of intervention, sent identified patients a video on diabetes management, and called to encourage video viewing and discuss any patient-perceived barriers to self-management. Initial markers of patient activation in self-management, patients' video-viewing behavior, and health care encounters in the subsequent 6 months were compared between groups. Results showed that patients targeted by an outreach health coach were more likely to view the video, be seen by their primary care physician (PCP) within 6 months, and have disease-relevant laboratory tests performed than patients receiving usual care from their PCP (p < .05). This approach, linking PCPs with collaborative care staff, is viewed as expanding the engagement of PCPs with the collaborative team for superior patient health outcomes.

  4. Barriers and facilitators of care for diverse patients: Nurse leader perspectives and nurse manager implications.

    PubMed

    Ogbolu, Yolanda; Scrandis, Debra A; Fitzpatrick, Grace

    2018-01-01

    To examine chief nurse executives' perspectives on: (1) the provision of culturally and linguistically appropriate services in hospitals and (2) to identify barriers and facilitators associated with the implementation of culturally and linguistically appropriate services. Hospitals continue to face challenges providing care to diverse patients. The uptake of standards related to culturally and linguistically appropriate services into clinical practice is sluggish, despite potential benefits, including reducing health disparities, patient errors, readmissions and improving patient experiences. A qualitative study with chief nurse executives from one eastern United States (US). Data were analysed using content analysis. Seven themes emerged: (1) lack of awareness of resources for health care organisations; (2) constrained cultural competency training; (3) suboptimal resources (cost and time); (4) mutual understanding; (5) limited workplace diversity; (6) community outreach programmes; and (7) the management of unvoiced patient expectations. As the American population diversifies, providing culturally and linguistically appropriate services remains a priority for nurse leaders. Being aware and utilizing the resources, policies and best practices available for the implementation of culturally and linguistically appropriate services can assist nursing managers in reaching their goals of providing high quality care to diverse populations. Nurse managers are key in aligning the unit's resources with organisational goals related to the provision of culturally and linguistically appropriate services by providing the operational leadership to eliminate barriers and to enhance the uptake of best practices related to culturally and linguistically appropriate services. © 2017 John Wiley & Sons Ltd.

  5. Evaluation and management of patients in the acute phase of myocardial infarction - the role of nuclear medicine in the coronary care unit

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Palac, R.T.; Gray, L.; Brown, P.H.

    1988-09-01

    This is the third article in a four-part continuing education series relating to patient care and management. After completing the article, the reader should be able to: 1) understand the application, potential, and problems of nuclear cardiology in the coronary care unit; 2) recognize the utilization of nuclear cardiology in acute coronary care management; and 3) appreciate the important role of nuclear cardiology in cardiac patient care.

  6. Evidence-based health care management: what is the research evidence available for health care managers?

    PubMed

    Jaana, Mirou; Vartak, Smruti; Ward, Marcia M

    2014-09-01

    In light of increasing interest in evidence-based management, we conducted a scoping review of systematic reviews (SRs) and meta-analyses (MAs) to determine the availability and accessibility of evidence for health care managers; 14 MAs and 61 SRs met the inclusion criteria. Most reviews appeared in medical journals (53%), originated in the United States (29%) or United Kingdom (22%), were hospital-based (55%), and targeted clinical providers (55%). Topics included health services organization (34%), quality/patient safety (17%), information technology (15%), organization/workplace management (13%), and health care workforce (12%). Most reviews addressed clinical topics of relevance to managers; management-related interventions were rare. The management issues were mostly classified as operational (65%). Surprisingly, 96.5% of search results were not on target. A better classification within PubMed is needed to increase the accessibility of meaningful resources and facilitate evidence retrieval. Health care journals should take initiatives encouraging the publication of reviews in relevant management areas. © The Author(s) 2013.

  7. Organizational Effectiveness and Patient Care Quality Study.

    DTIC Science & Technology

    1981-09-01

    health care) 2. Interpersonal Communication (unique medical terminology) 3. Problem Solving’ 4. Team Building 5. Feedback of Patient / Consumer ...AD-AIO5 755 ACADEMY OF HEALTH SCIENCES (ARMY) FORT SAM HOUSTON TX--ETC F/0 6/5ORGANIZATIONAL EFFECTIVENESS AND PATIENT CARE QALITY STUOY.(U)SEP 51 A...care settings must consider the mission requirements of the organization, the patient care requirements, management and health care provider needs

  8. A Statewide Survey Report of Roles and Responsibilities in Current Utah Care Management Processes.

    PubMed

    Luther, Brenda; Martial, Marc-Aurel; Barra, Joyce

    Measure current roles and responsibilities of care managers in the state of Utah. All settings of health care including inpatient, outpatient, community, payer, post-acute, and transitional care settings. A quantitative descriptive survey design was used to assess and describe current care management roles and responsibilities of 191 care managers within the state of Utah. Quantitative variables of roles and responsibilities were collected an electronic database (REDCap). Major results conclude that care managers spend most of their time on direct patient interactions including discharge planning, population care, and utilization review. These care managers are highly experienced in their field, with most being in their professional practice for more than 10 years. Most of the care managers are bachelor's prepared nurses. To create or expand care management processes to meet the goals of health care reform, systems first need to know what care managers/coordinators are doing and where their current focus on care presides. Educators, leaders, and, indeed, the care managers themselves are a part of preparing this dynamic workforce. The major responsibility of care management continues to be direct patient interactions, meaning that care managers are performing vital interpersonal patient interaction needed to achieve highly personalized patient care with assurances of quality and safety. No matter the name-care management, case management, or care coordination-these activities are an essential part of health care, with highly specialized skills that promote patient engagement and activation.

  9. Primary care provider turnover and quality in managed care organizations.

    PubMed

    Plomondon, Mary E; Magid, David J; Steiner, John F; MaWhinney, Samantha; Gifford, Blair D; Shih, Sarah C; Grunwald, Gary K; Rumsfeld, John S

    2007-08-01

    To examine the association between primary care provider turnover in managed care organizations and measures of member satisfaction and preventive care. Retrospective cohort study of a national sample of 615 managed care organizations that reported HEDIS data to the National Committee for Quality Assurance from 1999 through 2001. Multivariable hierarchical regression modeling was used to evaluate the association between health plan primary care provider turnover rate and member satisfaction and preventive care measures, including childhood immunization, well-child visits, cholesterol, diabetes management, and breast and cervical cancer screening, adjusting for patient and organizational characteristics, time, and repeated measures. The median primary care provider turnover rate was 7.1% (range, 0%-53.3%). After adjustment for plan characteristics, health plans with higher primary care provider turnover rates had significantly lower measures of member satisfaction, including overall rating of healthcare (P < .01). A 10% higher primary care provider turnover rate was associated with 0.9% fewer members rating high overall satisfaction with healthcare. Health plans with higher provider turnover rates also had lower rates of preventive care, including childhood immunization (P = .045), well-child visits (P = .002), cholesterol screening after cardiac event (P = .042), and cervical cancer screening (P = .024). For example, a 10% higher primary care provider turnover was associated with a 2.7% lower rate of child-members receiving well-child visits in the first 15 months of life. Primary care provider turnover is associated with several measures of care quality, including aspects of member satisfaction and preventive care. Future studies should evaluate whether interventions to reduce primary care provider turnover can improve quality of care and patient outcomes.

  10. The perceptions and perspectives of patients and health care providers on chronic diseases management in rural South Africa: a qualitative study.

    PubMed

    Maimela, Eric; Van Geertruyden, Jean-Pierre; Alberts, Marianne; Modjadji, Sewela E P; Meulemans, Herman; Fraeyman, Jesicca; Bastiaens, Hilde

    2015-04-08

    Preventive health care represents the future for health care delivery in South Africa to improve management of chronic diseases as this has been implemented for some time in several countries to tackle the increasing burden of chronic diseases. Individual person's health is unique, as they move in and out of chronic and acute health care phases, there is need to integrate chronic and acute care constructs to improve continuity of care and maximize health and improve wellbeing. The aim of this study was to determine the perceptions and perspectives of chronic patients' and nurses regarding chronic disease management in terms of barriers, facilitators and their experiences. To meet our aim we used qualitative methods involving the collection of information by means of focus group discussions in Dikgale Health and Demographic Surveillance System (HDSS). All data was recorded, transcribed verbatim and analysed using data-driven thematic analysis. Our study showed that chronic disease patients have a first contact with health care professionals at the primary health care level in the study area. The main barriers mentioned by both the health care workers and chronic disease patients are lack of knowledge on chronic diseases, shortage of medication and shortage of nurses in the clinics which causes patients to wait for a long periods in a clinic. Health care workers are poorly trained on the management of chronic diseases. Lack of supervision by the district and provincial health managers together with poor dissemination of guidelines has been found to be a contributing factor to lack of knowledge in nurses among the clinics within the study area. Both patients and nurses mentioned the need to involve community health workers and traditional healers and integrate their services in order to early detect and manage chronic diseases in the community. Nurses and chronic disease patients mentioned similar barriers to chronic disease management. Concerted action is needed to

  11. Use of DHCP to provide essential information for care and management of HIV patients.

    PubMed

    Pfeil, C N; Ivey, J L; Hoffman, J D; Kuhn, I M

    1991-01-01

    The Department of Veterans' Affairs (VA) has reported over 10,000 Acquired Immune Deficiency Syndrome (AIDS) cases since the beginning of the epidemic. These cases were distributed throughout 152 of the VA's network of 172 medical centers and outpatient clinics. This network of health care facilities presents a unique opportunity to provide computer based information systems for clinical care and resource monitoring for these patients. The VA further facilitates such a venture through its commitment to the Decentralized Hospital Computer Program (DHCP). This paper describes a new application within DHCP known as the VA's HIV Registry. This project addresses the need to support clinical information as well as the added need to manage the resources necessary to care for HIV patients.

  12. Use of DHCP to provide essential information for care and management of HIV patients.

    PubMed Central

    Pfeil, C. N.; Ivey, J. L.; Hoffman, J. D.; Kuhn, I. M.

    1991-01-01

    The Department of Veterans' Affairs (VA) has reported over 10,000 Acquired Immune Deficiency Syndrome (AIDS) cases since the beginning of the epidemic. These cases were distributed throughout 152 of the VA's network of 172 medical centers and outpatient clinics. This network of health care facilities presents a unique opportunity to provide computer based information systems for clinical care and resource monitoring for these patients. The VA further facilitates such a venture through its commitment to the Decentralized Hospital Computer Program (DHCP). This paper describes a new application within DHCP known as the VA's HIV Registry. This project addresses the need to support clinical information as well as the added need to manage the resources necessary to care for HIV patients. PMID:1807575

  13. How is agitation and restlessness managed in the last 24 h of life in patients whose care is supported by the Liverpool care pathway for the dying patient?

    PubMed

    Gambles, M; McGlinchey, T; Latten, R; Dickman, A; Lowe, D; Ellershaw, J E

    2011-12-01

    Guidance regarding the patient centred management of agitation and restlessness reinforces the importance of considering underlying causes, non-pharmacological approaches to treatment and judicious use of medications titrated to patient need. In contrast, recent reports in the literature suggest that the practice of continuous deep sedation until death is prevalent in the UK. To use data from the National Care of the Dying Audit-Hospitals (NCDAH) to explore the administration of medication for management of agitation and restlessness in the last 24 h of life. Hospitals submitted data from up to 30 consecutive adult patients whose care in the final hours/days of life was supported by the Liverpool Care Pathway for the Dying Patient (LCP). Data on the total dose received in the last 24 h of life PRN and the last dose prescribed for administration via continuous subcutaneous infusion (CSCI) for agitation and restlessness were submitted. 155 hospitals provided data from 3893 patients. Median total doses in the last 24 h for midazolam, haloperidol and levomepromazine, respectively, were: PRN only, 2.5, 1.5 and 6.25 mg; CSCI only, 10, 3 and 6.25 mg; PRN+CSCI, 15, 3 and 12.5 mg. Only 51% of patients received medication to alleviate agitation and restlessness in the last 24 h of life. Median doses were low in comparison to doses recommended for continuous deep sedation, suggesting that there is no 'blanket' policy for continuous deep sedation at the end of life for patients whose care is supported by the LCP.

  14. Reducing Suicidal Ideation in Home Health Care: Results from the CAREPATH Depression Care Management Trial

    PubMed Central

    Lohman PhD, Matthew C.; Raue PhD, Patrick J.; Greenberg, Rebecca L.; Bruce, Martha L.

    2016-01-01

    Objectives The study evaluated the effectiveness of a depression care management intervention in reducing suicidal ideation (SI) among home health patients. Methods Data come from the cluster-randomized effectiveness trial of the Depression Care for Patients at Home (Depression CAREPATH), an intervention that integrates depression care management into the routine nursing visits of Medicare home health patients screening positive for depression. Patients were interviewed at baseline, 3, 6, and 12 months follow-up. Suicidal ideation was measured using the Hamilton Rating Scale for Depression (HAM-D) item. We compared likelihood of any level of SI between intervention and usual care patients using longitudinal logistic mixed-effects models. Results A total of 306 eligible patients enrolled in the trial. Among them, 70 patients (22.9%) reported SI at baseline. Among patients with SI, patients under the care of nurses randomized to CAREPATH were less likely to report SI over the study period (OR=0.51, 95% CI; 0.24-1.07), with 63.6% of usual care versus 31.3% of CAREPATH participants continuing to report SI after one year. Baseline major depression, greater perceived burdensomeness, and greater functional disability were associated with greater likelihood of SI. Conclusion SI is reported in more than 10% of Medicare home health patients. The Depression CAREPATH intervention was associated with a reduction in patients reporting SI at one year, compared to enhanced usual care. Given relative low burden on nursing staff, depression care management may be an important component of routine home health practices producing long-term reduction in SI among high-risk patients. PMID:26552852

  15. Veterans Health Administration Office of Nursing Services exploration of positive patient care synergies fueled by consumer demand: care coordination, advanced clinic access, and patient self-management.

    PubMed

    Wertenberger, Sydney; Yerardi, Ruth; Drake, Audrey C; Parlier, Renee

    2006-01-01

    The consumers who utilize the Veterans Health Administration healthcare system are older, and most are learning to live with chronic diseases. Their desires and needs have driven changes within the Veterans Health Administration. Through patient satisfaction initiatives and other feedback sources, consumers have made it clear that they do not want to wait for their care, they want a say in what care is provided to them, and they want to remain as independent as possible. Two interdisciplinary processes/models of healthcare are being implemented on the national level to address these issues: advanced clinic access and care coordination. These programs have a synergistic relationship and are integrated with patient self-management initiatives. Positive outcomes of these programs also meet the needs of our staff. As these new processes and programs are implemented nationwide, skills of both patients and nursing staff who provide their care need to be enhanced to meet the challenges of providing nursing care now and into the 21st century. Veterans Health Administration Office of Nursing Services Strategic Planning Work Group is defining and implementing processes/programs to ensure nurses have the knowledge, information, and skills to meet these patient care demands at all levels within the organization.

  16. Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

    PubMed

    Darkins, Adam; Ryan, Patricia; Kobb, Rita; Foster, Linda; Edmonson, Ellen; Wakefield, Bonnie; Lancaster, Anne E

    2008-12-01

    Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

  17. [Challenges for home care services in the pain management of cancer patients : A qualitative study].

    PubMed

    Gnass, I; Krutter, S; Nestler, N

    2018-03-21

    People with cancer are increasingly supported by home care services. Pain is a relevant symptom of these diseases and nurses of home care services are involved in the treatment. The German National Expert Standard "Pain management in nursing" includes evidence-based recommendations for the implementation of adequate pain management. Considering the given structural conditions of home care services, nurses describe both barriers and challenges with the implementation. By means of five guideline-based discussion groups, nurses of 14 home care services were questioned about the challenges they had experienced in pain management. The questioning focuses on the level of implementation of the recommendation for each aspect: pain assessment, pharmacological pain therapy, non-pharmacological pain therapy, pain-related side effects, information, training, and counseling in the care of people with cancer. A qualitative content analysis was conducted. On the one hand, the results illustrate a need for further knowledge and possibilities, e.g., for the assessment of pain as a multidimensional phenomenon and, on the other hand, that the conditions for continuous pain monitoring of cancer patients in home care services are limited. The need for short-term reconciliation with the treatment team and the practitioners proved to be more difficult than the cooperation with the palliative care network. Involvement of family members is important to ensure uninterrupted treatment. Beside knowledge and competencies regarding nursing care, structures and processes for interprofessional pain management need further development and research.

  18. Clinical case management for patients with schizophrenia with high care needs.

    PubMed

    Mas-Expósito, Laia; Amador-Campos, Juan Antonio; Gómez-Benito, Juana; Mauri-Mas, Lluís; Lalucat-Jo, Lluís

    2015-02-01

    The aim of this study is to establish the effectiveness of a clinical case management (CM) programme compared to a standard treatment programme (STP) in patients with schizophrenia. Patients for the CM programme were consecutively selected among patients in the STP with schizophrenia who had poor functioning. Seventy-five patients were admitted to the CM programme and were matched to 75 patients in the STP. Patients were evaluated at baseline and at 1 year follow-up. At baseline, patients in the CM programme showed lower levels of clinical and psychosocial functioning and more care needs than patients in the STP. Both treatment programmes were effective in maintaining contact with services but the CM programme did not show advantages over the STP on outcomes. Differences between groups at baseline may be masking the effects of CM at one year follow-up. A longer follow-up may be required to evaluate the real CM practices effects.

  19. Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan

    PubMed Central

    Birnkrant, David J; Bushby, Katharine; Bann, Carla M; Apkon, Susan D; Blackwell, Angela; Colvin, Mary K; Cripe, Linda; Herron, Adrienne R; Kennedy, Annie; Kinnett, Kathi; Naprawa, James; Noritz, Garey; Poysky, James; Street, Natalie; Trout, Christina J; Weber, David R; Ward, Leanne M

    2018-01-01

    Improvements in the function, quality of life, and longevity of patients with Duchenne muscular dystrophy (DMD) have been achieved through a multidisciplinary approach to management across a range of health-care specialties. In part 3 of this update of the DMD care considerations, we focus on primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Many primary care and emergency medicine clinicians are inexperienced at managing the complications of DMD. We provide a guide to the acute and chronic medical conditions that these first-line providers are likely to encounter. With prolonged survival, individuals with DMD face a unique set of challenges related to psychosocial issues and transitions of care. We discuss assessments and interventions that are designed to improve mental health and independence, functionality, and quality of life in critical domains of living, including health care, education, employment, interpersonal relationships, and intimacy. PMID:29398641

  20. Diabetes management in an Australian primary care population.

    PubMed

    Krass, I; Hebing, R; Mitchell, B; Hughes, J; Peterson, G; Song, Y J C; Stewart, K; Armour, C L

    2011-12-01

    Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control. This was a retrospective, epidemiological study of primary care patients with T2DM diabetes, with HbA(1c) of >7%, recruited in 90 Australian community pharmacies. Data collected included demographic details, diabetes history, current medication regimen, height, weight, BP, physical activity and smoking status. Of the 430 patients, 98% used antidiabetics, 80% antihypertensives, 73% lipid lowering drugs and 38% aspirin. BP and all lipid targets were met by only 21% and 14% of the treated patients and 21% and 12% of the untreated patients respectively. Medication adherence was related to better glycaemic control (P = 0.04). An evidence-base prescribing practice gap was seen in this Australian primary care population of T2DM patients. Patients were undertreated with antihypertensive and lipid lowering medication, and several subgroups with co-morbidities were not receiving the recommended pharmacotherapy. Interventions are required to redress the current evidence-base prescribing practice gap in disease management in primary care. © 2011 Blackwell Publishing Ltd.

  1. Impact of a comprehensive supportive care team on management of hopelessly ill patients with multiple organ failure.

    PubMed

    Field, B E; Devich, L E; Carlson, R W

    1989-08-01

    We developed a supportive care team for hopelessly ill patients in an urban emergency/trauma hospital. The team includes a clinical nurse specialist and a faculty physician as well as a chaplain and social worker. The supportive care team provides an alternative to intensive care or conventional ward management of hopelessly ill patients and concentrates on the physical and psychosocial comfort needs of patients and their families. We describe our experience with 20 hopelessly ill patients with multiple organ failure vs a similar group treated before the development of the supportive care team. Although there was no difference in mortality (100 percent), the length of stay in the medical ICU for patients with multiple organ failure decreased by 12 days to 6 days. Additionally, there were 50 percent fewer therapeutic interventions provided by the supportive care team vs intensive care or conventional ward treatment of multiple organ failure patients. We describe the methods that the supportive care team uses in an attempt to meet the physical and psychosocial comfort needs of hopelessly ill multiple organ failure patients and their families. This multidisciplinary approach to the care of the hopelessly ill may have applications in other institutions facing the ethical, medical, and administrative challenges raised by these patients.

  2. Integrating Patient Concerns into Parkinson's Disease Management.

    PubMed

    Lim, Shen-Yang; Tan, Ai Huey; Fox, Susan H; Evans, Andrew H; Low, Soon Chai

    2017-01-01

    Parkinson's disease (PD) is a complex motor and non-motor disorder and management is often challenging. In this review, we explore emerging approaches to improve the care of patients, drawing from the literature regarding patient-centred care, patient and caregiver perspectives and priorities, gaps in knowledge among patients and caregivers and the need for accurate information, individual variability in disease manifestations, prognostication of disease course, new developments in health technologies and personalized medicine, specialty care, pharmacological and non-pharmacological management, financial burden, lifestyle and work-related issues, support groups and palliative care.

  3. The potential of palliative care for patients with respiratory diseases

    PubMed Central

    Narsavage, Georgia L.; Chen, Yea-Jyh; Korn, Bettina; Elk, Ronit

    2017-01-01

    Based on the demonstrated effectiveness of palliative care in the alleviation of symptoms and enhancement of life quality, it is important to incorporate palliative care early in the respiratory disease trajectory. Quality palliative care addresses eight domains that are all patient and family centred. Palliative care interventions in respiratory conditions include management of symptoms such as dyspnoea, cough, haemoptysis, sputum production, fatigue and respiratory secretion management, especially as the end-of-life nears. A practical checklist of activities based on the domains of palliative care can assist clinicians to integrate palliative care into their practice. Clinical management of patients receiving palliative care requires consideration of human factors and related organisational characteristics that involve cultural, educational and motivational aspects of the patient/family and clinicians. Educational aims To explain the basic domains of palliative care applicable to chronic respiratory diseases. To review palliative care interventions for patients with chronic respiratory diseases. To outline a checklist for clinicians to use in practice, based on the domains of palliative care. To propose recommendations for clinical management of patients receiving palliative care for chronic respiratory diseases. PMID:29209422

  4. The relationship between self-management abilities, quality of chronic care delivery, and wellbeing among patients with chronic obstructive pulmonary disease in The Netherlands

    PubMed Central

    Cramm, Jane Murray; Nieboer, Anna Petra

    2013-01-01

    Background This cross-sectional study aimed to identify the relationship between quality of chronic care delivery, self-management abilities, and wellbeing among patients with chronic obstructive pulmonary disease (COPD). Methods The study was conducted in 2012 and included 548 (out of 1303; 42% response rate) patients with COPD enrolled in a COPD care program in the region of Noord-Kennemerland in The Netherlands. We employed a multilevel random-effects model (548 patients nested in 47 healthcare practices) to investigate the relationship between quality of chronic care delivery, self-management abilities, and patients’ wellbeing. In the multilevel analyses we controlled for patients’ background characteristics and health behaviors. Results Multilevel analyses clearly showed a significant relationship between quality of chronic care delivery and wellbeing of patients with COPD (P ≤ 0.001). When self-management abilities were included in the equation while controlling for background characteristics, health behaviors, and quality of chronic care delivery, these abilities were found to have a strong positive relationship with patients’ wellbeing (P ≤ 0.001). Low educational level, single marital status, and physical exercise were not significantly associated with wellbeing when self-management abilities were included in the equation. Conclusion Self-management abilities and the quality of chronic care delivery are important for the wellbeing of patients with COPD. Furthermore, self-management abilities acted as mediators between wellbeing and low educational level, single status, and physical exercise among these patients. PMID:23641152

  5. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review)

    PubMed Central

    Miller, R G.; Jackson, C E.; Kasarskis, E J.; England, J D.; Forshew, D; Johnston, W; Kalra, S; Katz, J S.; Mitsumoto, H; Rosenfeld, J; Shoesmith, C; Strong, M J.; Woolley, S C.

    2009-01-01

    Objective: To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS). Methods: The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include breaking the news, multidisciplinary clinics, symptom management, cognitive and behavioral impairment, communication, and palliative care for patients with ALS. Results: The authors identified 2 Class I studies, 8 Class II studies, and 30 Class III studies in ALS, but many important areas have been little studied. More high-quality, controlled studies of symptomatic therapies and palliative care are needed to guide management and assess outcomes in patients with ALS. Recommendations: Multidisciplinary clinic referral should be considered for managing patients with ALS to optimize health care delivery and prolong survival (Level B) and may be considered to enhance quality of life (Level C). For the treatment of refractory sialorrhea, botulinum toxin B should be considered (Level B) and low-dose radiation therapy to the salivary glands may be considered (Level C). For treatment of pseudobulbar affect, dextromethorphan and quinidine should be considered if approved by the US Food and Drug Administration (Level B). For patients who develop fatigue while taking riluzole, withholding the drug may be considered (Level C). Because many patients with ALS demonstrate cognitive impairment, which in some cases meets criteria for dementia, screening for cognitive and behavioral impairment should be considered in patients with ALS (Level B). Other management strategies all lack strong evidence. GLOSSARY ALS = amyotrophic lateral sclerosis; ALS-FTD = amyotrophic lateral sclerosis with a dementia meeting the Neary criteria for frontotemporal dementia; ALSbi = amyotrophic lateral sclerosis with behavioral impairment; ALSci = amyotrophic lateral sclerosis with cognitive impairment; BTxA = botulinum toxin type A; BTxB = botulinum

  6. Primary care physician management, referral, and relations with specialists concerning patients at risk for cancer due to family history.

    PubMed

    Wood, M E; Flynn, B S; Stockdale, A

    2013-01-01

    Risk stratification based on family history is a feature of screening guidelines for a number of cancers and referral guidelines for genetic counseling/testing for cancer risk. Our aim was to describe primary care physician perceptions of their role in managing cancer risk based on family history. Structured interviews were conducted by a medical anthropologist with primary care physicians in 3 settings in 2 north-eastern states. Transcripts were systematically analyzed by a research team to identify major themes expressed by participants. Forty interviews were conducted from May 2003 through May 2006. Physicians provided a diversity of views on roles in management of cancer risk based on family history, management practices and patient responses to risk information. They also provided a wide range of perspectives on criteria used for referral to specialists, types of specialists referred to and expected management roles for referred patients. Some primary care physicians appeared to make effective use of family history information for cancer risk management, but many in this sample did not. Increased focus on efficient assessment tools based on recognized guidelines, accessible guides to management options, and patient education and decision aids may be useful directions to facilitate broader use of family history information for cancer risk management. Copyright © 2013 S. Karger AG, Basel.

  7. Simplifying anemia management in hemodialysis patients: ESAs administered at longer dosing intervals can enhance opportunities to provide patient-focused care.

    PubMed

    Schiller, Brigitte; Besarab, Anatole

    2011-08-01

    To review issues and challenges in caring for hemodialysis patients with anemia of chronic kidney disease, specifically focusing on the effects of longer erythropoiesis-stimulating agent (ESA) dosing intervals on processes of care. PubMed searches were performed limited to the last 10 years to February 2011, focusing on articles in English that were 'clinical trials,' assessed processes of care, measured associations of hemoglobin (Hb) with outcomes, and explored/analyzed extended dosing intervals of ESAs in hemodialysis patients and recommendations for increasing the quality of care of these patients. Some limitations included the fact that a meta-analysis was not conducted; many studies were associative and therefore unable to prove causality; and none of the clinical trials directly compared the impact of more frequent or less frequent ESA dosing strategies on patient care and outcomes. Progress over the past several decades has been substantial; however, unmet needs remain and there is room for improvement in efficiencies of care. Many patients fail to meet Hb targets, and nephrology professionals' time is consumed with preparing, administering, and monitoring therapy. Direct interaction between patients and care providers has been lost as attention has shifted to 'cost-effective' (not necessarily patient-centered) ways to deliver care. Use of ESAs at longer dosage intervals represents one opportunity to improve efficiency of care. Newer ESAs have been developed for less frequent dosing. Once-monthly dosing decreases time spent administering/monitoring therapy and allows nephrology professionals to provide comprehensive renal care, wherein the patient rather than task-oriented processes becomes the primary focus. A fragmented, uncoordinated care-delivery model heightens the urgency to systematically address issues related to delivery of care and improve efficiencies in anemia management as part of the patient-centered approach. ESAs designed for administration

  8. The Effect of Nurse Practitioner Co-Management on the Care of Geriatric Conditions

    PubMed Central

    Reuben, David B.; Ganz, David A.; Roth, Carol P.; McCreath, Heather E.; Ramirez, Karina D.; Wenger, Neil S.

    2013-01-01

    Background/Objectives The quality of care for geriatric conditions remains poor. The Assessing Care of Vulnerable Elders (ACOVE)-2 model (case finding, delegation of data collection, structured visit notes, physician and patient education, and linkage to community resources) improves the quality of care for geriatric conditions when implemented by primary care physicians (PCPs) or by nurse practitioners (NPs) co-managing care with an academic geriatrician. However, it is unclear whether community-based PCP-NP co-management can achieve similar results. Design Case study. Setting Two community-based primary care practices. Participants Patients > 75 years who screened positive for at least one condition: falls, urinary incontinence (UI), dementia, and depression. Intervention The ACOVE-2 model augmented by NP co-management of conditions. Measurements Quality of care by medical record review using ACOVE-3 quality indicators (QIs). Patients receiving co-management were compared with those who received PCP care alone in the same practices. Results Of 1084 screened patients, 658 (61%) screened positive for > 1 condition; 485 of these patients were randomly selected for chart review and triggered a mean of 7 QIs. A NP saw approximately half (49%) for co-management. Overall, patients received 57% of recommended care. Quality scores for all conditions (falls: 80% versus 34%; UI: 66% versus 19%; dementia: 59% versus 38%) except depression (63% versus 60%) were higher for patients seen by a NP. In analyses adjusted for gender, age of patient, number of conditions, site, and a NP estimate of medical management style, NP co-management remained significantly associated with receiving recommended care (p<0.001), as did the NP estimate of medical management style (p=0.02). Conclusion Compared to usual care using the ACOVE-2 model, NP co-management is associated with better quality of care for geriatric conditions in community-based primary care. PMID:23772723

  9. Factors affecting home care patients' acceptance of a web-based interactive self-management technology

    PubMed Central

    Karsh, Ben-Tzion; Severtson, Dolores J; Burke, Laura J; Brown, Roger L; Brennan, Patricia Flatley

    2010-01-01

    Objective With the advent of personal health records and other patient-focused health technologies, there is a growing need to better understand factors that contribute to acceptance and use of such innovations. In this study, we employed the Unified Theory of Acceptance and Use of Technology as the basis for determining what predicts patients' acceptance (measured by behavioral intention) and perceived effective use of a web-based, interactive self-management innovation among home care patients. Design Cross-sectional secondary analysis of data from a randomized field study evaluating a technology-assisted home care nursing practice with adults with chronic cardiac disease. Measurement and analysis A questionnaire was designed based on validated measurement scales from prior research and was completed by 101 participants for measuring the acceptance constructs as part of the parent study protocol. Latent variable modeling with item parceling guided assessment of patients' acceptance. Results Perceived usefulness accounted for 53.9% of the variability in behavioral intention, the measure of acceptance. Together, perceived usefulness, health care knowledge, and behavioral intention accounted for 68.5% of the variance in perceived effective use. Perceived ease of use and subjective norm indirectly influenced behavioral intention, through perceived usefulness. Perceived ease of use and subjective norm explained 48% of the total variance in perceived usefulness. Conclusion The study demonstrates that perceived usefulness, perceived ease of use, subjective norm, and healthcare knowledge together predict most of the variance in patients' acceptance and self-reported use of the web-based self-management technology. PMID:21131605

  10. A review of recent literature - nurse case managers in diabetes care: equivalent or better outcomes compared to primary care providers.

    PubMed

    Watts, Sharon A; Lucatorto, Michelle

    2014-07-01

    Primary care has changed remarkably with chronic disease burden growth. Nurse case managers assist with this chronic disease by providing if not significantly better care, than equivalent care to that provided by usual primary care providers. Chronic disease management requires patient-centered skills and tools, such as registries, panel management, review of home data, communicating with patients outside of face-to-face care, and coordinating multiple services. Evidence reviewed in this article demonstrates that registered nurse care managers (RNCM) perform many actions required for diabetes chronic disease management including initiation and titration of medications with similar or improved physiologic and patient satisfaction outcomes over usual care providers. Selection and training of the nurse case managers is of utmost importance for implementation of a successful chronic disease management program. Evidence based guidelines, algorithms, protocols, and adequate ongoing education and mentoring are generally cited as necessary support tools for the nurse case managers.

  11. Rheumatologist and Primary Care Management of Cardiovascular Disease Risk in Rheumatoid Arthritis: Patient and Provider Perspectives.

    PubMed

    Bartels, Christie M; Roberts, Tonya J; Hansen, Karen E; Jacobs, Elizabeth A; Gilmore, Andrea; Maxcy, Courtney; Bowers, Barbara J

    2016-04-01

    Despite increased cardiovascular disease (CVD) risk, rheumatoid arthritis (RA) patients often lack CVD preventive care. We examined CVD preventive care processes from RA patient and provider perspectives to develop a process map for identifying targets for future interventions to improve CVD preventive care. Thirty-one participants (15 patients, 7 rheumatologists, and 9 primary care physicians [PCPs]) participated in interviews that were coded using NVivo software and analyzed using grounded theory techniques. Patients and providers reported that receipt of preventive care depends upon identifying and acting on risk factors, although most noted that both processes rarely occurred. Engagement in these processes was influenced by various provider-, system-, visit-, and patient-related conditions, such as patient activation or patients' knowledge about their risk. While nearly half of patients and PCPs were unaware of RA-CVD risk, all rheumatologists were aware of risk. Rheumatologists reported not systematically identifying risk factors, or, if identified, they described communicating about CVD risk factors via clinic notes to PCPs instead of acting directly due to perceived role boundaries. PCPs suggested that scheduling PCP visits could improve CVD risk management, and all participants viewed comanagement positively. Findings from this study illustrate important gaps and opportunities to support identifying and acting on CVD risk factors in RA patients from the provider, system, visit, and patient levels. Future work should investigate professional role support through improved guidelines, patient activation, and system-based RA-CVD preventive care strategies. © 2016, American College of Rheumatology.

  12. Optimizing cardiothoracic surgery information for a managed care environment.

    PubMed

    Denton, T A; Matloff, J M

    1995-11-01

    The rapid change occurring in American healthcare is a direct response to rising costs. Managed care is the fastest growing model that attempts to control escalating costs through limitations in patient choice, the active use of guidelines, and placing providers at risk. Managed care is an information intensive system, and those providers who use information effectively will be at an advantage in the competitive healthcare marketplace. There are five classes of information that providers must collect to be competitive in a managed care environment: patient satisfaction, medical outcomes, continuous quality improvement, quality of the decision, and financial data. Each of these should be actively used in marketing, assuring the quality of patient care, and maintaining financial stability. Although changes in our healthcare system are occurring rapidly, we need to respond to the marketplace to maintain our viability, but as physicians, we have the singular obligation to maintain the supremacy of the individual patient and the physician-patient relationship.

  13. Comparison of maternal and neonatal outcomes for patients with placenta accreta spectrum between online-to-offline management model with standard care model.

    PubMed

    Sun, Wen; Yu, Lin; Liu, Shiliang; Chen, Yanhong; Chen, Juanjuan; Wen, Shi Wu; Chen, Dunjin

    2018-03-01

    Online-to-offline is a new model for emergent medical service with the ability to connect care providers with patients on instant basis. This study aims to evaluate maternal and neonatal outcomes in patients with placenta accreta spectrum managed by an online-to-offline care model. Starting from January 1, 2015, management of patients with placenta accreta spectrum was changed from standard care model into an online-to-offline care model through "Wechat" in Guangzhou Medical Centre for Critical Obstetrical Care. This study compared maternal and neonatal outcomes in patients affected by placenta accreta spectrum between 2015 (online-to-offline model) and 2014 (standard care model). A total of 209 cases of placenta accrete spectrum were treated in our center in 2015 and 218 such cases were treated in 2014. Patients treated in 2015 had lower rate of hysterectomy (14.83% versus 20.64%) and shorter hospital stay (7 days versus 8 days). The average interval from admission to emergency cesarean section for critically ill patients was 38.5 min in 2015 versus 50.7 min in 2014. Patients affected by placenta accreta spectrum managed by online-to-offline care model have reduced risk of hysterectomy, shorter hospital stay, and shorter response time from admission to emergency cesarean section. Copyright © 2018 Elsevier B.V. All rights reserved.

  14. Data systems can boost nursing care. Nurse management information systems in resource management.

    PubMed

    Wilson, J

    1992-02-01

    Resource management aims to improve patient care by matching resources with patient needs. Nurse management information systems provide data on skill mix, rostering requirements, ward costs and patient dependency levels, enabling a nursing strategy to be planned for the ward.

  15. Outcomes of an Interdisciplinary Transitional Care Quality Improvement Project on Self-Management and Health Care Use in Patients With Heart Failure.

    PubMed

    Hoover, Carrie; Plamann, Joy; Beckel, Jean

    2017-01-01

    Heart failure (HF) accounts for most U.S. Medicare hospital admissions. The purpose of the current study was to evaluate the effectiveness of a care transitions quality improvement (QI) intervention on self-management and readmission rates in older adults with HF. A quasi-experimental, descriptive study was conducted with 66 patients with HF in three medical units in a 489-bed Midwestern acute care hospital. The intervention included a nurse coach visit and follow up, pharmacy medication education and reconciliation, and HF clinic referral. Outcomes were assessed within 48 hours of admission and 30 days after discharge using the Self-Care of Heart Failure Index and medical record review. Following implementation, readmission rates decreased from 24% to 13%. Participants demonstrated a greater improvement in use of self-management strategies to control symptoms than the non-intervention group (p < 0.02) and more readily identified their symptoms of HF (p < 0.04). The evolution of population health, with increasing numbers of older adults living at home with complex chronic conditions, will require establishment of active partnerships among pharmacists, physicians, nurse specialists, home care nurses, and patients. [Journal of Gerontological Nursing, 43(1), 23-31.]. Copyright 2016, SLACK Incorporated.

  16. Toward population management in an integrated care model.

    PubMed

    Maddux, Franklin W; McMurray, Stephen; Nissenson, Allen R

    2013-04-01

    Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative.

  17. Toward population management in an integrated care model.

    PubMed

    Maddux, Franklin W; McMurray, Stephen; Nissenson, Allen R

    2013-01-01

    Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative. © 2013 S. Karger AG, Basel.

  18. [Management of patients under 18years of age by adult intensive care unit professionals: Level of training, workload, and specific challenges].

    PubMed

    Brossier, D; Villedieu, F; Letouzé, N; Pinto Da Costa, N; Jokic, M

    2017-03-01

    In routine practice, intensive care physicians rarely have to manage children under 18years of age, particularly those under 15. This study's objectives were to assess the quality of training in pediatrics of adult intensive care teams, to document the workload generated by care of pediatric patients, and to identify the difficulties encountered in managing minors as patients. A survey was administered in Lower Normandy from 4 April 2012 to 1 September 2012. Physicians, residents, nurses, and nurses' aides practicing in one of the nine intensive care units of Lower Normandy were asked to complete an electronic or paper format questionnaire. This questionnaire assessed their level of pediatric training, the workload management of pediatric patients entailed, and the challenges posed by these patients. One hundred and nine questionnaires were returned (by 26 attending physicians, 18 residents, 38 nurses, and 27 nurses' aides). Eighty-three of the respondents (76%) had no experience in a pediatric unit of any kind. Forty-two percent thought that the pediatric age range lies between 3months and 15years of age. However, more than 50% of respondents would like the upper limit to be 16years or even older. Ninety-three respondents (85%) estimated having some exposure to pediatric patients in their routine practice, but this activity remained quite low. Seventy-three (67%) reported difficulties with the management of these young patients. This survey provides current information regarding the level of training of adult intensive care unit professionals and their concerns about managing patients under 18years of age, both in terms of workload and specific challenges. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  19. Temporal changes in management and outcome of septic shock in patients with malignancies in the intensive care unit.

    PubMed

    Pène, Frédéric; Percheron, Stéphanie; Lemiale, Virginie; Viallon, Vivian; Claessens, Yann-Erick; Marqué, Sophie; Charpentier, Julien; Angus, Derek C; Cariou, Alain; Chiche, Jean-Daniel; Mira, Jean-Paul

    2008-03-01

    Septic shock is a severe, often terminal, complication of malignancy. For patients without malignancy, outcome from septic shock has improved with new advances in care. We wished to explore whether outcome from septic shock has similarly improved for cancer patients, with regard to implementation of recent adjuvant therapies. An 8-yr retrospective observational study. A 24-bed medical intensive care unit in a university hospital. Patients were 238 consecutive cancer patients (solid tumors or hematologic malignancies) with septic shock admitted to the intensive care unit within two consecutive 4-yr periods: 1998-2001 and 2002-2005. None. Septic shock occurred in 90 patients in 1998-2001 and 148 in 2002-2005. Management of septic shock between the two periods mostly differed by emergence of adjuvant therapies of sepsis (mainly low-dose glucocorticoids) and intensive insulin therapy and a more frequent use of renal replacement therapy in the recent period. Short-term survival rates were significantly higher during 2002-2005 compared with the previous 4-yr period: 28-day, intensive care unit, and hospital survival rates were 47.3% vs. 27.8% (p = .003), 41.2% vs. 26.7% (p = .02), and 36.5% vs. 21.1% (p = .01), respectively. After adjustment, intensive care unit admission between 2002 and 2005 was an independent favorable prognostic factor for short-term outcome. Improved survival was mainly observed in patients who did not require renal replacement therapy during their stay in the intensive care unit (hospital survival 65% in 2002-2005 vs. 21.4% in 1998-2001, p < .001). Improved outcome in critically ill cancer patients extended to the subgroup of patients with septic shock. This might be ascribed both to a better selection of patients and to improvements in the care and management, including new therapeutic strategies for sepsis.

  20. Impact of Neurointensivist Co-management on the Clinical Outcomes of Patients Admitted to a Neurosurgical Intensive Care Unit

    PubMed Central

    2017-01-01

    Limited data are available on improved outcomes after initiation of neurointensivist co-management in neurosurgical intensive care units (NSICUs) in Korea. We evaluated the impact of a newly appointed neurointensivist on the outcomes of neurosurgical patients admitted to an intensive care unit (ICU). This retrospective observational study involved neurosurgical patients admitted to the NSICU at Samsung Medical Center between March 2013 and May 2016. Neurointensivist co-management was initiated in October 1 2014. We compared the outcomes of neurosurgical patients before and after neurointensivist co-management. The primary outcome was ICU mortality. A total of 571 patients were admitted to the NSICU during the study period, 291 prior to the initiation of neurointensivist co-management and 280 thereafter. Intracranial hemorrhage (29.6%) and traumatic brain injury (TBI) (26.6%) were the most frequent reasons for ICU admission. TBI was the most common cause of death (39.0%). There were no significant differences in mortality rates and length of ICU stay before and after co-management. However, the rates of ICU and 30-day mortality among the TBI patients were significantly lower after compared to before initiation of neurointensivist co-management (8.5% vs. 22.9%; P = 0.014 and 11.0% vs. 27.1%; P = 0.010, respectively). Although overall outcomes were not different after neurointensivist co-management, initiation of a strategy of routine involvement of a neurointensivist significantly reduced the ICU and 30-day mortality rates of TBI patients. PMID:28480662

  1. Retaining customers in a managed care market. Hospitals must understand the connection between patient satisfaction, loyalty, retention, and revenue.

    PubMed

    Gemme, E M

    1997-01-01

    Traditionally, health care patients have been treated by health care professionals as people with needs rather than as customers with options. Although managed care has restricted patient choice, choice has not been eliminated. The premise of this article is that patients are primary health care consumers. Adopting such a premise and developing an active customer retention program can help health care organizations change their culture for the better, which may lead to higher customer retention levels and increased revenues. Customer retention programs based on service excellence that empower employees to provide excellent care can eventually lead to a larger market share for health care organizations trying to survive this era of intense competition.

  2. ESRD Managed Care Demonstration: Financial Implications

    PubMed Central

    Dykstra, Dawn M.; Beronja, Nancy; Menges, Joel; Gaylin, Daniel S.; Oppenheimer, Caitlin Carroll; Shapiro, Jennifer R.; Wolfe, Robert A.; Rubin, Robert J.; Held, Philip J.

    2003-01-01

    In 1996, CMS launched the end stage renal disease (ESRD) managed care demonstration to study the experience of offering managed care to ESRD patients. This article analyzes the financial impact of the demonstration, which sought to assess its economic impact on the Federal Government, the sites, and the ESRD Medicare beneficiaries. Medicare's costs for demonstration enrollees were greater than they would have been if these enrollees had remained in the fee-for-service (FFS) system. This loss was driven by the lower than average predicted Medicare spending given the demonstration patients' conditions. The sites experienced losses or only modest gains, primarily because they provided a larger benefit package than traditional Medicare coverage, including no patient obligations and other benefits, especially prescription drugs. Patient financial benefits were approximately $9,000 annually. PMID:14628400

  3. Bedside Reporting: Protocols for Improving Patient Care.

    PubMed

    Ferguson, Teresa D; Howell, Teresa L

    2015-12-01

    Bedside reporting continues to gain much attention and is being investigated to support the premise that "hand-off" communications enhance efficacy in delivery of patient care. Patient inclusion in shift reports enhances good patient outcomes, increased satisfaction with care delivery, enhanced accountability for nursing professionals, and improved communications between patients and their direct care providers. This article discusses the multiple benefits of dynamic dialogue between patients and the health care team, challenges often associated with bedside reporting, and protocols for managing bedside reporting with the major aim of improving patient care. Nursing research supporting the concept of bedside reporting is examined. Copyright © 2015 Elsevier Inc. All rights reserved.

  4. The impact of disease management on outcomes and cost of care: a study of low-income asthma patients.

    PubMed

    Rossiter, L F; Whitehurst-Cook, M Y; Small, R E; Shasky, C; Bovbjerg, V E; Penberthy, L; Okasha, A; Green, J; Ibrahim, I A; Yang, S; Lee, K

    2000-01-01

    An asthma disease management program designed specifically for low-income patients experiencing significant adverse events can improve health outcomes substantially, while lowering costs. The Virginia Health Outcomes Partnership aimed to help physicians in a fee-for-service primary care case management program manage asthma in Medicaid recipients. Approximately one-third of physicians treating asthma in an area designated as the intervention community volunteered to participate in training on disease management and communication skills. This large-scale study discovered that the rate of emergency visit claims for patients of participating physicians who received feedback reports dropped an average of 41% from the same quarter a year earlier, compared to only 18% for comparison community physicians. Although only a third of the intervention community physicians participated in the training, emergency visit rates for all intervention community physicians nonetheless declined by 6% relative to the comparison community among moderate-to-severe asthma patients when data for participating and nonparticipating physicians were combined. At the same time, the dispensing of some reliever drugs recommended for asthma increased 25% relative to the comparison community. A cost-effectiveness analysis projected direct savings to Medicaid of $3 to $4 for every incremental dollar spent providing disease management support to physicians. The results of this study demonstrate the potential this program offers, especially for Medicaid programs in other states that want to improve the care of their primary care case management networks and, at the same time, manage costs.

  5. [Anesthetic management of four patients with Fournier syndrome].

    PubMed

    Sato, Rui; Tomioka, Toshiya; Orii, Ryo; Yamada, Yoshitsugu

    2008-03-01

    We experienced anesthetic managements of four patients with Fournier syndrome. In the anesthetic management of the patients with Fournier syndrome the following three points should be kept in mind; (a) the necessity of careful preoperative examination, (b) the better anesthesia, and (c) the careful postoperative care.

  6. Individual care plans for chronically ill patients within primary care in the Netherlands: Dissemination and associations with patient characteristics and patient-perceived quality of care.

    PubMed

    Jansen, Daphne L; Heijmans, Monique; Rijken, Mieke

    2015-06-01

    To examine the use of individual care plans (ICPs) within primary chronic illness care in the Netherlands, and to explore the relationships between ICP use, patient characteristics, and patient-perceived quality of care. Cross-sectional study using survey data from a panel of chronically ill patients and medical registration data provided by their general practices. A sample of 1377 patients with somatic chronic disease(s) randomly selected in general practices throughout the Netherlands, supplemented with a sample of 225 COPD patients, also recruited from general practices. (i) Percentage of ICP use based on self-report by chronically ill patients, and (ii) patient-perceived quality of care as assessed using the Patient Assessment of Chronic Illness Care (PACIC). ICP use among the total generic sample was low (9%), but slightly higher (13%) among patients diagnosed with diabetes or COPD, diseases for which disease management programmes have been set up in the Netherlands. Patients with a low educational level and patients with poor(er) self-rated health were more likely to have an ICP. Compared with patients without an ICP, patients with an ICP more often reported that the care they received was patient-centred, proactive, planned, and included collaborative goal setting, problem-solving, and follow-up support. Findings reveal a discrepancy between practice and policy aspirations regarding ICP use in primary chronic illness care. More research is needed to gain insight into the effectiveness of ICPs to improve the quality of chronic illness care in various patient populations.

  7. Management matters: the link between hospital organisation and quality of patient care

    PubMed Central

    West, E.

    2001-01-01

    Some hospital trusts and health authorities consistently outperform others on different dimensions of performance. Why? There is some evidence that "management matters", as well as the combined efforts of individual clinicians and teams. However, studies that have been conducted on the link between the organisation and management of services and quality of patient care can be criticised both theoretically and methodologically. A larger, and arguably more rigorous, body of work exists on the performance of firms in the private sector, often conducted within the disciplines of organisational behaviour or human resource management. Studies in these traditions have focused on the effects of decentralisation, participation, innovative work practices, and "complementarities" on outcome variables such as job satisfaction and performance. The aim of this paper is to identify a number of reviews and research traditions that might bring new ideas into future work on the determinants of hospital performance. Ideally, future research should be more theoretically informed and should use longitudinal rather than cross sectional research designs. The use of statistical methods such as multilevel modelling, which allow for the inclusion of variables at different levels of analysis, would enable estimation of the separate contribution that structure and process make to hospital outcomes. Key Words: hospital organisation; hospital performance; management; quality of care PMID:11239143

  8. Multidsciplinary heart failure management and end of life care.

    PubMed

    Ryder, Mary; Beattie, James M; O'Hanlon, Rory; McDonald, Kenneth

    2011-12-01

    There has been much improvement in the treatment of heart failure over the past decade through the implementation of a multidisciplinary team approach to disease management focused on optimizing medication, the application of device-based therapy, surgical intervention and in promoting the education of patients and carers in self-management. This multidisciplinary strategy has now been extended to try and improve the care of those with advanced heart failure in the latter phases of the disease trajectory nearing the end of their lives. A growing consensus has emerged in the literature that confirms the need to extend multidisciplinary management beyond the early targets of reducing heart failure-related mortality and morbidity to address the significant care needs of those who decline due to the often inexorable progression of this syndrome. Multidisciplinary management facilitates the development of a comprehensive care plan that is specifically tailored to accommodate the requirements of individual patients and their families and fosters a collaborative approach to care to optimize symptom management, avoid potential treatments conflicts, and to fulfil their supportive care needs. Partnership working between the three principal clinical disciplines of cardiology, specialist palliative care and general practice is central to this process and promotes coordinated care across hospital, hospice and community-based services. Advanced heart failure management has improved over time; however, the incorporation of a multidisciplinary care model appears to offer significant promise in dealing with complex care needs of heart failure patients towards the end of life. Delivery of this practice requires the development of bespoke care structures that are relevant to the spectrum of healthcare service environments.

  9. Venetoclax: Management and Care for Patients With Relapsed or Refractory Chronic Lymphocytic Leukemia
.

    PubMed

    Brumbaugh Paradis, Heather; Alter, Debbie; Llerandi, Diane

    2017-10-01

    Venetoclax (Venclexta™) is a potent, selective, orally available, small-molecule B-cell lymphoma 2 inhibitor that achieves response rates of about 80% and has an acceptable safety profile for patients with relapsed or refractory chronic lymphocytic leukemia (CLL).
. The aim was to describe treatment management considerations when caring for patients using venetoclax.
. A review was done of safety and management considerations based on current clinical practice and 240 patients with CLL who received venetoclax monotherapy on clinical trials from 2011-2016.
. Common adverse events were neutropenia, diarrhea, nausea, anemia, upper respiratory tract infection, thrombocytopenia, and fatigue. Because of rapid tumor reduction with venetoclax, nurses should be aware of the potential for tumor lysis syndrome (TLS) and the need to educate patients on steps to minimize risks, including gradual dose ramp-up, adequate hydration, and use of prophylactic antihyperuricemia agents. Following implementation of these risk-reducing measures, no clinical TLS events were reported in ongoing trials.

  10. Decision support for patient care: implementing cybernetics.

    PubMed

    Ozbolt, Judy; Ozdas, Asli; Waitman, Lemuel R; Smith, Janis B; Brennan, Grace V; Miller, Randolph A

    2004-01-01

    The application of principles and methods of cybernetics permits clinicians and managers to use feedback about care effectiveness and resource expenditure to improve quality and to control costs. Keys to the process are the specification of therapeutic goals and the creation of an organizational culture that supports the use of feedback to improve care. Daily feedback on the achievement of each patient's therapeutic goals provides tactical decision support, enabling clinicians to adjust care as needed. Monthly or quarterly feedback on aggregated goal achievement for all patients on a clinical pathway provides strategic decision support, enabling clinicians and managers to identify problems with supposed "best practices" and to test hypotheses about solutions. Work is underway at Vanderbilt University Medical Center to implement feedback loops in care and management processes and to evaluate the effects.

  11. COPD self-management supportive care: chaos and complexity theory.

    PubMed

    Cornforth, Amber

    This paper uses the emergent theories of chaos and complexity to explore the self-management supportive care of chronic obstructive pulmonary disease (COPD) patients within the evolving primary care setting. It discusses the concept of self-management support, the complexity of the primary care context and consultations, smoking cessation, and the impact of acute exacerbations and action planning. The author hopes that this paper will enable the acquisition of new insight and better understanding in this clinical area, as well as support meaningful learning and facilitate more thoughtful, effective and high quality patient-centred care within the context of primary care.

  12. Patient's experience with comorbidity management in primary care: a qualitative study of comorbid pain and obesity.

    PubMed

    Janke, E Amy; Ramirez, Michelle L; Haltzman, Brittany; Fritz, Megan; Kozak, Andrea T

    2016-01-01

    The aim of this research is to examine perceptions of those with comorbid chronic pain and obesity regarding their experience of comorbidity management in primary care settings. Chronic pain and obesity are common comorbidities frequently managed in primary care settings. Evidence suggests individuals with this comorbidity may be at risk for suboptimal clinical interactions; however, treatment experiences and preferences of those with comorbid chronic pain and obesity have received little attention. Semi-structured interviews conducted with 30 primary care patients with mean body mass index=36.8 and comorbid persistent pain. The constant comparative method was used to analyze data. Participants discussed frustration with a perceived lack of information tailored to their needs and a desire for a personalized treatment experience. Participants found available medical approaches unsatisfying and sought a more holistic approach to management. Discussions also focused around the need for providers to initiate efforts at education and motivation enhancement and to show concern for and understanding of the unique difficulties associated with comorbidity. Findings suggest providers should engage in integrated communication regarding weight and pain, targeting this multimorbidity using methods aligned with priorities discussed by patients.

  13. Analysis of team types based on collaborative relationships among doctors, home-visiting nurses and care managers for effective support of patients in end-of-life home care.

    PubMed

    Fujita, Junko; Fukui, Sakiko; Ikezaki, Sumie; Otoguro, Chizuru; Tsujimura, Mayuko

    2017-11-01

    To define the team types consisting of doctors, home-visiting nurses and care managers for end-of-life care by measuring the collaboration relationship, and to identify the factors related to the team types. A questionnaire survey of 43 teams including doctors, home-visiting nurses and care managers was carried out. The team types were classified based on mutual evaluations of the collaborative relationships among the professionals. To clarify the factors between team types with the patient characteristics, team characteristics and collaboration competency, univariate analysis was carried out with the Fisher's exact test or one-way analysis and multiple comparison analysis. Three team types were classified: the team where the collaborative relationships among all healthcare professionals were good; the team where the collaborative relationships between the doctors and care managers were poor; and the team where the collaborative relationships among all of the professionals were poor. There was a statistically significant association between the team types and the following variables: patient's dementia level, communication tool, professionals' experience of working with other team members, home-visiting nurses' experience of caring for dying patients, care managers' background qualifications, doctor's face-to-face cooperation with other members and home-visiting nurses' collaborative practice. It is suggested that a collaborative relationship would be fostered by more experience of working together, using communication tools and enhancing each professional's collaboration competency. Geriatr Gerontol Int 2017; 17: 1943-1950. © 2017 Japan Geriatrics Society.

  14. Health information technology: transforming chronic disease management and care transitions.

    PubMed

    Rao, Shaline; Brammer, Craig; McKethan, Aaron; Buntin, Melinda B

    2012-06-01

    Adoption of health information technology (HIT) is a key effort in improving care delivery, reducing costs of health care, and improving the quality of health care. Evidence from electronic health record (EHR) use suggests that HIT will play a significant role in transforming primary care practices and chronic disease management. This article shows that EHRs and HIT can be used effectively to manage chronic diseases, that HIT can facilitate communication and reduce efforts related to transitions in care, and that HIT can improve patient safety by increasing the information available to providers and patients, improving disease management and safety. Copyright © 2012 Elsevier Inc. All rights reserved.

  15. [Management of dysphagia in internal intensive-care medicine].

    PubMed

    Michels, G; Motzko, M; Weinert, M; Bruckner, M; Pfister, R; Guntinas-Lichius, O

    2015-04-01

    Physicians specializing in dysphagia are needed in modern intensive care medicine. Long-term intubation is associated with aspiration and swallowing disorders. Early and standardised dysphagia management should be initiated during a patient's stay on intensive care unit. A clinically experienced, interdisciplinary team is required to provide optimal care for critically ill patients with dysphagia. Intensive care physicians should therefore know about basics in dysphagiology.

  16. Management of hyperphosphataemia: practices and perspectives amongst the renal care community.

    PubMed

    Nagel, Christina Johanna Maria; Casal, María Cruz; Lindley, Elizabeth; Rogers, Susan; Pancířová, Jitka; Kernc, Jennifer; Copley, J Brian; Fouque, Denis

    2014-12-01

    Protein-rich foods are a major source of dietary phosphorus; therefore, helping patients to increase their dietary protein intake, while simultaneously managing their hyperphosphataemia, poses a significant challenge for renal care professionals. To examine the clinical recommendations and practice perceptions of renal care professionals providing nutrition and phosphate control advice to patients with chronic kidney disease (CKD). Renal care professionals from four European countries completed an online survey on the clinical management of hyperphosphataemia. The majority of responders recommended a protein intake of less than 1.0 g/kg/day for pre-dialysis patients, 1.2 g/kg/day for patients undergoing peritoneal dialysis (PD) and 1.1-1.2 g/kg/day for patients undergoing haemodialysis (HD). The most common perception was that maintaining dietary protein intake and reducing dietary phosphorus intake are equally important for hyperphosphataemia management. For patients in the pre-dialysis stage, the majority of responders (59%) reported that their first-line management recommendation would be reduction of dietary phosphorus. For patients undergoing PD and HD, the majority of responders (53% and 59%, respectively) reported a first-line management recommendation of both reduction of dietary phosphorus and phosphate binder therapy. More renal nurses than dietitians perceived reducing dietary phosphorus to be more important than maintaining protein intake (for patients undergoing PD, 23% vs. 0%, respectively; for patients undergoing HD, 34% vs. 0%, respectively). This renal care community followed professionally accepted guidelines for patient nutrition and management of hyperphosphataemia. There was disparity in the perceptions and recommendations between nurses and dietitians, highlighting the need to standardise management practices amongst renal care professionals. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

  17. Stroke disease management--a framework for comprehensive stroke care.

    PubMed

    Venketasubramanian, N; Chan, B P L; Lim, E; Hafizah, Noor; Goh, K T; Lew, Y J; Loo, L; Yin, A; Widjaja, L; Loke, W C; Kuick, G; Lee, N L; Ong, B S; Koh, S F; Heng, B H; Cheah, J

    2002-07-01

    Disease management is an approach to patient care that coordinates medical resources for the patient across the entire healthcare delivery system throughout the lifetime of the patient with the disease. Stroke is suitable for disease management as it is a well-known disease with a high prevalence, high cost, variable practice pattern, poor clinical outcome, and managed by a non-integrated healthcare system. It has measurable and actionable outcomes, with available local expertise and support of the Ministry of Health. Developing the programme requires a multidisciplinary team, baseline data on target populations and healthcare services, identification of core components, collaboration with key stakeholders, development of evidence-based clinical practice guidelines and carepaths, institution of care coordinators, use of information technology and continuous quality improvement to produce an effective plan. Core components include public education, risk factor screening and management, primary care and specialist clinics, acute stroke units, inpatient and outpatient rehabilitation facilities, and supportive community services including medical, nursing, therapy, home help and support groups for patients and carers. The family physician plays a key role. Coordination of services is best done by a network of hospital and community-based care managers, and is enhanced by a coordinating call centre. Continuous quality improvement is required, with audit of processes and outcomes, facilitated by a disease registry. Pitfalls include inappropriate exclusion of deserving patients, misuse, loss of physician and patient independence, over-estimation of benefits, and care fragmentation. Collaboration and cooperative among all parties will help ensure a successful and sustainable programme.

  18. The impact of care management information technology model on quality of care after percutaneous coronary intervention: "Bridging the Divides".

    PubMed

    Weintraub, William S; Fanari, Zaher; Elliott, Daniel; Ostertag-Stretch, Jennifer; Muther, Ann; Lynahan, Margaret; Kerzner, Roger; Salam, Tabassum; Scherrer, Herbert; Anderson, Sharon; Russo, Carla A; Kolm, Paul; Steinberg, Terri H

    2017-07-03

    Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after percutaneous coronary intervention (PCI) and reduce readmissions. CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). An additional analytic engine [Neuron™ (ColdLight Solutions, LLC)] helps, evaluates and guide care. The "Bridges" program enrolled a total of 2054 PCI patients with 2835 admission from April, 1st 2013 through March 1st, 2015. The data of the program was compared with those of 3691 PCI patients with 4414 admissions in the 3years prior to the program. No impact was seen with respect to inpatient and observation readmission, or emergency department visits. Similarly no change was noticed in LDL control. There was minimal improvement in BP control and only in the CTM-3 and SAQ-7 physical limitation scores in the patients' reported outcomes. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. The Bridges program suggests that population health management must be a long-term goal, improving preventive care in the community. Copyright © 2017 Elsevier Inc. All rights reserved.

  19. Internet-based patient self-care: the next generation of health care delivery.

    PubMed

    Forkner-Dunn, June

    2003-01-01

    The United States health care system is an outdated model in need of fundamental change. As part of this change, the system must explore and take advantage of the potential benefits of the "e-revolution," a phenomenon that includes everyday use of the Internet by the general public. During 2002, an estimated 100 million Americans will have obtained information--including health information--from the Web as a basis for making decisions. The Internet is thus an influential force; and, as such, this medium could have a revolutionary role in retooling the trillion-dollar United States health care industry to improve patient self-management, patient satisfaction, and health outcomes. As a group, physicians use the Internet more than do many other sectors of the general adult population. However, physicians have not received sufficient information to convince them that they can provide higher-quality care by using the Internet; indeed, few studies have assessed the Internet's value for improving patients' medical self-management and health behavior, as well as their clinical outcomes and relationships with health care practitioners. New e-technology formats introduced to the growing consumer movement will drive the next generation of self-care by allowing patients to manage their own health conveniently and proficiently.

  20. Ethical issues in managed care for the obstetrician and gynecologist.

    PubMed

    Finnerty, J J; Pinkerton, J A

    1998-08-01

    The practice of medicine is now managed. Of this there is no doubt. The individual physician is placed in an ever-increasingly vulnerable position. He or she must cope with a myriad of contractual arrangements with strange concepts such as "withholds," "capitation," "covered lives," "limited liability on the part of the managed care organization;" "outcomes analysis," "practice guidelines," and, last but not least, "gag rules." Patients are being denied care that the physician may consider, if not essential, at least most desirable. On the one hand, the physician must serve a fiduciary obligation to the patient and act as the patient's advocate; on the other hand, the physician's income may be proportionally dependent on limiting the extent of the patient's access to unlimited care. The physician may be limited by restrictions imposed by the managed care organization as to what disclosures he or she may make to the patient regarding limitations of care. We will explore these issues from an ethical perspective and attempt to offer some insights on the basis of a review of the comments of many knowledgeable commentators on this topic, and we will explore the virtues that physicians will need to rely on to come to grips with the dilemmas they will face in the future with managed care.

  1. A randomized comparison of online- and telephone-based care management with internet training alone in adult patients with poorly controlled type 2 diabetes.

    PubMed

    McMahon, Graham T; Fonda, Stephanie J; Gomes, Helen E; Alexis, George; Conlin, Paul R

    2012-11-01

    Care management may improve the quality of diabetes care by enhancing contact between high-risk patients and their providers. This prospective, longitudinal, randomized trial sought to investigate whether telephone or online care management improves diabetes-related outcomes over time compared with usual care supplemented with Internet access and training. One hundred fifty-one adult subjects with type 2 diabetes mellitus and an elevated hemoglobin A1c (A1c) level (≥8.5%) were randomly assigned to online care management (n=51), telephone-based care management (n=51), or Web training (n=49) groups. Online and telephone participants interacted with a care manager through a diabetes education and care management Web site and by telephone, respectively. The Web training group was provided with online diabetes self-management resources but no care management support. The primary outcome measure was A1c measured every 3 months for a year. A1c declined significantly and substantially in all groups over 12 months. A1c declined linearly at a rate of 0.32% (P<0.0001) per quarter for the online group, 0.36% (P<0.0001) for the telephone group, and 0.41% for the Web training group (P<0.0001). The rate of change over time did not differ significantly among groups. The groups converged at 12 months with average absolute A1c difference of -1.5%. The number of interactions with care providers was not significantly associated with the change in A1c. Blood pressure, weight, lipid levels, and diabetes distress did not differ among groups over time. Online, telephone-based care management, and Web training for diabetes patients with elevated A1c were each associated with a substantial improvement in A1c over a 1-year period. Internet access and training alone may be as effective as care management in patients with poorly controlled diabetes.

  2. Cardiac patients' perception of patient-centred care: a qualitative study.

    PubMed

    Esmaeili, Maryam; Cheraghi, Mohammad A; Salsali, Mahvash

    2016-03-01

    The aim of this study was to explore cardiac patients' perception of patient-centred care. Despite patient's importance in the process of care, less attention has been paid to experiences and expectations of patients in definitions of patient-centred care. As patients are an important element in process of patient-centred care, organizing care programs according to their perceptions and expectations will lead to enhanced quality of care and greater patient satisfaction. This study is a descriptive qualitative study. Content analysis approach was performed for data analysis. Participants were 18 cardiac patients (10 women and 8 men) hospitalized in coronary care units of teaching hospitals affiliated to Tehran University of Medical Sciences. We collected the study data through conducting personal face-to-face semi-structured interviews. The participants' perceptions of patient-centred care fell into three main themes including managing patients uncertainty, providing care with more flexibility and establishing a therapeutic communication. The second theme consisted of two sub-themes: empathizing with patients and having the right to make independent decisions. Receiving patient-centred care is essential for cardiac patients. Attention to priorities and preferences of cardiac patients and making decisions accordingly is among effective strategies for achieving patient-centred care. Cardiac care unit nurses ought to be aware that in spite of technological developments and advances, it is still important to pay attention to patients' needs and expectations in order to achieve patient satisfaction. In planning care programs, they should consider accountability towards patients' needs, flexibility in process of care and establishing medical interactions as an effective strategy for improving quality of care. © 2014 British Association of Critical Care Nurses.

  3. Race/Ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care

    PubMed Central

    Weech-Maldonado, Robert; Morales, Leo S; Elliott, Marc; Spritzer, Karen; Marshall, Grant; Hays, Ron D

    2003-01-01

    Objective Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language. Data Sources Data were derived from the National CAHPS ® Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000. Data Collection The CAHPS® data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent. Study Design Data were analyzed using linear regression models. The dependent variables were CAHPS ® 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health. Principal Findings Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities. Conclusions This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access

  4. Factors associated with integrating self-management support into primary care.

    PubMed

    Crespo, Richard; Shrewsberry, Molly

    2007-06-01

    The purpose of this article is to expand the understanding of self-management support by describing factors that contribute to implementing a comprehensive self-management program in primary care. Four rural health centers in medically underserved areas participated in a study to document the implementation of a self-management program. This program consisted of a social marketing plan and decision-making tools to guide patients in making self-management behavior changes. The stages of change constructs of the transtheoretical model were used to design the social marketing plan. Key informant interviews were conducted at 6-month and 9-month intervals to document the implementation process. A standardized set of questions was used in the interviews. The data from the interviews were analyzed using content analysis techniques. One of the principle findings is that self-management support requires putting a system in place, not just adding a new component to primary care. The health centers that fully implemented the self-management program made an organizational commitment to keep self-management on the agenda in management meetings, clinical staff set the example by adopting self-management behaviors, and patient self-management support was implemented in multiple patient care venues. Primary care centers with limited financial resources are able to integrate self-management support into their system of chronic illness care.

  5. To tell the truth: disclosing the incentives and limits of managed care.

    PubMed

    Morreim, E H

    1997-01-01

    As managed care becomes more prevalent in the United States, concerns have arisen over the business practices of managed care companies. A particular concern is whether patients should be made aware of the financial incentives and treatment limits of their healthcare plan. At present, managed care organizations are not legally required to make such disclosures. However, such disclosures would be advisable for reasons of ethical fidelity, contractual clarity, and practical prudence. Physicians themselves may also have a fiduciary responsibility to discuss incentives and limits with their patients. Once the decision to disclose has been made, the managed care organization must draft a document that explains, clearly and honestly, limits of care in the plan and physician incentives that might restrict the care a patient receives.

  6. Clinical care management and workflow by episodes.

    PubMed Central

    Claus, P. L.; Carpenter, P. C.; Chute, C. G.; Mohr, D. N.; Gibbons, P. S.

    1997-01-01

    This paper describes the implementation of clinically defined episodes of care and the introduction of an episode-based summary list of patient problems across Mayo Clinic Rochester in 1996 and 1997. Although Mayo's traditional paper-based system has always relied on a type of 'episode of care' (called the "registration") for patient and history management, a new, more clinically relevant definition of episode of care was put into practice in November 1996. This was done to improve care management and operational processes and to provide a basic construct for the electronic medical record. Also since November 1996, a computer-generated summary list of patient problems, the "Master Sheet Summary Report," organized by episode, has been placed in all patient histories. In the third quarter of 1997, the ability to view the episode-based problem summary online was made available to the 3000+ EMR-capable workstations deployed across the Mayo Rochester campus. In addition, the clinically oriented problem summarization process produces an improved basic "package" of clinical information expected to lead to improved analytic decision support, outcomes analysis and epidemiological research. PMID:9357595

  7. Quality of chronic kidney disease management in primary care: a retrospective study.

    PubMed

    Van Gelder, Vincent A; Scherpbier-De Haan, Nynke D; De Grauw, Wim J C; Vervoort, Gerald M M; Van Weel, Chris; Biermans, Marion C J; Braspenning, Jozé C C; Wetzels, Jack F M

    2016-01-01

    Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model. Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic

  8. Usual care and management of fall risk increasing drugs in older dizzy patients in Dutch general practice

    PubMed Central

    Stam, Hanneke; Harting, Thomas; van der Sluijs, Marjolijn; van Marum, Rob; van der Horst, Henriëtte; van der Wouden, Johannes C.; Maarsingh, Otto R.

    2016-01-01

    Objective For general practitioners (GPs) dizziness is a challenging condition to deal with. Data on the management of dizziness in older patients are mostly lacking. Furthermore, it is unknown whether GPs attempt to decrease Fall Risk Increasing Drugs (FRIDs) use in the management of dizziness in older patients. The aim of this study is to gain more insight into GP’s management of dizziness in older patients, including FRID evaluation and adjustment. Design Data were derived from electronic medical records, obtained over a 12-month period in 2013. Setting Forty-six Dutch general practices. Patients The study sample comprised of 2812 older dizzy patients of 65 years and over. Patients were identified using International Classification of Primary Care codes and free text. Main outcome measures Usual care was categorized into wait-and-see strategy (no treatment initiated); education and advice; additional testing; medication adjustment; and referral. Results Frequently applied treatments included a wait-and-see strategy (28.4%) and education and advice (28.0%). Additional testing was performed in 26.8%; 19.0% of the patients were referred. Of the patients 87.2% had at least one FRID prescription. During the observation period, GPs adjusted the use of one or more FRIDs for 11.7% of the patients. Conclusion This study revealed a wide variety in management strategies for dizziness in older adults. The referral rate for dizziness was high compared to prior research. Although many older dizzy patients use at least one FRID, FRID evaluation and adjustment is scarce. We expect that more FRID adjustments may reduce dizziness and dizziness-related impairment. Key PointsIt is important to know how general practitioners manage dizziness in older patients in order to assess potential cues for improvement.This study revealed a wide variety in management strategies for dizziness in older patients.There was a scarcity in Fall Risk Increasing Drug (FRID) evaluation and adjustment

  9. Spiritual beliefs and barriers among managed care practitioners.

    PubMed

    McCauley, Jeanne; Jenckes, Mollie W; Tarpley, Margaret J; Koenig, Harold G; Yanek, Lisa R; Becker, Diane M

    2005-01-01

    Ninety percent of American adults believe in God and 82% pray weekly. A majority wants their physicians to address spirituality during their health care visit. However, clinicians incorporate spiritual discussion in less than 20% of visits. Our objectives were to measure clinician beliefs and identify perceived barriers to integrating spirituality into patient care in a statewide, primary care, managed care group. Practitioners completed a 30-item survey including demographics and religious involvement (DUREL), spirituality in patient care (SPC), and barriers (BAR). We analyzed data using frequencies, means, standard deviations, and ANOVA. Clinicians had a range of religious denominations (67% Christian, 14% Jewish, 11% Muslim, Hindu or Buddhist, 8% agnostic), were 57% female and 24% had training in spirituality. Sixty-six percent reported experiencing the divine. Ninety-five percent felt that a patient's spiritual outlook was important to handling health difficulties and 68% percent agreed that addressing spirituality was part of the physician's role. Ninety-five percent of our managed care group noted 'lack of time' as an important barrier, 'lack of training' was indicated by 69%, and 21% cited 'fear of response from administration'. Managed care practitioners in a time constrained setting were spiritual themselves and believed this to be important to patients. Respondents indicated barriers of time and training to implementing these beliefs. Comparing responses from our group to those in other published surveys on clinician spirituality, we find similar concerns. Clinician education may overcome these barriers and improve ability to more fully meet their patients' expressed needs regarding spirituality and beliefs.

  10. [Benefits of nursing care service in the assisted reproduction clinic to self-cycle-management and self-efficiency of infertility patients].

    PubMed

    Li, Xiao-Qin; Sun, Chao-Feng; Guo, Mei

    2017-06-01

    To investigate the benefits of nursing care service in the assisted reproduction clinic to self-cycle-management and self-efficiency of the outpatients with infertility. We randomly divided 600 females preliminarily diagnosed with infertility into a control and an experimental group, 288 in the former and 285 in the latter group excluding those whose husbands had azoospermia. For the women patients of the experimental group, we conducted nursing care intervention concerning related knowledge, skills, diet, excise, medication, and psychology, by one-to-one consultation, individualized or group communication, establishing files, telephone follow-up, and wechat guidance. After 3 months of intervention, we compared the compliance of medical visits, effectiveness of cycle management, sense of self-efficiency, satisfaction, and anxiety score between the two groups of patients. In comparison with the controls, the patients of the experimental group showed significantly better knowledge about assisted reproduction and higher effectiveness of self-cycle-management, self-efficiency, and satisfaction (P <0.05), but a markedly lower degree of anxiety (P <0.05). Nursing care service in the assisted reproduction clinic can improve the compliance of medical visits, effectiveness of self-cycle-management, self-efficiency, and satisfaction and reduce the anxiety of the patients.

  11. Status Update on Translation of Integrated Primary Dental-Medical Care Delivery for Management of Diabetic Patients.

    PubMed

    Glurich, Ingrid; Nycz, Gregory; Acharya, Amit

    2017-06-01

    Escalating prevalence of both diabetes and periodontal disease, two diseases associated with bi-directional exacerbation, has been reported. Periodontal disease represents a modifiable risk factor that may reduce diabetes onset or progression, and integrated models of cross-disciplinary care are needed to establish and manage glycemic control in affected patients. An ad-hoc environmental scan of current literature and media sought to characterize factors impacting status of integrated care models based on review of the existing evidence base in literature and media surrounding: (1) current cross-disciplinary practice patterns, (2) epidemiological updates, (3) status on risk assessment and screening for dysglycemia in the dental setting, (4) status on implementation of quality metrics for oral health, (5) care model pilots, and (6) public health perspectives. The survey revealed: escalating prevalence of diabetes and periodontitis globally; greater emphasis on oral health assessment for diabetic patients in recent medical clinical practice guidelines; high knowledgeability surrounding oral-systemic impacts on diabetes and growing receptivity to medical-dental integration among medical and dental providers; increasing numbers of programs/studies reporting on positive impact of emerging integrated dental-medical care models on diabetic patient healthcare access and health outcomes; a growing evidence base for clinically significant rates of undiagnosed dysglycemia among dental patients reported by point-of-care pilot studies; no current recommendation for population-based screening for dysglycemia in dental settings pending a stronger evidence base; improved definition of true periodontitis prevalence in (pre)/diabetics; emerging recognition of the need for oral health quality indicators and tracking; evidence of persistence in dental access disparity; updated status on barriers to integration. The potential benefit of creating clinically-applicable integrated care

  12. [AC-STB: dedicated software for managed healthcare of chronic headache patients].

    PubMed

    Wallasch, T-M; Bek, J; Pabel, R; Modahl, M; Demir, M; Straube, A

    2009-04-01

    This paper examines a new approach to managed healthcare where a network of care providers exchanges patient information through the internet. Integrating networks of clinical specialists and general care providers promises to achieve qualitative and economic improvements in the German healthcare system. In practice, problems related to patient management and data exchange between the managing clinic and assorted caregivers arise. The implementation and use of a cross-spectrum computerized solution for the management of patients and their care is the key for a successful managed healthcare system. This paper documents the managed healthcare of chronic headache patients and the development of an IT-solution capable of providing distributed patient care and case management.

  13. German diabetes management programs improve quality of care and curb costs.

    PubMed

    Stock, Stephanie; Drabik, Anna; Büscher, Guido; Graf, Christian; Ullrich, Walter; Gerber, Andreas; Lauterbach, Karl W; Lüngen, Markus

    2010-12-01

    This paper reports the results of a large-scale analysis of a nationwide disease management program in Germany for patients with diabetes mellitus. The German program differs markedly from "classic" disease management in the United States. Although it combines important hallmarks of vendor-based disease management and the Chronic Care Model, the German program is based in primary care practices and carried out by physicians, and it draws on their personal relationships with patients to promote adherence to treatment goals and self-management. After four years of follow-up, overall mortality for patients and drug and hospital costs were all significantly lower for patients who participated in the program compared to other insured patients with similar health profiles who were not in the program. These results suggest that the German disease management program is a successful strategy for improving chronic illness care.

  14. Innovative approach to patient-centered care coordination in primary care practices.

    PubMed

    Clarke, Robin; Bharmal, Nazleen; Di Capua, Paul; Tseng, Chi-Hong; Mangione, Carol M; Mittman, Brian; Skootsky, Samuel A

    2015-09-01

    Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients. Matched case-control differences-in-differences. Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity. CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001). Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

  15. Fragmentation of care threatens patient safety in peripheral vascular catheter management in acute care--a qualitative study.

    PubMed

    Castro-Sánchez, Enrique; Charani, Esmita; Drumright, Lydia N; Sevdalis, Nick; Shah, Nisha; Holmes, Alison H

    2014-01-01

    The use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety. Ten doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework. FOUR KEY THEMES EMERGED: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety. Fragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.

  16. Health Care Systems Support to Enhance Patient-Centered Care: Lessons from a Primary Care-Based Chronic Pain Management Initiative.

    PubMed

    Elder, Charles R; Debar, Lynn L; Ritenbaugh, Cheryl; Rumptz, Maureen H; Patterson, Charlotte; Bonifay, Allison; Cowan, Penney; Lancaster, Lindsay; Deyo, Richard A

    2017-01-01

    Supporting day-to-day self-care activities has emerged as a best practice when caring for patients with chronic pain, yet providing this support may introduce challenges for both patients and primary care physicians. It is essential to develop tools that help patients identify the issues and outcomes that are most important to them and to communicate this information to primary care physicians at the point of care. We describe our process to engage patients, primary care physicians, and other stakeholders in the context of a pilot randomized controlled trial of a patient-centered assessment process implemented in an everyday practice setting. We identify lessons on how to engage stakeholders and improve patient-centered care for those with chronic conditions within the primary care setting. A qualitative analysis of project minutes, interviews, and focus groups was conducted to evaluate stakeholder experiences. Stakeholders included patients, caregivers, clinicians, medical office support staff, health plan administrators, an information technology consultant, and a patient advocate. Our stakeholders included many patients with no prior experience with research. This approach enriched the applicability of feedback but necessitated extra time for stakeholder training and meeting preparation. Types of stakeholders varied over the course of the project, and more involvement of medical assistants and Information Technology staff was required than originally anticipated. Meaningful engagement of patient and physician stakeholders must be solicited in a well-coordinated manner with broad health care system supports in place to ensure full execution of patient-centered processes.

  17. Challenges faced by nurses in managing pain in a critical care setting.

    PubMed

    Subramanian, Pathmawathi; Allcock, Nick; James, Veronica; Lathlean, Judith

    2012-05-01

    To explore nurses' challenges in managing pain among ill patients in critical care. Pain can lead to many adverse medical consequences and providing pain relief is central to caring for ill patients. Effective pain management is vital since studies show patients admitted to critical care units still suffer from significant levels of acute pain. The effective delivery of care in clinical areas remains a challenge for nurses involved with care which is dynamic and constantly changing in critically ill. Qualitative prospective exploratory design. This study employed semi structured interviews with nurses, using critical incident technique. Twenty-one nurses were selected from critical care settings from a large acute teaching health care trust in the UK. A critical incident interview guide was constructed from the literature and used to elicit responses. Framework analysis showed that nurses perceived four main challenges in managing pain namely lack of clinical guidelines, lack of structured pain assessment tool, limited autonomy in decision making and the patient's condition itself. Nurses' decision making and pain management can influence the quality of care given to critically ill patients. It is important to overcome the clinical problems that are faced when dealing with pain experience. There is a need for nursing education on pain management. Providing up to date and practical strategies may help to reduce nurses' challenges in managing pain among critically ill patients. Broader autonomy and effective decision making can be seen as beneficial for the nurses besides having a clearer and structured pain management guidelines. © 2011 Blackwell Publishing Ltd.

  18. Differences in pain management between hematologists and hospitalists caring for patients with sickle cell disease hospitalized for vasoocclusive crisis.

    PubMed

    Shah, Nirmish; Rollins, Margo; Landi, Daniel; Shah, Radhika; Bae, Jonathan; De Castro, Laura M

    2014-03-01

    Sickle cell disease (SCD) is a chronic disease characterized by multiple vaso-occlusive complications and is increasingly cared for by hospitalists. The purpose of this study is to examine differences in pain management between hematologists and hospitalists. We performed a single-institution, retrospective review of pain management patterns and outcomes in adult SCD patients hospitalized for vaso-occlusive crisis. Over 26 months, we found a total of 298 patients (120 cared for by the hematologists and 178 by hospitalists), with a mean age of 32 (range 19-58). Patients cared for by hospitalists had a lower total number of hours on a patient controlled analgesia (PCA) device (171 vs. 212 hours, P=0.11). Hospitalists also were significantly more likely to utilize demand only PCA (42% vs. 23%, P=0.002) and had a significantly lower rate of using both continuous and demand PCA (54% vs. 67%, P=0.04). In addition, patients cared for by hospitalists had a significantly shorter hospitalization (8.4 days) compared to hematologists (10 days, P=0.04) with a non-significant difference in 7 and 30 day readmission rates (7.2% vs. 6.7% and 40% vs. 35% respectively). We found patients cared for by hospitalists more frequently utilized home oral pain medication during admission, had shorter lengths of hospitalization, and did not have a significant increase in readmission rates.

  19. Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014

    PubMed Central

    Schpero, William L.; Schlesinger, Mark J.; Trivedi, Amal N.

    2017-01-01

    Importance State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. Objective To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Design, Setting, and Participants Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Exposures Plan exit, defined as the withdrawal of a managed care plan from a state’s Medicaid program. Main Outcomes and Measures Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10–point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Results Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state’s Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95

  20. Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014.

    PubMed

    Ndumele, Chima D; Schpero, William L; Schlesinger, Mark J; Trivedi, Amal N

    2017-06-27

    State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program. Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1

  1. Usual care and management of fall risk increasing drugs in older dizzy patients in Dutch general practice.

    PubMed

    Stam, Hanneke; Harting, Thomas; Sluijs, Marjolijn van der; Marum, Rob van; Horst, Henriëtte van der; Wouden, Johannes C van der; Maarsingh, Otto R

    2016-06-01

    For general practitioners (GPs) dizziness is a challenging condition to deal with. Data on the management of dizziness in older patients are mostly lacking. Furthermore, it is unknown whether GPs attempt to decrease Fall Risk Increasing Drugs (FRIDs) use in the management of dizziness in older patients. The aim of this study is to gain more insight into GP's management of dizziness in older patients, including FRID evaluation and adjustment. Data were derived from electronic medical records, obtained over a 12-month period in 2013. Forty-six Dutch general practices. The study sample comprised of 2812 older dizzy patients of 65 years and over. Patients were identified using International Classification of Primary Care codes and free text. Usual care was categorized into wait-and-see strategy (no treatment initiated); education and advice; additional testing; medication adjustment; and referral. Frequently applied treatments included a wait-and-see strategy (28.4%) and education and advice (28.0%). Additional testing was performed in 26.8%; 19.0% of the patients were referred. Of the patients 87.2% had at least one FRID prescription. During the observation period, GPs adjusted the use of one or more FRIDs for 11.7% of the patients. This study revealed a wide variety in management strategies for dizziness in older adults. The referral rate for dizziness was high compared to prior research. Although many older dizzy patients use at least one FRID, FRID evaluation and adjustment is scarce. We expect that more FRID adjustments may reduce dizziness and dizziness-related impairment. Key Points It is important to know how general practitioners manage dizziness in older patients in order to assess potential cues for improvement. This study revealed a wide variety in management strategies for dizziness in older patients. There was a scarcity in Fall Risk Increasing Drug (FRID) evaluation and adjustment. The referral rate for dizziness was high compared with previous research.

  2. Management of urinary incontinence in residential care.

    PubMed

    Lim, David S

    2016-07-01

    Urinary incontinence is prevalent in residential care and rates are expected to increase with the ageing population in Australia. It contributes to poor quality of life (QoL), functional impairments in activities of daily living, and deterioration of mental and sexual health. Management depends on the type of incontinence, its aetiology, the severity of symptoms, the effects on QoL, and patient factors. Treatment options include active treatment and passive containment. However, not all active treatment options are feasible in residential care. There is little evidence to advise on standard best practice. The aims of this article are to review treatment options for urinary incontinence in residential care, feasibility of service delivery and challenges associated with this. A greater understanding of the issues surrounding the management of urinary incontinence in residential care is required to deliver satisfactory patient-centred care on a consistent basis.

  3. Critical care nurses management of prolonged weaning: an interview study.

    PubMed

    Cederwall, Carl-Johan; Plos, Kaety; Rose, Louise; Dübeck, Amanda; Ringdal, Mona

    2014-09-01

    For most critically ill patients requiring mechanical ventilation in the intensive care unit (ICU) weaning is uncomplicated. For the remainder, weaning is a challenge and may result in further complications and increased risk of mortality. Critical care nurses (CCNs) require substantial knowledge and experience to manage patients experiencing prolonged weaning. The aim of this study was to explore CCNs approach for management of patients experiencing prolonged weaning in the ICU. A descriptive qualitative design. Semi-structured interviews with 19 experienced CCNs were conducted. Data were analysed using content analysis. Participants used various strategies for weaning that were grouped into four categories: individualized planning for the weaning process, assessing patient's capacity, managing the process and team interaction. The overall theme that emerged was: CCNs drive the weaning process using both a patient centred and targeted approach. CCNs in these ICUs performed weaning using a patient centred approach to plan, initiate, assess and establish a holistic weaning process. Team collaboration among all health care practitioners was important. CCNs have a key role in prioritizing weaning and driving the process forward. Closeness to the patient and a key role in management of the mechanical ventilated patient in ICU gives the CCN unique potential to develop and create models and tools for prolonged weaning. These tools, specially designed for patients undergoing prolonged weaning, would give focus on continuous planning, collaborating, managing and evaluation in the process of liberating patients from mechanical ventilation. © 2014 British Association of Critical Care Nurses.

  4. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review

    PubMed Central

    Stellefson, Michael; Stopka, Christine

    2013-01-01

    Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. PMID:23428085

  5. Exemplars in the use of technology for management of depression in primary care.

    PubMed

    Serrano, Neftali; Molander, Rachel; Monden, Kimberley; Grosshans, Ashley; Krahn, Dean D

    2012-06-01

    Depression care management as part of larger efforts to integrate behavioral health care into primary care has been shown to be effective in helping patients and primary care clinicians achieve improved outcomes within the primary care environment. Central to care management systems is the use of registries which enable effective clinic population management. The aim of this article is to detail the methods and utility of technology in depression care management processes while also highlighting the real-world variations and barriers that exist in different clinical environments, namely a federally qualified health center and a Veterans Administration clinic. We analyzed descriptive data from the registries of Access Community Health Centers and the William S. Middleton Veterans Administration clinics along with historical reviews of their respective care management processes. Both registry reviews showed trend data indicating improvement in scores of depression and provided baseline data on important system variables, such as the number of patients who are not making progress, the percentage of patients who are unreachable by phone, and the kind of actions needed to ensure evidence-based and efficient care. Both sites also highlighted systemic technical barriers to more complete implementation of care management processes. Care management processes are an effective and efficient part of population-based care for depression in primary care. Implementation depends on available resources including hardware, software, and clinical personnel. Additionally, care management processes and technology have evolved over time based on local needs and are part of an integrated method to support the work of primary care clinicians in providing care for patients with depression.

  6. Alcohol withdrawal management in adult patients in a high acuity medical surgical transitional care unit: a best practice implementation project.

    PubMed

    Sukhenko, Olga

    2016-01-15

    Excessive alcohol consumption, a major health problem worldwide, affects about 6% of the United States population. Caring for patients with alcohol withdrawal syndrome in a hospital ward presents complex physiologic and psycho-social challenges which are best met with evidence-based practices. An academic medical center in the United States has been experiencing an increase in patients with alcohol withdrawal syndrome. However, gaps in clinician knowledge and infrastructure supporting the management of these patients still existed. The aim of this project was to improve the continuity of care of patients undergoing alcohol withdrawal in a medical surgical high acuity transitional care unit by incorporating evidence-based practices, and thereby to positively impact on patient outcomes. Specific objectives were related to standardized assessments and pharmacologic management strategies. The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting change in health practice. A baseline clinical audit was conducted to assess compliance with best practices for managing alcohol withdrawal syndrome, which was followed by several interventions targeted at nurses and providers. A follow-up audit was conducted to assess compliance with the implemented strategies. The follow-up audit used the same evidence-based audit criteria as those used for the baseline audit. A non-probabilistic, convenience sampling approach was used. A sample size of 15 patients was used for both the baseline and follow-up audits. The baseline audit revealed a high compliance rate for four of the five audit criteria concerning risk assessment and pharmacologic strategies. There was sub-optimal compliance (53%) with the criterion regarding use of the Clinical Institute Withdrawal Assessment of Alcohol Scale (revised) (CIWA-Ar) scale to assess patients with alcohol withdrawal. After the interventions were

  7. Improving organizational climate for excellence in patient care.

    PubMed

    Arnold, Edwin

    2013-01-01

    Managers in health care organizations today are expected to achieve higher-quality patient care at a lower cost. Developing and maintaining a positive organizational climate can help improve motivation and foster higher employee performance. In turn, this will help the organization deliver better patient care at a lower cost. This article offers metrics for assessing organizational climate, analyzes barriers to a positive climate, and explores strategies that managers can use to build the type of climate that fosters high performance.

  8. Improving Quality of Care in Patients with Liver Cirrhosis.

    PubMed

    Saberifiroozi, Mehdi

    2017-10-01

    Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients.

  9. Palliative Care Office Hours for Patients with Hematologic Malignancies: An Innovative Model for Symptom Management and Education.

    PubMed

    Foxwell, Anessa M; Moyer, Mary E; Casarett, David J; O'Connor, Nina R

    2017-10-01

    Palliative care programs are experiencing rapid growth, with demand for consults surpassing staffing. Innovative models are needed to equip nonpalliative care providers to manage basic palliative care issues. To develop a novel program of palliative care office hours for hematologic oncology advanced practice providers, and to evaluate its impact on palliative care consult volume and composition. A palliative care nurse practitioner or pharmacist was available for weekday office hours to all inpatient hematologic oncology advanced practice providers at an academic medical center to offer advice on pain, nonpain symptoms, and psychosocial distress. A retrospective study looking at outcome measures after six months of office hour utilization and palliative care consults from the hematologic oncology services. Palliative care office hours had a mean duration of 16 minutes per day (range 5 to 55). A mean of 11 patients were discussed per week (range 4 to 20). Pain, nausea, and anxiety were the issues most frequently raised. Of 299 patients discussed during office hours, 44 (14.7%) subsequently required a full palliative care consult. Overall, palliative care consults from the hematologic oncology services decreased from 19.6% to 10.2% of admissions (87/445 vs. 61/594, p < 0.001) with an increase in consults for goals of care. Office hours are an efficient way to address palliative care needs when demand for palliative care consults exceeds capacity. Office hours may serve an educational function as well, enabling primary teams to manage basic palliative care issues with increasing independence over time.

  10. Health care waste management practice in a hospital.

    PubMed

    Paudel, R; Pradhan, B

    2010-10-01

    Health-care waste is a by-product of health care. Its poor management exposes health-care workers, waste handlers and the community to infections, toxic effects and injuries including damage of the environment. It also creates opportunities for the collection of disposable medical equipment, its re-sale and potential re-use without sterilization, which causes an important burden of disease worldwide. The purpose of this study was to find out health care waste management practice in hospital. A cross-sectional study was conducted in Narayani Sub-Regional Hospital, Birgunj from May to October 2006 using both qualitative and quantitative methods. Study population was four different departments of the hospital (Medical/Paediatric, Surgical/Ortho, Gynae/Obstetric and Emergency), Medical Superintendent, In-charges of four different departments and all sweepers. Data was collected using interview, group discussion, observation and measurement by weight and volume. Total health-care waste generated was 128.4 kg per day while 0.8 kg per patient per day. The composition of health care waste was found to be 96.8 kg (75.4%) general waste, 24.1 kg (8.8%) hazardous waste and 7.5 kg (5.8%) sharps per day by weight. Health staffs and sweepers were not practicing the waste segregation. Occupational health and safety was not given due attention. Majority of the sweepers were unaware of waste management and need of safety measures to protect their own health. Health care waste management practice in the hospital was unsatisfactory because of the lack of waste management plan and carelessness of patients, visitors and staffs. Therefore the hospital should develop the waste management plan and strictly follow the National Health Care Waste Management Guideline.

  11. Simulation modeling for the health care manager.

    PubMed

    Kennedy, Michael H

    2009-01-01

    This article addresses the use of simulation software to solve administrative problems faced by health care managers. Spreadsheet add-ins, process simulation software, and discrete event simulation software are available at a range of costs and complexity. All use the Monte Carlo method to realistically integrate probability distributions into models of the health care environment. Problems typically addressed by health care simulation modeling are facility planning, resource allocation, staffing, patient flow and wait time, routing and transportation, supply chain management, and process improvement.

  12. SMART DOCS: A New Patient-Centered Outcomes and Coordinated-Care Management Approach for the Future Practice of Sleep Medicine

    PubMed Central

    Kushida, Clete A.; Nichols, Deborah A.; Holmes, Tyson H.; Miller, Ric; Griffin, Kara; Cardell, Chia-Yu; Hyde, Pamela R.; Cohen, Elyse; Manber, Rachel; Walsh, James K.

    2015-01-01

    The practice of medicine is currently undergoing a transformation to become more efficient, cost-effective, and patient centered in its delivery of care. The aim of this article is to stimulate discussion within the sleep medicine community in addressing these needs by our approach as well as other approaches to sleep medicine care. The primary goals of the Sustainable Methods, Algorithms, and Research Tools for Delivering Optimal Care Study (SMART DOCS) are: (1) to introduce a new Patient-Centered Outcomes and Coordinated-Care Management (PCCM) approach for the future practice of sleep medicine, and (2) to test the PCCM approach against a Conventional Diagnostic and Treatment Outpatient Medical Care (CONV) approach in a randomized, two-arm, single-center, long-term, comparative effectiveness trial. The PCCM approach is integrated into a novel outpatient care delivery model for patients with sleep disorders that includes the latest technology, allowing providers to obtain more accurate and rapid diagnoses and to make evidence-based treatment recommendations, while simultaneously enabling patients to have access to personalized medical information and reports regarding their diagnosis and treatment so that they can make more informed health care decisions. Additionally, the PCCM approach facilitates better communication between patients, referring primary care physicians, sleep specialists, and allied health professionals so that providers can better assist patients in achieving their preferred outcomes. A total of 1,506 patients 18 y or older will be randomized to either the PCCM or CONV approach and will be followed for at least 1 y with endpoints of improved health care performance, better health, and cost control. Clinical Trials Registration: ClinicalTrials.gov Identifier: NCT02037438. Citation: Kushida CA, Nichols DA, Holmes TH, Miller R, Griffin K, Cardell CY, Hyde PR, Cohen E, Manber R, Walsh JK. SMART DOCS: a new patient-centered outcomes and coordinated-care

  13. Time for chronic disease care and management

    PubMed Central

    Montague, Terrence J; Gogovor, Amédé; Krelenbaum, Marilyn

    2007-01-01

    To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better. PMID:17932573

  14. Time for chronic disease care and management.

    PubMed

    Montague, Terrence J; Gogovor, Amédé; Krelenbaum, Marilyn

    2007-10-01

    To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better.

  15. Clinical outcomes in managed-care patients with coronary heart disease treated aggressively in lipid-lowering disease management clinics: the alliance study.

    PubMed

    Koren, Michael J; Hunninghake, Donald B

    2004-11-02

    This study sought to determine if an aggressive, focused low-density lipoprotein cholesterol (LDL-C)-lowering strategy was superior to usual care for coronary heart disease (CHD) patients enrolled in health maintenance organization or Veterans Administration settings. Statin therapy benefits are well established. No prospective, randomized studies have tested strategies to optimize these benefits in a "real-world" setting. A total of 2,442 CHD patients with hyperlipidemia were randomized to either an aggressive treatment arm using atorvastatin or usual care and followed for 51.5 months on average. Atorvastatin-group patients were titrated to LDL-C goals of <80 mg/dl (2.1 mmol/l) or a maximum atorvastatin dose of 80 mg/day. Usual-care patients received any treatment deemed appropriate by their regular physicians. End point assessments were complete in 958 atorvastatin-group and 941 usual-care patients. Partial assessments occurred in 259 patients in the atorvastatin group and 284 patients in the usual care group who did not complete four years of study participation because of adverse events, withdrawn consent, or follow-up loss. The primary efficacy parameter was time to first cardiovascular event. A total of 289 (23.7%) patients in the atorvastatin group compared with 333 (27.7%) patients in the usual care group experienced a primary outcome (hazard ratio, 0.83; 95% confidence interval 0.71 to 0.97, p = 0.02). This reduction in morbidity was largely due to fewer non-fatal myocardial infarctions (4.3% vs. 7.7%, p = 0.0002). Levels of LDL-C were reduced more (34.3% vs. 23.3%, p < 0.0001) and National Cholesterol Education Program goals (LDL-C <100 mg/dl) more likely met at end-of-study visits (72.4% vs. 40.0%) in patients receiving atorvastatin compared with those receiving usual care. An aggressive, focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD.

  16. Managed care and critical pathway development: the joint replacement experience.

    PubMed

    Benham, A J

    1999-01-01

    This article examines the economic, social, ethical, and political issues affecting total joint replacement patients in a managed care environment. Using general systems theory as a framework, it examines the interrelated historical events that have shaped the development of both joint replacement procedures and managed care, and discusses the extent to which these two phenomena have been mutually influential. Specifically, the article examines the initial development, implementation, and continuing evolution of clinical pathways as an easily identified and relatively discrete manifestation of managed care for the joint replacement population. While the overall impact of managed care is beyond the scope of this presentation, it is hoped that a focus on the practical application of clinical pathways to joint replacement will allow some general principles to emerge that may be useful for both patients and practitioners operating in other aspects of the managed care environment.

  17. The impact of care management information technology model on quality of care after Coronary Artery Bypass Surgery: "Bridging the Divides".

    PubMed

    Weintraub, William S; Elliott, Daniel; Fanari, Zaher; Ostertag-Stretch, Jennifer; Muther, Ann; Lynahan, Margaret; Kerzner, Roger; Salam, Tabassum; Scherrer, Herbert; Anderson, Sharon; Russo, Carla A; Kolm, Paul; Steinberg, Terri H

    Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after Coronary Artery Bypass Surgery (CABG) and reduce readmissions. CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). In addition there is an analytic engine to help evaluate and guide care, Neuron™ (Coldlight Solutions, LLC). The "Bridges" program enrolled a total of 716 CABG patients with 850 admissions from April 2013 through March 2015. The data of the program was compared with those of 1111 CABG patients with 1203 admissions in the 3years prior to the program. No impact was seen with respect to readmissions, Blood Pressure or LDL control. There was no significant improvement in patients' reported outcomes using either the CTM-3 or any of the SAQ-7 scores. Patient follow-up with physicians within 1week of discharge improved during the Bridges years. The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. German diabetes disease management programs are appropriate for restructuring care according to the chronic care model: an evaluation with the patient assessment of chronic illness care instrument.

    PubMed

    Szecsenyi, Joachim; Rosemann, Thomas; Joos, Stefanie; Peters-Klimm, Frank; Miksch, Antje

    2008-06-01

    With the introduction of diabetes disease management programs (DMPs) in Germany, there is a necessity to evaluate whether patients receive care that is congruent to the Chronic Care Model (CCM) and evidence-based behavioral counseling. We examined differences as perceived and experienced by patients with type 2 diabetes between those enrolled in a DMP compared with patients receiving usual care in two federal states of Germany. A random, heterogeneous sample of 3,546 patients (59.3% female) received a mailed questionnaire from their regional health fund, including the German version of the Patient Assessment of Chonic Illness Care (PACIC) instrument, which had additional items for behavioral advice (5A). Two weeks later, a general reminder was sent out. A total of 1,532 questionnaires were returned (response rate 42.2%), and valid data could be obtained for 1,399 patients. Mean age of responders was 70.3 years, of which 53.6% were female. Overall, patients enrolled in a DMP scored significantly higher (3.21 of a possible 5) than patients not enrolled in a DMP (2.86) (P < 0.001). Significant differences in the same direction were found on all five subscales of the PACIC. For the 5A scales, similar differences were found for all five subscales plus the sum score (P < 0.001; mean for DMP = 3.08, mean for non-DMP = 2.78). DMPs, as currently established in primary care in Germany, may impact provided care significantly. The changes in daily practice that have been induced by the DMPs are recognized by patients as care that is more structured and that to a larger extent reflects the core elements of the CCM and evidence-based counseling compared with usual care.

  19. [EMOTIONAL MANAGEMENT AND CRITICAL THINKING IN THE AID RELATIONSHIP OF THE HOLISTIC CARE OF PALLIATIVE PATIENTS].

    PubMed

    De Blas Gómez, Irene; Rodríguez García, Marta

    2015-05-01

    To care for palliative patients is essential that healthcare professionals develop emotional competencies. This means acquiring the habit of self reflection and be emphatic with other people, in order to be able to identify the personal emotions of patients, family and team. Reflection involves a continuing effort to reason about aspects of professional practice, especially on issues as complex as suffering and death. Both reflective reasoning and emotional management are vital in an Aid Relationship. For nursing healthcare professionals, to care the emotional aspects means becoming aware of their own and others feelings, and get to understand and accept to handle them properly. Nursing actions involves many qualities of social competence, such as empathy, understanding, communication skills, honesty, flexibility and adaptability to the individual needs of people cared. In the context of palliative care patients and their families all these aspects are fundamental and are part of the same philosophy. Emotional education still remains a challenge in our profession both in the initial and continuing training.

  20. Impact of electronic order management on the timeliness of antibiotic administration in critical care patients.

    PubMed

    Cartmill, Randi S; Walker, James M; Blosky, Mary Ann; Brown, Roger L; Djurkovic, Svetolik; Dunham, Deborah B; Gardill, Debra; Haupt, Marilyn T; Parry, Dean; Wetterneck, Tosha B; Wood, Kenneth E; Carayon, Pascale

    2012-11-01

    To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients. We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated. The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration. The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  1. Use of the short form 36 in a primary care based disease management program for patients with congestive heart failure.

    PubMed

    Sidorov, Jaan; Shull, Robert D; Girolami, Sabrina; Mensch, Debra

    2003-01-01

    While disease management has been described as an important strategy for the care of patients with congestive heart failure (CHF) in the managed care setting, little is known about the impact of this approach on overall health-related quality of life. In this study the Short Form 36 (SF-36) was administered to all patients entering CHF disease management at the time of program entry and at 1 year following entry. Scores on the eight subscales and the two composite scales were calculated and compared before and after. Patients were enrolled from a mixed-model health maintenance organization (HMO) with 34,740 Medicare + Choice enrollees residing in 38 counties in central and northeastern Pennsylvania. Two hundred sixty-eight continuously enrolled patients in an HMO-sponsored CHF disease state management program with completed baseline and follow-up SF-36 surveys were sampled. All patients entered into disease management received primary care based, nurse-directed education about CHF self-management including instruction on etiology of CHF, the importance of medication compliance, home care services if indicated, monitoring weight gain, increased understanding of the warning signs of worsening CHF, and coaching on strategies to contact a physician in a timely manner when CHF worsens. Nurses also facilitated for CHF guidelines among primary care physicians, including the need to obtain a baseline assessment of cardiac function, prescribe angiotensin I-converting enzyme (ACE) inhibitors and beta blockers when appropriate, and initiated appropriate specialist referral. Compared with enrollees who did not complete a pair of SF-36 surveys, the 268 respondents were younger and had a significantly higher rate of cardiac imaging as well as use of ACE inhibitors and beta blocker medications. Analysis of the SF-36 data revealed that three of the eight (Role Physical, General Health Perceptions, and Role Emotional) subscales increased in a statistically significant manner, as

  2. Personalised Care Plan Management Utilizing Guideline-Driven Clinical Decision Support Systems.

    PubMed

    Laleci Erturkmen, Gokce Banu; Yuksel, Mustafa; Sarigul, Bunyamin; Lilja, Mikael; Chen, Rong; Arvanitis, Theodoros N

    2018-01-01

    Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans.

  3. Management of patients in a combined thyroid eye clinic in secondary care.

    PubMed

    Benzimra, J D; Quinn, A G; Kersey, T; McGrane, D; Goss, L; Vaidya, B

    2014-02-01

    The European Group on Graves' Orbitopathy (EUGOGO) recommends the use of specialised multidisciplinary clinics for the management of thyroid eye disease (TED). In the UK, many patients with TED are managed outside of specialised clinics. We describe the organisation of a combined TED clinic in a secondary care setting and present the result of a prospective audit of the patient characteristics and outcomes during the first four years of a combined TED clinic. Of a total of 132 patients referred to the TED clinic, 114 (86 %) had TED (90 females, median age 56 years; range 17-90 years). At presentation, 77 (67 %) were current or ex-smokers and 99 (87 %) were biochemically euthyroid. Median duration of eye symptoms was 12 months. Fifty-two percent, 45 and 3 had mild, moderate-to-severe and sight-threatening TED, respectively. Only 18 % of patients had a clinical activity score (CAS) of ≥3. Sixty-nine patients (61 %) required follow-up appointments in the TED clinic. In those who required follow-up, 43 % (n = 30) received either immunosuppressive or surgical treatment. CAS improved from first to final visit, with 29 % (n = 20) having a CAS of ≥3 at the first visit and 1 % (n = 1) at the final visit (p = 0.0001). There was also a decrease in prevalence of smoking and thyroid dysfunction at the final visit. A multidisciplinary specialised TED clinic offers an optimal setting for managing patients with TED; however, patients are often referred late to a specialist TED clinic.

  4. Supportive Care: Integration of Patient-Centered Kidney Care to Manage Symptoms and Geriatric Syndromes

    PubMed Central

    Jassal, Sarbjit Vanita

    2016-01-01

    Dialysis care is often associated with poor outcomes including low quality of life (QOL). To improve patient-reported outcomes, incorporation of the patient’s needs and perspective into the medical care they receive is essential. This article provides a framework to help clinicians integrate symptom assessment and other measures such as QOL and frailty scores into a clinical approach to the contemporary supportive care of patients with advanced CKD. This approach involves (1) defining our understanding of kidney supportive care, patient-centered dialysis, and palliative dialysis; (2) understanding and recognizing common symptoms associated with advanced CKD; (3) discussing the concepts of physical function, frailty, and QOL and their role in CKD; and (4) identifying the structural and process barriers that may arise when patient-centered dialysis is being introduced into clinical practice. PMID:27510454

  5. Quality of care in patients with psoriasis: an initial clinical study of an international disease management programme.

    PubMed

    de Korte, J; Van Onselen, J; Kownacki, S; Sprangers, M A G; Bos, J D

    2005-01-01

    Patients with psoriasis have to cope with their disease for many years or even throughout their entire life. To provide optimal care, a disease management programme was developed. This programme consisted of disease education, disease management training, and psychological support, together with topical treatment. To test a disease management programme in dermatological practice, to assess patients' satisfaction with this programme, and adherence to topical treatment. Additionally, disease severity and quality of life were assessed. An initial clinical investigation was conducted in 10 European treatment centres. A total of 330 patients were included. Patient satisfaction, adherence, disease severity and quality of life were measured with study-specific and standardized self-report questionnaires. Patients reported a high degree of satisfaction with the programme, and a high degree of adherence to topical treatment. Disease severity and quality of life significantly improved. The programme was well received by the participating professionals. The disease management programme was found to be a useful tool in the management of psoriasis, providing patients with relief from the burden of psoriasis in everyday life. A full-scale evaluation is recommended.

  6. An examination of the relationship between care management with coaching for activation and patient outcomes.

    PubMed

    Reistroffer, Cindy; Hearld, Larry R; Szychowski, Jeff M

    2017-02-01

    A growing body of research has established the benefits of patient activation, which is defined as the knowledge, skills, confidence, and motivation to make effective decisions and take action to maintain or improve one's health. Consequently, healthcare stakeholders of all types continue to seek ways to improve patient activation. The purpose of this study was to empirically examine whether enrollment in a health plan-sponsored care management (CM) program that included coaching for activation (CFA) was associated with utilization, medication adherence, and clinical outcomes. Cross-sectional, quantitative study of commercially insured enrollees in a Midwest-based health plan. Poisson, logistic, and ordinary least squares regression models were used to test the relationships between CM programs and outcomes. The benefit of measuring patient activation and offering CFA was associated with reduced healthcare utilization and better clinical outcomes. Relative to respondents in the CFA CM group (ie, intervention), respondents in the usual CM group experienced 18.29% more emergency department visits, 97.78% more hospital admissions, a higher glycated hemoglobin level (β = 0.48; P <.001), and higher systolic blood pressure (β = 1.19; P <.01). These findings suggest that coaching interventions based on activation level may help care managers engage in more effective interactions that strengthen a patient's role in managing his or her healthcare. Programs that are more targeted in their application, rather than uniformly developed and implemented, may be an important factor in reducing utilization and improving clinical outcomes.

  7. Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners.

    PubMed

    Lindell, Kathleen Oare; Olshansky, Ellen; Song, Mi-Kyung; Zullo, Thomas G; Gibson, Kevin F; Kaminski, Naftali; Hoffman, Leslie A

    2010-01-01

    Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled "Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management," which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden. Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management. After the intervention, experimental group patients rated their HRQoL less positively (P = .038) and tended to report more anxiety (P = .077) compared with controls. Care partners rated their stress at a lower level (P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others. Further exploration of the impact of disease-management

  8. Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners

    PubMed Central

    Lindell, Kathleen Oare; Olshansky, Ellen; Song, Mi-Kyung; Zullo, Thomas G.; Gibson, Kevin F.; Kaminski, Naftali; Hoffman, Leslie A.

    2012-01-01

    BACKGROUND Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled “Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management,” which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden. METHODS Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management. RESULTS After the intervention, experimental group patients rated their HRQoL less positively (P = .038) and tended to report more anxiety (P = .077) compared with controls. Care partners rated their stress at a lower level (P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others. CONCLUSION

  9. Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study

    PubMed Central

    Phua, Jason; Du, Bin; Tang, Yao-Qing; Divatia, Jigeeshu V; Tan, Cheng Cheng; Gomersall, Charles D; Faruq, Mohammad Omar; Shrestha, Babu Raja; Gia Binh, Nguyen; Arabi, Yaseen M; Salahuddin, Nawal; Wahyuprajitno, Bambang; Tu, Mei-Lien; Wahab, Ahmad Yazid Haji Abd; Hameed, Akmal A; Nishimura, Masaji; Procyshyn, Mark; Chan, Yiong Huak

    2011-01-01

    Objectives To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign’s resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance. Design Prospective cohort study. Setting 150 intensive care units in 16 Asian countries. Participants 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients’ baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded. Main outcome measure Compliance with the Surviving Sepsis Campaign’s resuscitation (six hours) and management (24 hours) bundles. Results Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle. Conclusions While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures

  10. Patient Experience Shows Little Relationship with Hospital Quality Management Strategies

    PubMed Central

    Groene, Oliver; Arah, Onyebuchi A.; Klazinga, Niek S.; Wagner, Cordula; Bartels, Paul D.; Kristensen, Solvejg; Saillour, Florence; Thompson, Andrew; Thompson, Caroline A.; Pfaff, Holger; DerSarkissian, Maral; Sunol, Rosa

    2015-01-01

    Objectives Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures. Materials and Methods We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level. Results Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute

  11. Patient Experience Shows Little Relationship with Hospital Quality Management Strategies.

    PubMed

    Groene, Oliver; Arah, Onyebuchi A; Klazinga, Niek S; Wagner, Cordula; Bartels, Paul D; Kristensen, Solvejg; Saillour, Florence; Thompson, Andrew; Thompson, Caroline A; Pfaff, Holger; DerSarkissian, Maral; Sunol, Rosa

    2015-01-01

    Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures. We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level. Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute myocardial infarction n = 1,379, hip fracture

  12. A randomized trial of an acid-peptic disease management program in a managed care environment.

    PubMed

    Ofman, Joshua J; Segal, Richard; Russell, Wayne L; Cook, Deborah J; Sandhu, Meenu; Maue, Susan K; Lowenstein, Edward H; Pourfarzib, Ray; Blanchette, Erv; Ellrodt, Gray; Weingarten, Scott R

    2003-06-01

    To study the effectiveness of a disease management program for patients with acid-related disorders. A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice." Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study.

  13. Patient-centered blood management.

    PubMed

    Hohmuth, Benjamin; Ozawa, Sherri; Ashton, Maria; Melseth, Richard L

    2014-01-01

    Transfusions are common in hospitalized patients but carry significant risk, with associated morbidity and mortality that increases with each unit of blood received. Clinical trials consistently support a conservative over a liberal approach to transfusion. Yet there remains wide variation in practice, and more than half of red cell transfusions may be inappropriate. Adopting a more comprehensive approach to the bleeding, coagulopathic, or anemic patient has the potential to improve patient care. We present a patient-centered blood management (PBM) paradigm. The 4 guiding principles of effective PBM that we present include anemia management, coagulation optimization, blood conservation, and patient-centered decision making. PBM has the potential to decrease transfusion rates, decrease practice variation, and improve patient outcomes. PBM's value proposition is highly aligned with that of hospital medicine. Hospitalists' dual role as front-line care providers and quality improvement leaders make them the ideal candidates to develop, implement, and practice PBM. © 2013 Society of Hospital Medicine.

  14. [Care and optimal management of the face- and neck-lift patients].

    PubMed

    Delay, E

    2017-10-01

    Surgical and case management for patients demanding a face- and neck-lift are very important. The purpose of this paper is to help the plastic surgeons with information and recommendations useful for the best medical care of patients requiring a face- and neck-lift. The first consultation is the most important contact with the patient. The preoperative discussion helps to define patient demands and to evaluate eventual contraindications for surgery. The clinical exam and patient requirements are useful in the construction of the therapeutic proposition. This proposition is then confronted with patients' expectations and demands. The confrontation between the surgical proposition and patients' expectations allows to evaluate if it is appropriate, or not, to operate. At the end of the first consultation, the patient receives the information sheets of the French Plastic Surgery Society (SOFCPRE) according to the proposed surgical treatment. The second consultation makes it possible to verify the pertinence of the surgical act, to reiterate the preoperative recommendations, to confirm that the information given to the patient was well understood and to obtain the written consent from the patient. The written consent should include the fact that the patient received the information sheets of the SOFCPRE, that they were read and understood, and that the surgeon has transmitted the necessary information in order for the patient to take an informed and free decision to pursue with the surgery. The follow-up after surgery is as important as the surgery itself. In some cases, cosmetic gestures can be performed in the following months to obtain the best results possible and the highest satisfaction. The face- and neck-lift is an "adventure" for the patients and the postoperative difficulties should not be underestimated. However, the caring and professional support of the plastic surgeon and the support of someone of the patients' entourage can help the patient overcome this

  15. Conservative Management and End-of-Life Care in an Australian Cohort with ESRD

    PubMed Central

    Webster, Angela C.; McGeechan, Kevin; Howard, Kirsten; Murtagh, Fliss E.M.; Gray, Nicholas A.; Kerr, Peter G.; Germain, Michael J.; Snelling, Paul

    2016-01-01

    Background and objectives We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. Design, setting, participants, & measurements A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two–sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. Results In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serum albumin <3.0 versus 3.7–5.4 g/dl (hazard ratio, 4.31; 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively. Conclusions Survival after 3 years of conservative management is common, with relatively

  16. Patient engagement and patient-centred care in the management of advanced chronic kidney disease and chronic kidney failure.

    PubMed

    Bear, Robert Allan; Stockie, Suzanne

    2014-01-01

    The purpose of this article is to review the current status of patient-centred care (PCC) and patient engagement (PE) in the management of patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD), to identify some of the barriers that exist to the achievement of PCC and PE, and to describe how these barriers can be overcome. The review is based on the professional experience of one of the authors (RB) as a Nephrologist and health care consultant, on the MBA thesis of one of the authors (SS) and on a review of pertinent internet-based information and published literature. Evidence exists that, currently, the care of patients with advanced CKD and ESRD is not fully patient-centred or fully supportive of PE. A number of barriers exist, including: conflict with other priorities; lack of training and fear of change; the unequal balance of power between patients and providers; physician culture and behaviour; the fee-for-service model of physician compensation; slow implementation of electronic health records; and, fear of accountability. These barriers can be overcome by committed leadership and the development of an information-based implementation plan. Established Renal Agencies in Canada appear interested in facilitating this work by collaborating in the development of a toolkit of recommended educational resources and preferred implementation practices for use by ESRD Programs. A limitation of this review is the absence of a substantial pre-existing literature on this topic. Receiving care that is patient-centred and that promotes PE benefits patients with serious chronic diseases such as advanced CKD and ESRD. Considerable work is required by ESRD Programs to ensure that such care is provided. Canadian Renal Agencies can play an important role by ensuring that ESRD Programs have access to essential educational material and proven implementation approaches and that implementation successes are celebrated. In this area, enabling

  17. Addressing hospital-acquired pressure ulcers: patient care managers enhancing outcomes at the point of service.

    PubMed

    Frumenti, Jeanine M; Kurtz, Abby

    2014-01-01

    An innovative leadership training program for patient care managers (PCMs) aimed at improving the management of operational failures was conducted at a large metropolitan hospital center. The program focused on developing and enhancing the transformational leadership skills of PCMs by improving their ability to manage operational failures in general and, in this case, hospital-acquired pressure ulcers. The PCMs received 8 weeks of intense training using the Toyota Production System process improvement approach, along with executive coaching. Compared with the control group, the gains made by the intervention group were statistically significant.

  18. Patients' and Health Care Providers' Perception of Stressors in the Intensive Care Units.

    PubMed

    Abuatiq, Alham

    2015-01-01

    The purposes of this study is first, to investigate intensive care patients' perceptions of stressors; second, to investigate the health care provider's perception of what constitutes a stressor from the patient's perspective; and third, to describe how health care providers manage their patients' stressors. This was a mixed-methods study; the quantitative section replicated Cornock's 1998 study of stress in the intensive care unit (ICU), with difference in sampling to include all health care providers in the ICU, in addition to nurses. The qualitative section added information to the current literature by describing how health care providers manage their patient's stressors. This article reports the quantitative findings of this study, as the qualitative section is presented in a separate article. It is important to describe ICU patients' stressful experiences to assess patient's stressors, provide holistic care to eliminate stressors, and provide feedback to health care providers. There is a need to describe the clinical practice related to stress perception and management of stressors in the critical care environment. A mixed-methods comparative descriptive design was used for the quantitative section, and a phenomenological approach guided the qualitative section. Lazarus and Folkman's theory formed the bases for integrating all variables investigated in this study. The sample included 70 ICU patients and 70 ICU health care providers. After consenting to participate in this study, subjects were given a demographic form and a paper-based tool, the Environmental Stressors graphic data form Questionnaire. Questionnaires were filled out by subjects anonymously in the ICU and returned to the researcher in the same setting. Descriptive statistics were analyzed using SPSS data analysis software. The top 3 most stressful items ranked by the patients included "being in pain," followed by "not being able to sleep" and "financial worries"; on the other hand, health care

  19. From shared care to disease management: key-influencing factors.

    PubMed

    Eijkelberg, I M; Spreeuwenberg, C; Mur-Veeman, I M; Wolffenbuttel, B H

    2001-01-01

    In order to improve the quality of care of chronically ill patients the traditional boundaries between primary and secondary care are questioned. To demolish these boundaries so-called 'shared care' projects have been initiated in which different ways of substitution of care are applied. When these projects end, disease management may offer a solution to expand the achieved co-operation between primary and secondary care. Answering the question: What key factors influence the development and implementation of shared care projects from a management perspective and how are they linked? The theoretical framework is based on the concept of the learning organisation. Reference point is a multiple case study that finally becomes a single case study. Data are collected by means of triangulation. The studied cases concern two interrelated Dutch shared care projects for type 2 diabetic patients, that in the end proceed as one disease management project. In these cases the predominant key-influencing factors appear to be the project management, commitment and local context, respectively. The factor project management directly links the latter two, albeit managing both appear prerequisites to its success. In practice this implies managing the factors' interdependency by the application of change strategies and tactics in a committed and skillful way. Project management, as the most important and active key factor, is advised to cope with the interrelationships of the influencing factors in a gradually more fundamental way by using strategies and tactics that enable learning processes. Then small-scale shared care projects may change into a disease management network at a large scale, which may yield the future blueprint to proceed.

  20. Hospital revenue cycle management and payer mix: do Medicare and Medicaid undermine hospitals' ability to generate and collect patient care revenue?

    PubMed

    Rauscher, Simone; Wheeler, John R C

    2010-01-01

    The continuing efforts of government payers to contain hospital costs have raised concerns among hospital managers that serving publicly insured patients may undermine their ability to manage the revenue cycle successfully. This study uses financial information from two sources-Medicare cost reports for all US hospitals for 2002 to 2007 and audited financial statements for all bond-issuing, not-for-profit hospitals for 2000 to 2006 to examine the relationship between hospitals' shares of Medicare and Medicaid patients and the amount of patient care revenue they generate as well as the speed with which they collect their revenue. Hospital-level fixed effects regression analysis finds that hospitals with higher Medicare and Medicaid payer mix collect somewhat higher average patient care revenues than hospitals with more privately insured and self-pay patients. Hospitals with more Medicare patients also collect on this revenue faster; serving more Medicaid patients is not associated with the speed of patient revenue collection. For hospital managers, these findings may represent good news. They suggest that, despite increases in the number of publicly insured patients served, managers have frequently been able to generate adequate amounts of patient revenue and collect it in a timely fashion.

  1. Changing office practice and health care systems to facilitate diabetes self-management.

    PubMed

    Funnell, Martha M; Anderson, Robert M

    2003-04-01

    Diabetes is a self-managed disease for which patients provide 99% of their own care. For patients to succeed as diabetes self-managers, they need office practices and health care systems that can prepare and support them in their diabetes self-management efforts over the long term. In order to provide effective diabetes education and ongoing support, office practices and health care systems will have to fundamentally redefine the roles of health professionals and patients with diabetes, and redesign practices and systems to allow for effective long-term self-management education and support. Although it is difficult for both people and systems to change, change is essential if we are going to provide self-management support for the majority of patients suffering from this serious chronic disease.

  2. Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients

    PubMed Central

    2012-01-01

    Background Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework. Method/design For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework. Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to

  3. Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients.

    PubMed

    Fung, Colman S C; Chin, Weng Yee; Dai, Daisy S K; Kwok, Ruby L P; Tsui, Eva L H; Wan, Yuk Fai; Wong, Wendy; Wong, Carlos K H; Fong, Daniel Y T; Lam, Cindy L K

    2012-12-05

    Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework. For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework.Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to monitor quality of life

  4. Guideline for the management of terminal haemorrhage in palliative care patients with advanced cancer discharged home for end-of-life care.

    PubMed

    Ubogagu, Edith; Harris, Dylan G

    2012-12-01

    Terminal haemorrhage is a rare and distressing emergency in palliative oncology. We present an algorithm for the management of terminal haemorrhage in patients likely to receive end-of-life care at home, based on a literature review of the management of terminal haemorrhage for patients with advanced cancer, where a DNAR (do not attempt resuscitation) order is in place and the patient wishes to die at home. A literature review was conducted to identify literature on the management of terminal haemorrhage in patients with advanced cancer who are no longer amenable to active interventional/invasive procedures. Electronic databases, the grey literature, local guidelines from hospitals and hospices, and online web portals were all searched systematically. The literature review was used to formulate a management algorithm. The evidence base is very limited. A three-step practical algorithm is suggested: preparing for the event, managing the event ('ABC') and 'aftercare'. Step 1 involves the identification and optimisation of risk factors. Step 2 (the event) consists of A (assure and re-assure the patient), B (be there - above all stay with the patient) and C (comfort, calm, consider dark towels and anxiolytics if possible). Step 3 (the aftercare) involves the provision of practical and psychological support to those involved including relatives and professionals. Terminal haemorrhage is a rare yet highly feared complication of advanced cancer, for which there is a limited evidence base to guide management. The suggested three-step approach to managing this situation gives professionals a logical framework within which to work.

  5. Sustained impact of anticoagulant control achieved in an anticoagulation management service after transfer of management to the primary care physician.

    PubMed

    Bungard, Tammy J; Ritchie, Bruce; Garg, Sipi; Tsuyuki, Ross T

    2012-02-01

    To determine whether the impact of anticoagulant control achieved in an Anticoagulation Management Service (AMS) is sustained after transfer of anticoagulation management to the primary care physician (PCP), and to assess patient satisfaction with their anticoagulation management by both the AMS and PCP. Prospective, randomized trial. Pharmacist-directed ambulatory AMS located in a tertiary medical care facility and PCP practices in Canada. Sixty-two adults who had received at least 6 months of warfarin therapy managed by the AMS. Patients were randomly assigned to remain with AMS care (32 patients) or to transfer their anticoagulation management care to their PCP (30 patients). After 4.5 months of care, patients in both groups completed a validated survey instrument assessing their satisfaction with the management of their warfarin therapy. Of 295 patients screened, most were excluded from the study for denying consent or for having previous bleeding or clotting complications while taking warfarin. Patients in the AMS and PCP groups who completed the study were similar in age (median 70 and 76 yrs, respectively), and most had atrial fibrillation as an indication for warfarin (75% and 83%, respectively). The primary outcome measure-mean percentage of time within the desired international normalized ratio (INR) range after 6 months-was compared between the two groups, using both the actual range (INR 2.5 ± 0.5) and an expanded range (INR 2.5 ± 0.7). No significant difference was noted in this outcome between the groups (73.5 ± 19.1% vs 76.9 ± 24.5% for the AMS vs PCP groups, p=0.54). Other outcome measures were rates of thrombotic and hemorrhagic events resulting in emergency department visits or hospitalizations, patients' overall satisfaction with warfarin therapy, and patients' preferred anticoagulation management strategy. Two hemorrhagic events and one thrombotic event occurred in each group. Patients were more satisfied with their anticoagulant

  6. [Management of pediatric multiple trauma patients. Perspective of the pediatric intensive care unit].

    PubMed

    Carreras González, E; Rey Galán, C; Concha Torre, A; Cañadas Palaz, S; Serrano González, A; Cambra Lasaosa, F J

    2007-08-01

    To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%. In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

  7. Academic medicine meets managed care: a high-impact collision.

    PubMed

    Carey, R M; Engelhard, C L

    1996-08-01

    The managed care revolution is sweeping the country as a result of intense marketing on the part of managed care organizations and the widespread belief that price-sensitive managed care systems will control health costs. Although few believe that managed care alone can adequately stem the growth of nation health care spending, competition based on price has emerged as a powerful force in the health care sector. Academic health center (AHCs) stand to suffer with this new managed care regime because their special missions of teaching, research, and highly specialized clinical care make them more expensive than nonacademic hospitals and place them at a noncompetitive disadvantage. The traditional focus of the acute care hospital with individual departmentally designed programs will be narrow. Major changes will be required on the part of AHCs if they are to survive and preserve patient volume, maintain the integrity of medical education, advance scientific research, and provide highly specialized care. AHCs will have to make unprecedented adjustments in virtually every phase of their operations, particularly in the areas of clinical decision making and speedy patient-related information flow. A premium will be placed on multidisciplinary, inclusive medical services that can assume total health care risks for large populations. New ways of educating students in ambulatory settings with an emphasis on outcomes and population-based health will be needed along with the traditional responsibility of pursuing new approaches to the diagnosis, treatment, and prevention of disease. The extent to which managed care will ultimately alter the traditional role of AHCs in the American health care system is unclear, but successful adaptation in the short term will require them to respond broadly, flexibly, and in a timely fashion to the anticipated health care scene.

  8. A Framework for Fibromyalgia Management for Primary Care Providers

    PubMed Central

    Arnold, Lesley M.; Clauw, Daniel J.; Dunegan, L. Jean; Turk, Dennis C.

    2012-01-01

    Fibromyalgia is a chronic widespread pain disorder commonly associated with comorbid symptoms, including fatigue and nonrestorative sleep. As in the management of other chronic medical disorders, the approach for fibromyalgia management follows core principles of comprehensive assessment, education, goal setting, multimodal treatment including pharmacological (eg, pregabalin, duloxetine, milnacipran) and nonpharmacological therapies (eg, physical activity, behavioral therapy, sleep hygiene, education), and regular education and monitoring of treatment response and progress. Based on these core management principles, this review presents a framework for primary care providers through which they can develop a patient-centered treatment program for patients with fibromyalgia. This proactive and systematic treatment approach encourages ongoing education and patient self-management and is designed for use in the primary care setting. PMID:22560527

  9. Patient-centered health care using pharmacist-delivered medication therapy management in rural Mississippi.

    PubMed

    Ross, Leigh Ann; Bloodworth, Lauren S

    2012-01-01

    To describe and provide preliminary clinical and economic outcomes from a pharmacist-delivered patient-centered health care (PCHC) model implemented in the Mississippi Delta. Mississippi between July 2008 and June 2010. 13 community pharmacies in nine Mississippi Delta counties. This PCHC model implements a comprehensive medication therapy management (MTM) program with pharmacist training, individualized patient encounters and group education, provider outreach, integration of pharmacists into health information technology, and on-site support in community pharmacies in a medically underserved region with a large burden of chronic disease and health disparities. The program also expands on traditional MTM services through initiatives in health literacy/cultural competency and efforts to increase the provider network and improve access to care. Criteria-based clinical outcomes, quality indicator reports, cost avoidance. PCHC services have been implemented in 13 pharmacies in nine counties in this underserved region, and 78 pharmacists and 177 students have completed the American Pharmacists Association's MTM Certificate Training Program. Preliminary data from 468 patients showed 681 encounters in which 1,471 drug therapy problems were identified and resolved. Preliminary data for clinical indicators and economic outcome measures are trending in a positive direction. Preliminary data analyses suggest that pharmacist-provided PCHC is beneficial and has the potential to be replicated in similar rural communities that are plagued with chronic disease and traditional primary care provider shortages. This effort aligns with national priorities to reduce medication errors, improve health outcomes, and reduce health care costs in underserved communities.

  10. When doctor becomes patient: challenges and strategies in caring for physician-patients.

    PubMed

    Domeyer-Klenske, Amy; Rosenbaum, Marcy

    2012-01-01

    The current study was aimed at exploring the challenges that arise in the doctor-patient relationship when the patient is also a physician and identifying strategies physicians use to meet these challenges. No previous research has systematically investigated primary care physicians' perspectives on caring for physician-patients. Family medicine (n=15) and general internal medicine (n=14) physicians at a large Midwestern university participated in semi-structured interviews where they were asked questions about their experiences with physician-patients and the strategies they used to meet the unique needs of this patient population. Thematic analysis was used to identify common responses. Three of the challenges most commonly discussed by physician participants were: (1) maintaining boundaries between relationships with colleagues or between roles as physician/colleague/friend, (2) avoiding assumptions about patient knowledge and health behaviors, and (3) managing physician-patients' access to informal consultations, personal test results, and opinions from other colleagues. We were able to identify three main strategies clinicians use in addressing these perceived challenges: (1) Ignore the physician-patient's background, (2) Acknowledge the physician-patient's background and negotiate care, and (3) Allow care to be driven primarily by the physician-patient. It is important that primary care physicians understand the challenges inherent in treating physicians and develop a strategy with which they are comfortable addressing them. Explicitly communicating with the physician-patient to ensure boundaries are maintained, assumptions about the physician-patient are avoided, and physician-patient access is properly managed are key to providing quality care to physician-patients.

  11. Bluffing, puffing and spinning in managed-care organizations.

    PubMed

    Illingworth, P

    2000-02-01

    I argue that because bluffing, puffing, and spinning are features of corporate life, they are likely to characterize the doctor-patient relationship in managed care medicine. I show that managed-care organizations (MCOs) and the physicians who contract with them make liberal use of puffing and spinning. In this way, they create a context in which it is likely that patients will also use deceptive mechanisms. Unfortunately, patients risk their health when they deceive their doctors. Using the warranty theory of truth I argue that although bluffing may be ethical in business because all participants agree to it and business has not warranted truth-telling, it is not ethical in a medical context because physicians and MCOs have warranted truth-telling and the quality of medical care depends on it.

  12. Patient safety in psychiatric inpatient care: a literature review.

    PubMed

    Kanerva, A; Lammintakanen, J; Kivinen, T

    2013-08-01

    Patient safety is widely discussed, but little has been written from the perspective of psychiatric inpatient care, nor on which factors create its patient safety. This paper seeks to understand the concept of patient safety and its intension in psychiatric inpatient care, and to identify factors in organization management, staff and patients' roles which constitute patient safety in such units. A literature search was conducted, and the articles selected were analysed by identifying factors defined to be connected to patient safety and classifying them according to their connection to organization management, staff and patient roles. According to the literature, organization safety culture is present in all aspects of patient safety. Organization management has the main role in patient safety within the organization culture, for example, through leadership, safety practices and creating good working conditions and environment for the staff. Staff's role is influenced by management, but has more individual input in different areas, while the patient's role is more that of an informant so that care can be planned according to the patient's preferences. When developing patient safety it is important to remember the diversity of the concept so that all areas are considered in the developmental work. © 2012 John Wiley & Sons Ltd.

  13. Managing the care of patients who have visual impairment.

    PubMed

    Watkinson, Sue; Scott, Eileen

    An ageing population means that the incidence of people who are visually impaired will increase. However, extending the role of ophthalmic nurses will promote delivery of a more effective health service for these patients. Using Maslow's hierarchy of needs as a basis for addressing the care of patients with visual impairment is a means of ensuring that they receive high quality, appropriate care at the right time.

  14. Corporate social responsibility and the future health care manager.

    PubMed

    Collins, Sandra K

    2010-01-01

    The decisions and actions of health care managers are oftentimes heavily scrutinized by the public. Given the current economic climate, managers may feel intense pressure to produce higher results with fewer resources. This could inadvertently test their moral fortitude and their social consciousness. A study was conducted to determine what corporate social responsibility orientation and viewpoint future health care managers may hold. The results of the study indicate that future health care managers may hold patient care in high regard as opposed to profit maximization. However, the results of the study also show that future managers within the industry may continue to need rules, laws, regulations, and legal sanctions to guide their actions and behavior.

  15. Anaesthetic management of patients with severe sepsis.

    PubMed

    Eissa, D; Carton, E G; Buggy, D J

    2010-12-01

    Severe sepsis, a syndrome characterized by systemic inflammation and acute organ dysfunction in response to infection, is a major healthcare problem affecting all age groups throughout the world. Anaesthetists play a central role in the multidisciplinary management of patients with severe sepsis from their initial deterioration at ward level, transfer to the diagnostic imaging suite, and intraoperative management for emergency surgery. The timely administration of appropriate i.v. antimicrobial therapy is a crucial step in the care of patients with severe sepsis who may require surgery to control the source of sepsis. Preoperative resuscitation, aimed at optimizing major organ perfusion, is based on judicious use of fluids, vasopressors, and inotropes. Intraoperative anaesthesia management requires careful induction and maintenance of anaesthesia, optimizing intravascular volume status, avoidance of lung injury during mechanical ventilation, and ongoing monitoring of arterial blood gases, lactate concentration, haematological and renal indices, and electrolyte levels. Postoperative care overlaps with ongoing management of the severe sepsis syndrome patient in the intensive care unit. These patients are by definition, high risk, already requiring multiple supports, and require experienced and skilful decision-making to optimize their chances of a favourable outcome. Similar to acute myocardial infarction, stroke, or acute trauma, the initial hours (golden hours) of clinical management of severe sepsis represent an important opportunity to reduce morbidity and mortality. Rapid clinical assessment, resuscitation and surgical management by a focused multidisciplinary team, and early effective antimicrobial therapy are the key components to improved patient outcome.

  16. From shared care to disease management: key-influencing factors

    PubMed Central

    Eijkelberg, Irmgard M.J.G.; Spreeuwenberg, Cor; Mur-Veeman, Ingrid M.; Wolffenbuttel, Bruce H.R.

    2001-01-01

    Abstract Background In order to improve the quality of care of chronically ill patients the traditional boundaries between primary and secondary care are questioned. To demolish these boundaries so-called ‘shared care’ projects have been initiated in which different ways of substitution of care are applied. When these projects end, disease management may offer a solution to expand the achieved co-operation between primary and secondary care. Objective Answering the question: What key factors influence the development and implementation of shared care projects from a management perspective and how are they linked? Theory The theoretical framework is based on the concept of the learning organisation. Design Reference point is a multiple case study that finally becomes a single case study. Data are collected by means of triangulation. The studied cases concern two interrelated Dutch shared care projects for type 2 diabetic patients, that in the end proceed as one disease management project. Results In these cases the predominant key-influencing factors appear to be the project management, commitment and local context, respectively. The factor project management directly links the latter two, albeit managing both appear prerequisites to its success. In practice this implies managing the factors' interdependency by the application of change strategies and tactics in a committed and skilful way. Conclusion Project management, as the most important and active key factor, is advised to cope with the interrelationships of the influencing factors in a gradually more fundamental way by using strategies and tactics that enable learning processes. Then small-scale shared care projects may change into a disease management network at a large scale, which may yield the future blueprint to proceed. PMID:16896415

  17. Managing chronic illness: physician practices increased the use of care management and medical home processes.

    PubMed

    Wiley, James A; Rittenhouse, Diane R; Shortell, Stephen M; Casalino, Lawrence P; Ramsay, Patricia P; Bibi, Salma; Ryan, Andrew M; Copeland, Kennon R; Alexander, Jeffrey A

    2015-01-01

    The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance. Project HOPE—The People-to-People Health Foundation, Inc.

  18. Evaluation of a patient centered e-nursing and caring system.

    PubMed

    Tsai, Lai-Yin; Shan, Huang; Mei-Bei, Lin

    2006-01-01

    This study aims to develop an electronic nursing and caring system to manage patients' information and provide patients with safe and efficient services. By transmitting data among wireless cards, optical network, and mainframe computer, nursing care will be delivered more systematically and patients' safety centered caring will be delivered more efficiently and effectively. With this system, manual record keeping time was cut down, and relevant nursing and caring information was linked up. With the development of an electronic nursing system, nurses were able to make the best use of the Internet resources, integrate information management systematically and improve quality of nursing and caring service.

  19. Does Physician Education on Depression Management Improve Treatment in Primary Care?

    PubMed Central

    Lin, Elizabeth H B; Simon, Gregory E; Katzelnick, David J; Pearson, Steven D

    2001-01-01

    OBJECTIVE To assess the effect of physician training on management of depression. DESIGN Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial. SETTING One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States. PATIENTS/PARTICIPANTS Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians. INTERVENTIONS Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants. MEASUREMENTS AND MAIN RESULTS Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P = .95) or new prescription of antidepressant medicines (P = .10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P = .53) as measured by 12 weeks of continuous antidepressant treatment. CONCLUSIONS After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy. PMID:11556942

  20. Managed care redux: health plans shift responsibilities to consumers.

    PubMed

    Draper, Debra A; Claxton, Gary

    2004-03-01

    Confronted with conflicting pressures to stem double-digit premium increases and provide unfettered access to care, health plans are developing products that shift more financial and care management responsibilities to consumers, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. Plans are pursuing these strategies in collaboration with employers that want to gain control over rapidly rising premiums while continuing to respond to employee demands for less restrictive managed care practices. Mindful of the managed care backlash, health plans also are stepping up utilization management activities for high-cost services and focusing care management on high-cost patients. While the move toward greater consumer engagement is clear, the impact on costs and consumer willingness to assume these new responsibilities remain to be seen.

  1. Barriers and facilitators to providing primary care-based weight management services in a patient centered medical home for Veterans: a qualitative study.

    PubMed

    Jay, Melanie; Chintapalli, Sumana; Squires, Allison; Mateo, Katrina F; Sherman, Scott E; Kalet, Adina L

    2015-11-14

    Obesity is highly prevalent among Veterans. In the United States, the Veterans Health Administration (VHA) offers a comprehensive weight management program called MOVE!. Yet, fewer than 10 % of eligible patients ever attend one MOVE! visit. The VHA has a patient-centered medical home (PCMH) model of primary care (PC) called Patient-Aligned Care Teams (PACT) at all Veterans Affairs (VA) Medical Centers. PACT teamlets conduct obesity screening, weight management counseling, and refer to MOVE!. As part of a needs assessment to improve delivery of weight management services, the purpose of this study was to assess PACT teamlet and MOVE! staff: 1) current attitudes and perceptions regarding obesity care; 2) obesity-related counseling practices 3) experiences with the MOVE! program; and 4) targets for interventions to improve implementation of obesity care in the PC setting. We recruited 25 PACT teamlet members from a single VA study site-11 PC physicians, 5 registered nurses, 5 licensed practical nurses, 1 clerical assistant, and 3 MOVE! staff (2 dietitians, 1 psychologist)-for individual interviews using a combination of convenience and snowball sampling. Audio recorded interviews were professionally transcribed and iteratively coded by two independent reviewers. The analytic process was guided by discourse analysis in order to discover how the participants perceived and provided weight management care and what specific attitudes affected their practices, all as bounded within the organization. Emerging themes included: 1) role perceptions, 2) anticipated outcomes of weight management counseling and programs, and 3) communication and information dissemination. Perceived role among PCPs was influenced by training, whereas personal experience with their own weight management impacted role perception among LPNs/RNs. Attitudes about whether or not they could impact patients' weight outcomes via counseling or referral to MOVE! varied. System-level communication about VHA

  2. Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care

    PubMed Central

    2014-01-01

    Background There is a need for cost-effective weight management interventions that primary care can deliver to reduce the morbidity caused by obesity. Automated web-based interventions might provide a solution, but evidence suggests that they may be ineffective without additional human support. The main aim of this study was to carry out a feasibility trial of a web-based weight management intervention in primary care, comparing different levels of nurse support, to determine the optimal combination of web-based and personal support to be tested in a full trial. Methods This was an individually randomised four arm parallel non-blinded trial, recruiting obese patients in primary care. Following online registration, patients were randomly allocated by the automated intervention to either usual care, the web-based intervention only, or the web-based intervention with either basic nurse support (3 sessions in 3 months) or regular nurse support (7 sessions in 6 months). The main outcome measure (intended as the primary outcome for the main trial) was weight loss in kg at 12 months. As this was a feasibility trial no statistical analyses were carried out, but we present means, confidence intervals and effect sizes for weight loss in each group, uptake and retention, and completion of intervention components and outcome measures. Results All randomised patients were included in the weight loss analyses (using Last Observation Carried Forward). At 12 months mean weight loss was: usual care group (n = 43) 2.44 kg; web-based only group (n = 45) 2.30 kg; basic nurse support group (n = 44) 4.31 kg; regular nurse support group (n = 47) 2.50 kg. Intervention effect sizes compared with usual care were: d = 0.01 web-based; d = 0.34 basic nurse support; d = 0.02 regular nurse support. Two practices deviated from protocol by providing considerable weight management support to their usual care patients. Conclusions This study demonstrated the

  3. Patient-reported care coordination: associations with primary care continuity and specialty care use.

    PubMed

    Liss, David T; Chubak, Jessica; Anderson, Melissa L; Saunders, Kathleen W; Tuzzio, Leah; Reid, Robert J

    2011-01-01

    Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

  4. Chronic Care Management evolves towards Integrated Care in Counties Manukau, New Zealand.

    PubMed

    Rea, Harry; Kenealy, Tim; Wellingham, John; Moffitt, Allan; Sinclair, Gary; McAuley, Sue; Goodman, Meg; Arcus, Kim

    2007-04-13

    Despite anecdotes of many chronic care management and integrated care projects around New Zealand, there is no formal process to collect and share relevant learning within (but especially between) District Health Boards (DHBs). We wish to share our experiences and hope to stimulate a productive exchange of ongoing learning. We define chronic care management and integrated care, then summarise current theory and evidence. We describe national policy development (relevant to integrated care, since 2000) including the New Zealand Health Strategy, the NZ Primary Care Strategy, the development of Primary Health Organisations (PHOs), capitation payments, Care Plus, and Services to Improve Access funding. We then describe chronic care management in Counties Manukau, which evolved both prior to and during the international refinement of theory and evidence and the national policy development and implementation. We reflect on local progress to date and opportunities for (and barriers to) future improvements, aided by comparative reflections on the United Kingdom (UK). Our most important messages are addressed as follows: To policymakers and funders--a fragile culture change towards teamwork in the health system is taking place in New Zealand; this change needs to be specifically and actively supported. To PHOs--general practices need help to align their internal (within-practice) financial signals with the new world of capitation and integrated care. To primary and secondary care doctors, nurses, and other carers - systematic chronic care management and integrated care can improve patient quality of life; and if healthcare structures and systems are properly managed to support integration, then healthcare provider professional and personal satisfaction will improve.

  5. Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial.

    PubMed

    Bruce, Martha L; Lohman, Matthew C; Greenberg, Rebecca L; Bao, Yuhua; Raue, Patrick J

    2016-11-01

    To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization. Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams). Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone. Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306). The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks. Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments. The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants. Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

  6. RN Diabetes Virtual Case Management: A New Model for Providing Chronic Care Management.

    PubMed

    Brown, Nancy N; Carrara, Barbara E; Watts, Sharon A; Lucatorto, Michelle A

    2016-01-01

    The U.S. chronic disease health care system has substantial gaps in delivery of services. New models of care change traditional delivery of care and explore new settings for care. This article describes a new model of diabetes chronic care delivery: nurse-delivered care that includes protocol-based insulin titration and patient education delivered solely in a virtual environment. In phase 1, the clinical outcome of time to achievement of glycated hemoglobin (A(1C)) goals (P < .001; 95% confidence interval, 1.68-2.24) was significantly improved by registered nurse (RN) standing order intervention (n = 24) as compared with historical controls (n = 28). In phase 2, patients who were referred to an RN-managed insulin titration protocol with individualized A(1C) goals had a significant (P < .001; 95% confidence interval, 1.680-2.242) reduction in results from a mean of 9.6% at baseline to 7.7% at completion. Average patient age was 66 years, with a mean duration of 11 years diagnosed with diabetes. Safety was demonstrated by the absence of hypoglycemia related to RN protocol adjustment. There were no admissions or emergency room (ER) visits for hypoglycemia. This study demonstrates safety and efficacy of RN virtual chronic disease management for an older population of patients with long-standing diabetes.

  7. The Managed Care Backlash: Perceptions and Rhetoric in Health Care Policy and the Potential for Health Care Reform

    PubMed Central

    Mechanic, David

    2001-01-01

    The focus on managed care and the managed care backlash divert attention from more important national health issues, such as insurance coverage and quality of care. The ongoing public debate often does not accurately convey the key issues or the relevant evidence. Important perceptions of reduced encounter time with physicians, limitations on physicians' ability to communicate options to patients, and blocked access to inpatient care, among others, are either incorrect or exaggerated. The public backlash reflects a lack of trust resulting from cost constraints, explicit rationing, and media coverage. Inevitable errors are now readily attributed to managed care practices and organizations. Some procedural consumer protections may help restore the eroding trust and refocus public discussion on more central issues. PMID:11286094

  8. Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management

    PubMed Central

    Chabot, Elizabeth; Nirula, Ram

    2017-01-01

    The term “open abdomen” refers to a surgically created defect in the abdominal wall that exposes abdominal viscera. Leaving an abdominal cavity temporarily open has been well described for several indications, including damage control surgery and abdominal compartment syndrome. Although beneficial in certain patients, the act of keeping an abdominal cavity open has physiologic repercussions that must be recognized and managed during postoperative care. This review article describes these issues and provides guidelines for the critical care physician managing a patient with an open abdomen. PMID:29766080

  9. ESRD in the geriatric population: the crisis of managed care and the opportunity of disease management.

    PubMed

    Steinman, Theodore I

    2002-01-01

    The geriatric population with end-stage renal disease (ESRD) is placed at risk with regards to the quality and extent of medical coverage because of the rapidly changing financial environment. Managed care organizations (MCOs) are generally for-profit companies that must focus on the bottom line. While the verbal commitment to quality care is voiced, the financial pressures on MCOs have led to a decrease in coverage of many services and outright denial for some necessary treatments. While denying services, the MCOs have also reduced payments to providers for services rendered. The coverage crisis is compounded by health maintenance organizations (HMOs) quitting Medicare because the reimbursement from the Health Care Financing Administration (HCFA) is less than their costs. Because of the above issues which can potentially impact on the quality of care delivered to the ESRD geriatric population, a new approach to disease management has created the opportunity to improve total patient care to a level not yet achieved in the United States. Disease management encompasses integrated care across all disciplines. Every component of care can be tracked by a dedicated information system. Improvement in outcomes has far exceeded the U.S. Renal Data System (USRDS) benchmark performance measurements with a disease management model approach. The key to success is the health service coordinator (HSC), a senior nurse with many years of ESRD experience. This individual coordinates care across all disciplines and expedites necessary referrals. With rapid attention to patient needs there has been a significant reduction in hospital admissions, hospital length of stay, and emergency room visits. Patient care will steadily improve as the disease management system matures as a consequence of understanding the patients total physical and psychosocial needs.

  10. Orthotic management of the neuropathic foot: an interdisciplinary care perspective.

    PubMed

    Robinson, Christopher; Major, Matthew J; Kuffel, Charles; Hines, Kevin; Cole, Pamela

    2015-02-01

    Clinical management of the patient with neuropathic foot is becoming commonplace in orthotic clinics worldwide. The presentations that can result from neuropathic foot are diverse, requiring clinicians to understand the pathomechanics of ulceration, infection, and Charcot joint arthropathy to provide effective interventions. The purpose of this clinical perspective is to provide a review of the literature regarding clinical concepts associated with orthotic management of neuropathic foot. Literature review and clinical case study. Relevant literature were reviewed and summarized, and a clinical case study synthesizing reviewed concepts was presented. Given the multifactorial nature of the neuropathic foot, treatments must be multifaceted and patient-specific to effectively address the underlying disease processes. While systemic issues such as peripheral arterial disease are treated by physicians, local issues such as foot deformity are managed by orthotists. Orthotic interventions commonly include custom footwear to reduce the risk of ulceration through creation of a protective environment or targeted plantar offloading. Patient and caregiver education to encourage management compliance is equally as important to ensure successful treatment. Patients with neuropathic foot benefit from an interdisciplinary care approach which engages physicians, wound care practitioners, and orthotists to treat and manage systemic and local problems. Addressing this pathology through interdisciplinary care may positively affect the patient's health status while lowering associated healthcare costs through improved treatment efficacy. The commonality of neuropathic foot and associated complications including ulceration, infection, and Charcot joint arthropathy requires that the patient care team have a fundamental understanding of these pathologies and common treatment modalities. We review orthotic treatment modalities to assist clinicians with the management of patients with

  11. Managed Care

    MedlinePlus

    ... three types of managed care plans: Health Maintenance Organizations (HMO) usually only pay for care within the ... who coordinates most of your care. Preferred Provider Organizations (PPO) usually pay more if you get care ...

  12. Remission in Depressed Geriatric Primary Care Patients: A Report From the PROSPECT Study

    PubMed Central

    Alexopoulos, George S.; Katz, Ira R.; Bruce, Martha L.; Heo, Moonseong; Have, Thomas Ten; Raue, Patrick; Bogner, Hillary R.; Schulberg, Herbert C.; Mulsant, Benoit H.; Reynolds, Charles F.

    2009-01-01

    Objective This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. Method Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (≥60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. Results First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. Conclusions Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled. PMID:15800144

  13. Patient initiated clinics for patients with chronic or recurrent conditions managed in secondary care: a systematic review of patient reported outcomes and patient and clinician satisfaction

    PubMed Central

    2013-01-01

    Background The cost to the NHS of missed or inappropriate hospital appointments is considerable. Alternative methods of appointment scheduling might be more flexible to patients’ needs without jeopardising health and service quality. The objective was to systematically review evidence of patient initiated clinics in secondary care on patient reported outcomes among patients with chronic/recurrent conditions. Methods Seven databases were searched from inception to June 2013. Hand searching of included studies references was also conducted. Studies comparing the effects of patient initiated clinics with traditional consultant led clinics in secondary care for patients with long term chronic or recurrent diseases on health related quality of life and/or patient satisfaction were included. Data was extracted by one reviewer and checked by a second. Results were synthesised narratively. Results Seven studies were included in the review, these covered a total of 1,655 participants across three conditions: breast cancer, inflammatory bowel disease and rheumatoid arthritis. Quality of reporting was variable. Results showed no significant differences between the intervention and control groups for psychological and health related quality of life outcomes indicating no evidence of harm. Some patients reported significantly more satisfaction using patient-initiated clinics than usual care (p < 0.001). Conclusions The results show potential for patient initiated clinics to result in greater patient and clinician satisfaction. The patient-consultant relationship appeared to play an important part in patient satisfaction and should be considered an important area of future research as should the presence or absence of a guidebook to aid self-management. Patient initiated clinics fit the models of care suggested by policy makers and so further research into long term outcomes for patients and service use in this area of practice is both relevant and timely. PMID:24289832

  14. Marketing quality and value to the managed care market.

    PubMed

    Kazmirski, G

    1998-11-01

    Quantifying quality and marketing care delivery have been long-term challenges in the health care market. Insurers, employers, other purchasers of care, and providers face a constant challenge in positioning their organizations in a proactive, competitive niche. Tools that measure patient's self-reported perception of health care needs and expectations have increased the ability to quantify quality of care delivery. When integrated with case management and disease management strategies, outcomes reporting and variance analysis tracking can be packaged to position a provider in a competitive niche.

  15. Chronic care management for patients with COPD: a critical review of available evidence.

    PubMed

    Lemmens, Karin M M; Lemmens, Lidwien C; Boom, José H C; Drewes, Hanneke W; Meeuwissen, Jolanda A C; Steuten, Lotte M G; Vrijhoef, Hubertus J M; Baan, Caroline A

    2013-10-01

    Clinical diversity and methodological heterogeneity exists between studies on chronic care management. This study aimed to examine the effectiveness of chronic care management in chronic obstructive pulmonary disease (COPD) while taking heterogeneity into account, enabling the understanding of and the decision making about such programmes. Three investigated sources of heterogeneity were study quality, length of follow-up, and number of intervention components. We performed a review of previously published reviews and meta-analyses on COPD chronic care management. Their primary studies that were analyzed as statistical, clinical and methodological heterogeneity were present. Meta-regression analyses were performed to explain the variances among the primary studies. Generally, the included reviews showed positive results on quality of life and hospitalizations. Inconclusive effects were found on emergency department visits and no effects on mortality. Pooled effects on hospitalizations, emergency department visits and quality of life of primary studies did not reach significant improvement. No effects were found on mortality. Meta-regression showed that the number of components of chronic care management programmes explained present heterogeneity for hospitalizations and emergency department visits. Four components showed significant effects on hospitalizations, whereas two components had significant effects on emergency department visits. Methodological study quality and length of follow-up did not significantly explain heterogeneity. This study demonstrated that COPD chronic care management has the potential to improve outcomes of care; heterogeneity in outcomes was explained. Further research is needed to elucidate the diversity between COPD chronic care management studies in terms of the effects measured and strengthen the support for chronic care management. © 2011 John Wiley & Sons Ltd.

  16. The complex nature of informal care in home-based heart failure management.

    PubMed

    Clark, Alexander M; Reid, Margaret E; Morrison, Caroline E; Capewell, Simon; Murdoch, David L; McMurray, John J

    2008-02-01

    This paper is a report of a study to examine the complexities of informal caregiving for people with chronic heart failure. Little is known of the activities involved and underlying informal care. Heart failure is a common and burdensome condition in which carers play an important management role. Semi-structured interviews were carried out with 30 informal carers nominated by patients with mild-to-moderate heart failure (24 spouses, four children, one sibling and one neighbour). Interviews examined knowledge of heart failure, its effects, reported management practices and concerns, decision making and support. The data were collected in 2001. The management of heart failure was a shared and ongoing responsibility between the carer and patient. Carers' clinical knowledge of the condition and management was often limited, but they developed extensive knowledge of its personal effects on the patient. Invisible care activities included monitoring signs of symptom exacerbation and energy boundaries against perceived current and future demands and priorities. Visible care activities included medication management, dressing, bathing and help-seeking. Carers responded to patients' capacities, and adopted philosophies that sought to foster independence while facilitating as normal a life for the patient as was possible and safe. Interventions for informal carers around effective chronic heart failure management should address both visible and invisible informal caring. Future research is needed to develop interventions with carers to improve quality of care, reduce costs and improve patient quality of life. More research is needed to explore the complexities of lay caregiving and to explore the invisible dimensions of informal care further.

  17. Pediatric Irritable Bowel Syndrome Patient and Parental Characteristics Differ by Care Management Type.

    PubMed

    Hollier, John M; Czyzewski, Danita I; Self, Mariella M; Weidler, Erica M; Smith, E O'Brian; Shulman, Robert J

    2017-03-01

    This study evaluates whether certain patient or parental characteristics are associated with gastroenterology (GI) referral versus primary pediatrics care for pediatric irritable bowel syndrome (IBS). A retrospective clinical trial sample of patients meeting pediatric Rome III IBS criteria was assembled from a single metropolitan health care system. Baseline socioeconomic status (SES) and clinical symptom measures were gathered. Various instruments measured participant and parental psychosocial traits. Study outcomes were stratified by GI referral versus primary pediatrics care. Two separate analyses of SES measures and GI clinical symptoms and psychosocial measures identified key factors by univariate and multiple logistic regression analyses. For each analysis, identified factors were placed in unadjusted and adjusted multivariate logistic regression models to assess their impact in predicting GI referral. Of the 239 participants, 152 were referred to pediatric GI, and 87 were managed in primary pediatrics care. Of the SES and clinical symptom factors, child self-assessment of abdominal pain duration and lower percentage of people living in poverty were the strongest predictors of GI referral. Among the psychosocial measures, parental assessment of their child's functional disability was the sole predictor of GI referral. In multivariate logistic regression models, all selected factors continued to predict GI referral in each model. Socioeconomic environment, clinical symptoms, and functional disability are associated with GI referral. Future interventions designed to ameliorate the effect of these identified factors could reduce unnecessary specialty consultations and health care overutilization for IBS.

  18. [Strengthening Cooperation between Medical and Nursing Care - A Collaborative Meeting of Home Care Doctors and Care Managers in Shinjuku-City].

    PubMed

    Watanabe, Yurie; Itatani, Tomoya

    2015-12-01

    The number of elderly patients requiring home care is expected to increase as a result of the aging population and a decrease in the average length of hospital stay in Shinjuku Ward. Therefore, cooperation between medical and nursing staff is increasingly important. According to research on care managers conducted by Shinjuku Ward, care managers have little opportunity to discuss plans of care with doctors, which requires improvement. In order to strengthen the cooperation between medical and nursing staff, Shinjuku Ward conducted a collaborative meeting for home care doctors and care managers. In the results of the questionnaire given to participants, all respondents answered"Helpful"when asked if the meeting was useful, and 95% of respondents indicated that"understanding and perspective of each other's area has deepened."Therefore, additional collaborative meetings were suggested to promote cooperation and mutual understanding between doctors and care managers.

  19. Management of Simple Clavicle Fractures by Primary Care Physicians.

    PubMed

    Stepanyan, Hayk; Gendelberg, David; Hennrikus, William

    2017-05-01

    The clavicle is the most commonly fractured bone. Children with simple fractures are often referred to orthopedic surgeons by primary care physician to ensure adequate care. The objective of this study was to show that simple clavicle fractures have excellent outcomes and are within the scope of primary care physician's practice. We performed a retrospective chart review of 16 adolescents with simple clavicle fractures treated with a sling. Primary outcomes were bony union, pain, and function. The patients with simple clavicle fractures had excellent outcomes with no complications or complaints of pain or restriction of their activities of daily living. The outcomes are similar whether treated by an orthopedic surgeon or a primary care physician. The cost to society and the patient is less when the primary care physician manages the fracture. Therefore, primary care physicians should manage simple clavicle fractures.

  20. Characteristics and management of patients with chronic hepatitis B in an integrated care setting.

    PubMed

    Sarkar, Monika; Shvachko, Valentina A; Ready, Joanna B; Pauly, Mary Pat; Terrault, Norah A; Peters, Marion G; Manos, M Michele

    2014-09-01

    Few population-based studies have described characteristics and management of patients with chronic hepatitis B (CHB) in the USA. We retrospectively studied adults with CHB in the Northern California Kaiser Permanente Medical Care Program (KPNC) from July 2009 to December 2010 (n = 12,016). Laboratory tests, treatment patterns, and hepatocellular carcinoma (HCC) surveillance were ascertained during a "recent" 18-month study window (July 2009-December 2010), or as "ever" based on records dating to 1995. The mean age was 49 years; 51 % were men, 83 % Asian, and 87 % KPNC members >5 years. Overall, 51 % had ≥ 1 liver-related visit, 14 % with gastroenterology or infectious disease specialists, and 37 % with primary care providers (PCP) only. Less than 40 % of patients had both hepatitis B virus (HBV) DNA and ALT testing conducted recently, while 56 % of eligible patients had received HCC surveillance. Recent laboratory testing and HCC surveillance were more frequent in patients seen by a specialist versus PCP only (90 vs. 47 % and 92 vs. 73 %, respectively, p values <0.001). During the study period, 1,649 (14 %) received HBV treatment, while 5 % of untreated patients had evidence of treatment eligibility. Among 599 patients newly initiated on HBV therapy, 76 % had guideline-based indications for treatment. Most patients initiated on HBV treatment met eligibility, and very few patients with evidence of needing treatment were left untreated. However, monitoring of ALT and HBV DNA levels, as well as HCC surveillance, were not frequent, underestimating the proportion of patients that warranted HBV therapy. Viral monitoring and cancer surveillance are therefore important targets for improving the scope of CHB care in the community setting.

  1. Enhancing the Safe and Effective Management of Chronic Pain in Accountable Care Organization Primary Care Practices in Kentucky.

    PubMed

    Wubu, Selam; Hall, Laura Lee; Straub, Paula; Bair, Matthew J; Marsteller, Jill A; Hsu, Yea-Jen; Schneider, Doron; Hood, Gregory A

    Chronic pain is a prevalent chronic condition with significant burden and economic impact in the United States. Chronic pain is particularly abundant in primary care, with an estimated 52% of chronic pain patients obtaining care from primary care physicians (PCPs). However, PCPs often lack adequate training and have limited time and resources to effectively manage chronic pain. Chronic pain management is complex in nature because of high co-occurrence of psychiatric disorders and other medical comorbidities in patients. This article describes a quality improvement initiative conducted by the American College of Physicians (ACP), in collaboration with the Kentucky ACP Chapter, and the Center for Health Services and Outcomes Research at the Johns Hopkins Bloomberg School of Public Health, to enhance chronic pain management in 8 primary care practices participating in Accountable Care Organizations in Kentucky, with a goal of enhancing the screening, diagnosis, and treatment of patients with chronic pain.

  2. Management of Chronic Kidney Disease Patients in the Intensive Care Unit: Mixing Acute and Chronic Illness.

    PubMed

    De Rosa, Silvia; Samoni, Sara; Villa, Gianluca; Ronco, Claudio

    2017-01-01

    Patients with chronic kidney disease (CKD) are at high risk for developing critical illness and for admission to intensive care units (ICU). 'Critically ill CKD patients' frequently develop an acute worsening of renal function (i.e. acute-on-chronic, AoC) that contributes to long-term kidney dysfunction, potentially leading to end-stage kidney disease (ESKD). An integrated multidisciplinary effort is thus necessary to adequately manage the multi-organ damage of those kidney patients and contemporaneously reduce the progression of kidney dysfunction when they are critically ill. The aim of this review is to describe (1) the pathophysiological mechanisms underlying the development of AoC kidney dysfunction and its role in the progression toward ESKD; (2) the most common clinical presentations of critical illness among CKD/ESKD patients; and (3) the continuum of care for CKD/ESKD patients from maintenance hemodialysis/peritoneal dialysis to acute renal replacement therapy performed in ICU and, vice-versa, for AoC patients who develop ESKD. © 2017 S. Karger AG, Basel.

  3. [Transferring palliative-care patients from hospital to community care: A qualitative study].

    PubMed

    Correa-Casado, Matías; Granero-Molina, José; Hernández-Padilla, José Manuel; Fernández-Sola, Cayetano

    To know the experience of case-manager nurses with regard to transferring palliative-care patients from the hospital to their homes. Qualitative phenomenological study carried out in 2014-2015. Poniente and Almería health districts, which referral hospitals are Poniente Hospital and Torrecárdenas Hospital, respectively. A purposive sample comprised of 12 case-manager nurses was recruited from the aforementioned setting. Theoretical data saturation was achieved after performing 7 in-depth individual interviews and 1 focus group. Data analysis was performed following Colaizzi's method. Three themes emerged: (1) 'Case-management nursing as a quality, patient-centred service' (2) 'Failures of the information systems', with the subthemes "patients" insufficient and inadequate previous information" and "ineffective between-levels communication channels for advanced nursing"; (3) 'Deficiencies in discharge planning', with the subthemes "deficient management of resources on admission", "uncertainty about discharge" and "insufficient human resources to coordinate the transfer". Case-manager nurses consider themselves a good-quality service. However, they think there are issues with coordination, information and discharge planning of palliative patients from hospital. It would be useful to review the communication pathways of both care and discharge reports, so that resources needed by palliative patients are effectively managed at the point of being transferred home. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

  4. Adult obesity management in primary care, 2008-2013.

    PubMed

    Fitzpatrick, Stephanie L; Stevens, Victor J

    2017-06-01

    In the U.S., the occurrence of weight counseling in primary care for patients with obesity decreased by 10% between 1995-1996 and 2007-2008. There have been several national recommendations and policies to improve obesity management since 2008. The purpose of this study was to examine the rates of body mass index (BMI) screening, obesity diagnosis, and weight management counseling in the U.S. from 2008 to 2013. The National Ambulatory Medical Care Survey visit-level data for adults 18 and over with a primary care visit during survey years 2008-2009, 2010-2011, and 2012-2013 was included in the analyses using SAS v9.3. Study outcomes included percent of visits with: BMI screening; obesity diagnosis; and weight counseling. We compared survey years on these outcomes using 2008-2009 as the reference as well as examined patient and practice-level predictors. Analyses were conducted from 2015 to early 2017. Of the total 55,608 adult primary care visits sampled, 14,143 visits (25%) were with patients with obesity. BMI screening significantly increased between 2008-2009 and 2012-2013 from 54% to 73% (OR=1.75, 95% CI 1.28-2.41); however, percent of visits with an obesity diagnosis remained low at <30%. Weight management counseling during visits significantly declined from 33% to 21% between 2008-2009 and 2012-2013 (OR=0.62, 95% CI 0.41-0.92). Despite emerging recommendations and policies, from 2008 to 2013, obesity management in primary care remained suboptimal. Identifying practical strategies to enforce policies and implement evidence-based behavioral treatment in primary care should be a high priority in healthcare reform. Copyright © 2017 Elsevier Inc. All rights reserved.

  5. Transcultural nursing and a care management partnership project.

    PubMed

    Lazure, G; Vissandjée, B; Pepin, J; Kérouac, S

    1997-09-01

    This paper aims to illustrate how Leininger's Theory of Culture Care Diversity and Universality has influenced the research process of a study that emerged from a care management partnership between Canadian nursing teachers and Tunisian nurses. The purpose of the study was to investigate the meanings of care as viewed by university hospital-based Tunisian nurses. The qualitative analysis of data gathered through observation-participation and interviews highlights recurrent patterns and reveals three major professional care themes. For Tunisian nurses care means to secure the patient's cooperation towards the medical regimen within established rules in the hospital; to contribute to curing the patient by using current technology as well as by maintaining their technical skills and improving their medical knowledge; to take charge of the patient to assist the physician in treating disease. This study showed that Tunisian nurses emphasize curing rather than widely shared community values such as interdependence, intercommunication, understanding, presence and responsibility for others. Discussion of the study's findings draws upon the perspective provided by Freire's Oppressed Group Theory. In order to promote cultural congruence within the Care Management Partnership Project in Tunisia, the three predicted modes of care within Leininger's theory guide the decisions and actions for future nursing research and partnership activities.

  6. Primary care providers' experiences caring for complex patients in primary care: a qualitative study.

    PubMed

    Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A

    2016-03-22

    Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of

  7. Beyond inpatient and outpatient care: alternative model for hypertension management.

    PubMed

    Ho, P Michael; Rumsfeld, John S

    2006-10-19

    Hypertension is a major contributor to worldwide cardiovascular mortality, however, only one-third of patients with hypertension have their blood pressure treated to guideline recommended levels. To improve hypertension control, there may need to be a fundamental shift in care delivery, one that is population-based and simultaneously addresses patient, provider and system barriers. One potential approach is home-based disease management, based on the triad of home monitoring, team care, and patient self-care. Although there may be challenges to achieving the vision of home-based disease management, there are tremendous potential benefits of such an approach for reducing the global burden of cardiovascular disease.

  8. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes.

    PubMed

    Rothman, Russell L; Malone, Robb; Bryant, Betsy; Shintani, Ayumi K; Crigler, Britton; Dewalt, Darren A; Dittus, Robert S; Weinberger, Morris; Pignone, Michael P

    2005-03-01

    To assess the efficacy of a pharmacist-led, primary care-based, disease management program to improve cardiovascular risk factors and glycated hemoglobin (A(1C)) levels in vulnerable patients with poorly controlled diabetes. A randomized controlled trial of 217 patients with type 2 diabetes and poor glycemic control (A(1C) level >or=8.0%) was conducted at an academic general medicine practice from February 2001 to April 2003. Intervention patients received intensive management from clinical pharmacists, as well as from a diabetes care coordinator who provided diabetes education, applied algorithms for managing glucose control and decreasing cardiovascular risk factors, and addressed barriers to care. Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider. Outcomes were recorded at baseline and at 6 and 12 months. Primary outcomes included blood pressure, A(1C) level, cholesterol level, and aspirin use. Secondary outcomes included diabetes knowledge, satisfaction, use of clinical services, and adverse events. For the 194 patients (89%) with 12-month data, the intervention group had significantly greater improvement than did the control group for systolic blood pressure (-9 mm Hg; 95% confidence interval [CI]: -16 to -3 mm Hg) and A(1C) level (-0.8%; 95% CI: -1.7% to 0%). Change in total cholesterol level was not significant. At 12 months, aspirin use was 91% in the intervention group versus 58% among controls (P <0.0001). Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients. There were no significant differences in use of clinical services or adverse events. Our comprehensive disease management program reduced cardiovascular risk factors and A(1C) levels among vulnerable patients with type 2 diabetes and poor glycemic control.

  9. Suboptimal management of cardiovascular risk factors in coronary heart disease patients in primary care occurs particularly in women.

    PubMed

    Driscoll, A; Beauchamp, A; Lyubomirsky, G; Demos, L; McNeil, J; Tonkin, A

    2011-10-01

    Patients with established coronary heart disease (CHD) are at the highest risk of further events. Despite proven therapies, secondary prevention is often suboptimal. General practitioners (GPs) are in an ideal position to improve secondary prevention. To contrast management of cardiovascular risk factors in patients with established CHD in primary care to those in clinical guidelines and according to gender. GPs throughout Australia were approached to participate in a programme incorporating a disease management software (mdCare) program. Participating practitioners (1258 GPs) recruited individual patients whose cardiovascular risk factor levels were measured. The mdCare programme included 12,509 patients (58% male) diagnosed with CHD. Their mean age was 71.7years (intra-quartile range 66-78) for men and 74years (intra-quartile range 68-80) for women. Low-density-lipoprotein cholesterol was above target levels in 69% (2032) of women compared with 58% (2487) in men (P < 0.0001). There was also a higher proportion of women with total cholesterol above target levels (76%, 3592) compared with men (57%, 3787) (P < 0.0001). In patients who were prescribed lipid-lowering medication, 53% (2504) of men and 72% (2285) of women continued to have a total cholesterol higher than recommended target levels (P < 0.0001). Overall, over half (52%, 6538) had at least five cardiovascular risk factors (55% (2914) in women and 50% (3624) in men, P < 0.0001). This study found less intensive management of cardiovascular risk factors in CHD patients, particularly among women, despite equivalent cardiovascular risk. This study has shown that these patients have multiple risk factors where gender also plays a role. © 2011 The Authors. Internal Medicine Journal © 2011 Royal Australasian College of Physicians.

  10. Critical care and the urologic patient.

    PubMed

    Leung, Anne K H; Tan, Ian K S

    2003-01-01

    Changing concepts of disease management, expanding indications for invasive therapy to elderly patients, together with technologic advances have changed the management of various urologic diseases. Although minimally invasive surgery may have reduced the need for ICU care, we are faced with new and unique treatment problems.

  11. What part of the total care consumed by type 2 diabetes patients is directly related to diabetes? Implications for disease management programs.

    PubMed

    van Dijk, Christel E; Verheij, Robert A; Swinkels, Ilse C S; Rijken, Mieke; Schellevis, François G; Groenewegen, Peter P; de Bakker, Dinny H

    2011-10-01

    Disease management programs (DMP) aim at improving coordination and quality of care and reducing healthcare costs for specific chronic diseases. This paper investigates to what extent total healthcare utilization of type 2 diabetes patients is actually related to diabetes and its implications for diabetes management programs. Healthcare utilization for diabetes patients was analyzed using 2008 self-reported data (n=316) and data from electronic medical records (EMR) (n=9023), and divided whether or not care was described in the Dutch type 2 diabetes multidisciplinary healthcare standard. On average 4.3 different disciplines of healthcare providers were involved in the care for diabetes patients. Ninety-six percent contacted a GP-practice and 63% an ophthalmologist, 24% an internist, 32% a physiotherapist and 23% a dietician. Diabetes patients had on average 9.3 contacts with GP-practice of which 53% were included in the healthcare standard. Only a limited part of total healthcare utilization of diabetes patients was included in the healthcare standard and therefore theoretically included in DMPs. Organizing the care for diabetics in a DMP might harm the coordination and quality of all healthcare for diabetics. DMPs should be integrated in the overall organization of care.

  12. Caring for Depression in Older Home Health Patients.

    PubMed

    Bruce, Martha L

    2015-11-01

    Depression is common in older home health patients and increases their risk of adverse outcomes. Depression screening is required by Medicare's Outcome and Assessment Information Set. The Depression Care for Patients at Home (CAREPATH) was developed as a feasible strategy for home health nurses to manage depression in their patients. The protocol builds on nurses' existing clinical skills and is designed to fit within routine home visits. Major components include ongoing clinical assessment, care coordination, medication management, education, and goal setting. In a randomized trial, Depression CAREPATH patients had greater improvement in depressive symptoms compared to usual care. The difference between groups was significant at 3 months, growing larger and more clinically meaningful over 1 year. The intervention had no impact on patient length of stay, number of home visits, or duration of visits. Thus, nurses can play a pivotal role in the long-term course and outcomes of patients with depression. Copyright 2015, SLACK Incorporated.

  13. [Disease management for chronic heart failure patient].

    PubMed

    Bläuer, Cornelia; Pfister, Otmar; Bächtold, Christa; Junker, Therese; Spirig, Rebecca

    2011-02-01

    Patients with chronic heart failure (HF) are limited in their quality of life, have a poor prognosis and face frequent hospitalisations. Patient self-management was shown to improve quality of life, reduce rehospitalisations and costs in patients with chronic HF. Comprehensive disease management programmes are critical to foster patient self-management. The chronic care model developed by the WHO serves as the basis of such programmes. In order to develop self-management skills a needs orientated training concept is mandatory, as patients need both knowledge of the illness and the ability to use the information to make appropriate decisions according to their individual situation. Switzerland has no established system for the care of patients with chronic diseases in particular those with HF. For this reason a group of Swiss experts for HF designed a model for disease management for HF patients in Switzerland. Since 2009 the Swiss Heart Foundation offers an education programme based on this model. The aim of this programme is to offer education and support for practitioners, patients and families. An initial pilot evaluation of the program showed mixed acceptance by practitioners, whereas patient assessed the program as supportive and in line with their requirements.

  14. Wireless home monitoring and health care activity management through the Internet in patients with chronic diseases.

    PubMed

    Tura, Andrea; Quareni, Luca; Longo, David; Condoluci, Claudia; van Rijn, Astrid; Albertini, Giorgio

    2005-12-01

    A project was developed for the creation of an Internet-based network aimed at improved management of home care activities in brain-injured children. At the patient's side, a home care unit was provided, made of a portable medical device, and a tablet PC. Measured clinical data were blood oxygen saturation, heart rate, breath rate and quantity of movement. Thanks to device portability, the patient was free to move while measurements were taken. At prescribed time intervals, measured data were automatically transmitted to the tablet PC via Bluetooth. From the tablet PC, data were transmitted remotely to a Service Centre (via ADSL or GPRS) and made available for consultation by health care professionals through the project Web portal. At the portal, other functionalities were also available, both for patients and families, and for professionals (such as weekly planning agenda, access to relevant information resources, communication tools). Information was delivered for the right participant through a workflow engine. A first trial involving nine patients was performed for two months. At the end, although some improvements were suggested, good acceptance was detected, and 78% of patients and families claimed to be interested in further use of the platform.

  15. Development and Evaluation of an Educational E-Tool to Help Patients With Non-Hodgkin's Lymphoma Manage Their Personal Care Pathway.

    PubMed

    Stienen, Jozette Jc; Ottevanger, Petronella B; Wennekes, Lianne; Dekker, Helena M; van der Maazen, Richard Wm; Mandigers, Caroline Mpw; van Krieken, Johan Hjm; Blijlevens, Nicole Ma; Hermens, Rosella Pmg

    2015-01-09

    An overload of health-related information is available for patients on numerous websites, guidelines, and information leaflets. However, the increasing need for personalized health-related information is currently unmet. This study evaluates an educational e-tool for patients with non-Hodgkin's lymphoma (NHL) designed to meet patient needs with respect to personalized and complete health-related information provision. The e-tool aims to help NHL patients manage and understand their personal care pathway, by providing them with insight into their own care pathway, the possibility to keep a diary, and structured health-related information. Together with a multidisciplinary NHL expert panel, we developed an e-tool consisting of two sections: (1) a personal section for patients' own care pathway and their experiences, and (2) an informative section including information on NHL. We developed an ideal NHL care pathway based on the available (inter)national guidelines. The ideal care pathway, including date of first consultation, diagnosis, and therapy start, was used to set up the personal care pathway. The informative section was developed in collaboration with the patient association, Hematon. Regarding participants, 14 patients and 6 laymen were asked to evaluate the e-tool. The 24-item questionnaire used discussed issues concerning layout (6 questions), user convenience (3 questions), menu clarity (3 questions), information clarity (5 questions), and general impression (7 questions). In addition, the panel members were asked to give their feedback by email. A comprehensive overview of diagnostics, treatments, and aftercare can be established by patients completing the questions from the personal section. The informative section consisted of NHL information regarding NHL in general, diagnostics, therapy, aftercare, and waiting times. Regarding participants, 6 patients and 6 laymen completed the questionnaire. Overall, the feedback was positive, with at least 75

  16. Specialty pharmaceuticals care management in an integrated health care delivery system with electronic health records.

    PubMed

    Monroe, C Douglas; Chin, Karen Y

    2013-05-01

    The specialty pharmaceuticals market is expanding more rapidly than the traditional pharmaceuticals market. Specialty pharmacy operations have evolved to deliver selected medications and associated clinical services. The growing role of specialty drugs requires new approaches to managing the use of these drugs. The focus, expectations, and emphasis in specialty drug management in an integrated health care delivery system such as Kaiser Permanente (KP) can vary as compared with more conventional health care systems. The KP Specialty Pharmacy (KP-SP) serves KP members across the United States. This descriptive account addresses the impetus for specialty drug management within KP, the use of tools such as an electronic health record (EHR) system and process management software, the KP-SP approach for specialty pharmacy services, and the emphasis on quality measurement of services provided. Kaiser Permanente's integrated system enables KP-SP pharmacists to coordinate the provision of specialty drugs while monitoring laboratory values, physician visits, and most other relevant elements of the patient's therapy. Process management software facilitates the counseling of patients, promotion of adherence, and interventions to resolve clinical, logistic, or pharmacy benefit issues. The integrated EHR affords KP-SP pharmacists advantages for care management that should become available to more health care systems with broadened adoption of EHRs. The KP-SP experience may help to establish models for clinical pharmacy services as health care systems and information systems become more integrated.

  17. What Contributes Most to High Health Care Costs? Health Care Spending in High Resource Patients.

    PubMed

    Pritchard, Daryl; Petrilla, Allison; Hallinan, Shawn; Taylor, Donald H; Schabert, Vernon F; Dubois, Robert W

    2016-02-01

    U.S. health care spending nearly doubled in the decade from 2000-2010. Although the pace of increase has moderated recently, the rate of growth of health care costs is expected to be higher than the growth in the economy for the near future. Previous studies have estimated that 5% of patients account for half of all health care costs, while the top 1% of spenders account for over 27% of costs. The distribution of health care expenditures by type of service and the prevalence of particular health conditions for these patients is not clear, and is likely to differ from the overall population. To examine health care spending patterns and what contributes to costs for the top 5% of managed health care users based on total expenditures. This retrospective observational study employed a large administrative claims database analysis of health care claims of managed care enrollees across the full age and care spectrum. Direct health care expenditures were compared during calendar year 2011 by place of service (outpatient, inpatient, and pharmacy), payer type (commercially insured, Medicare Advantage, and Medicaid managed care), and therapy area between the full population and high resource patients (HRP). The mean total expenditure per HRP during calendar year 2011 was $43,104 versus $3,955 per patient for the full population. Treatment of back disorders and osteoarthritis contributed the largest share of expenditures in both HRP and the full study population, while chronic renal failure, heart disease, and some oncology treatments accounted for disproportionately higher expenditures in HRP. The share of overall expenditures attributed to inpatient services was significantly higher for HRP (40.0%) compared with the full population (24.6%), while the share of expenditures attributed to pharmacy (HRP = 18.1%, full = 21.4%) and outpatient services (HRP = 41.9%, full = 54.1%) was reduced. This pattern was observed across payer type. While the use of physician

  18. A framework for fibromyalgia management for primary care providers.

    PubMed

    Arnold, Lesley M; Clauw, Daniel J; Dunegan, L Jean; Turk, Dennis C

    2012-05-01

    Fibromyalgia is a chronic widespread pain disorder commonly associated with comorbid symptoms, including fatigue and nonrestorative sleep. As in the management of other chronic medical disorders, the approach for fibromyalgia management follows core principles of comprehensive assessment, education, goal setting, multimodal treatment including pharmacological (eg, pregabalin, duloxetine, milnacipran) and nonpharmacological therapies (eg, physical activity, behavioral therapy, sleep hygiene, education), and regular education and monitoring of treatment response and progress. Based on these core management principles, this review presents a framework for primary care providers through which they can develop a patient-centered treatment program for patients with fibromyalgia. This proactive and systematic treatment approach encourages ongoing education and patient self-management and is designed for use in the primary care setting. Copyright © 2012 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

  19. Value-based resource management: a model for best value nursing care.

    PubMed

    Caspers, Barbara A; Pickard, Beth

    2013-01-01

    With the health care environment shifting to a value-based payment system, Catholic Health Initiatives nursing leadership spearheaded an initiative with 14 hospitals to establish best nursing care at a lower cost. The implementation of technology-enabled business processes at point of care led to a new model for best value nursing care: Value-Based Resource Management. The new model integrates clinical patient data from the electronic medical record and embeds the new information in care team workflows for actionable real-time decision support and predictive forecasting. The participating hospitals reported increased patient satisfaction and cost savings in the reduction of overtime and improvement in length of stay management. New data generated by the initiative on nursing hours and cost by patient and by population (Medicare severity diagnosis-related groups), and patient health status outcomes across the acute care continuum expanded business intelligence for a value-based population health system.

  20. Dietary trends and management of hyperphosphatemia among patients with chronic kidney disease: an international survey of renal care professionals.

    PubMed

    Fouque, Denis; Cruz Casal, Maria; Lindley, Elizabeth; Rogers, Susan; Pancířová, Jitka; Kernc, Jennifer; Copley, J Brian

    2014-03-01

    The objective of this study was to review the opinions and experiences of renal care professionals to examine dietary trends among patients with chronic kidney disease (CKD) and problems associated with the clinical management of hyperphosphatemia. This was an online survey comprising open and closed questions requesting information on patient dietary trends and the clinical management of hyperphosphatemia. The study was conducted in 4 European countries (the Netherlands, Spain, Sweden, and the United Kingdom). Participants were 84 renal care professionals. This was an online survey. Responder-reported experiences and perceptions of patient dietary trends and hyperphosphatemia management were assessed. Most survey responders (56%) observed an increase in the consumption of processed convenience food, 48% noticed an increase in the consumption of foods rich in phosphorus-containing additives, and 60% believed that there has been a trend of increasing patient awareness of the phosphorus content of food. Patients undergoing hemodialysis (HD) were most likely to experience difficulties in following advice on dietary phosphorus restriction (38% of responders estimated that 25-50% of their patients experienced difficulties, and 29% estimated that 51-75% experienced difficulties). Maintaining protein intake and restricting dietary phosphorus were perceived as being equally important by at least half of responders for predialysis patients (56%) and for those undergoing peritoneal dialysis and HD (54% and 50%, respectively). There were international variations in dietary trends and hyperphosphatemia management. Although most responders have observed a trend of increasing awareness of the phosphorus content of food among patients with CKD, the survey results indicate that many patients continue to experience difficulties when attempting to restrict dietary phosphorus. The survey responses reflect the global trend of increasing consumption of processed convenience foods and

  1. Patient outcomes for the chronically critically ill: special care unit versus intensive care unit.

    PubMed

    Rudy, E B; Daly, B J; Douglas, S; Montenegro, H D; Song, R; Dyer, M A

    1995-01-01

    The purpose of this study was to compare the effects of a low-technology environment of care and a nurse case management case delivery system (special care unit, SCU) with the traditional high-technology environment (ICU) and primary nursing care delivery system on the patient outcomes of length of stay, mortality, readmission, complications, satisfaction, and cost. A sample of 220 chronically critically ill patients were randomly assigned to either the SCU (n = 145) or the ICU (n = 75). Few significant differences were found between the two groups in length of stay, mortality, or complications. However, the findings showed significant cost savings in the SCU group in the charges accrued during the study period and in the charges and costs to produce a survivor. The average total cost of delivering care was $5,000 less per patient in the SCU than in the traditional ICU. In addition, the cost to produce a survivor was $19,000 less in the SCU. Results from this 4-year clinical trial demonstrate that nurse case managers in a SCU setting can produce patient outcomes equal to or better than those in the traditional ICU care environment for long-term critically ill patients.

  2. Patient participation in quality pain management during an acute care admission.

    PubMed

    McTier, Lauren J; Botti, Mari; Duke, Maxine

    2014-04-01

    The objective of the study was to explore patient participation in the context of pain management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease. This is a single-institution study, with a case-study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including preadmission and predischarge patient interviews (n=98), naturalistic observations (n=48), and focus group interviews (n=2). Patients' preference for participation in pain management was not always commensurate with their involvement in pain management. Patients displayed a greater understanding of their role in pain management in terms of reporting pain and the use of multimodal analgesics after surgery. The majority of patients, however, did not understand the importance of reporting pain to avoid complications. Patients had limited opportunity to participate in their pain management. On occasions in which clinicians did involve patients, the involvement appeared to be focused on reporting pain rather than treatment of pain. Patient participation in pain management during hospitalization is not optimal. This has implications for the quality of pain management patients receive. Higher engagement of patients in their pain management during hospitalization is required to ensure comfort, reduce potential for complications, and adequately prepare the patients to manage their pain following discharge from hospital.

  3. Relationship of nursing education and care management inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

    PubMed Central

    Bailey, Joy; Dijkers, Marcel P.; Gassaway, Julie; Thomas, Jane; Lingefelt, Patricia; Kreider, Scott E.D.; Whiteneck, Gale

    2012-01-01

    Objective To investigate associations of nursing bedside education and care management activities during inpatient rehabilitation with functional, participation, and quality-of-life outcomes for patients with traumatic spinal cord injury (SCI). Methods In a prospective observational study, data were obtained by means of systematic recording of nursing activities by registered nurses (RNs), chart review and patient interview. Results Greater patient participation in nursing activities is associated with better outcomes. More time spent by RNs in coordination with other members of the care team, consultants and specialists, along with participation in physician rounds (team process) is associated with patient report of higher life satisfaction and higher CHART mobility at the one-year injury anniversary; more time providing psychosocial support is associated with higher CHART mobility and occupation scores and with greater likelihood of working or being in school at the anniversary. More time spent providing education about specific care needs is associated with several outcomes but not as consistently as might be expected. Conclusion(s) Higher levels of patient participation in nursing care activities is associated with multiple better outcomes, and hence, nurses should promote active patient participation during all aspects of care and interactions between themselves and patients with SCI. Time spent providing psychosocial support of patients and their families should be evaluated to ensure that other necessary education or care management interventions are not minimized. Note This is the seventh of nine articles in the SCIRehab series. PMID:23318039

  4. Care management role in end-of-life discussions.

    PubMed

    Meyer, Star

    2012-01-01

    How do we prepare our patients for decisions that will need to be made for end-of-life care? End-of-life care discussions should occur early on in the patient's disease process and often requires a great deal of coordination between multiple caregivers. There are also ethical, cultural social and spiritual considerations during this very important time in the disease process. Research suggests that we are not doing an adequate job of addressing end-of-life care with our patients and that a great deal of money and resources are being spent in the last days of life when there may be no clinical indication to do so. Registered nurse case managers have a unique knowledge base to serve in the role of coordinating care and leading the multidisciplinary care team in an effort to use resources responsibly while providing patients and families with options for end-of-life care.

  5. Hospitalist management of vaso-occlusive pain crisis in patients with sickle cell disease using a pathway of care.

    PubMed

    Allen Liles, Edmund; Kirsch, Jonathan; Gilchrist, Michael; Adem, Mukhtar

    2014-04-01

    Patients with sickle cell disease (SCD) suffer from intermittent vaso-occlusive pain crises (VOCs). These crises lead to frequent hospitalizations, significant morbidity, and increased mortality risk. Care pathways can enhance efficiency and quality of care. Our study sought to evaluate the development and implementation of a care pathway for patients with SCD experiencing VOCs. The University of North Carolina (UNC) Comprehensive Sickle Cell Program provides all levels of care for a large population of patients with sickle cell anemia. All patients admitted to UNC Hospitals with SCD VOCs from January 2009 through June 2011 were evaluated. During this time period, we also assessed sequential prospective cohorts during progressive phases of developing and implementing a quality improvement and pathway of care program for this patient population in our study. The developed pathway entailed geographic localization for VOC patients, a single group of faculty physicians caring for these patients, and early use of patient-controlled analgesia (PCA) to achieve pain control. Physicians from the UNC Hospital Medicine Program were responsible for the initiatives. Cohorts were compared to a baseline historical control. Outcomes of interest included patient length of stay (LOS) in the hospital, 30-day readmission rate, need for transfusion, incidence of acute chest syndrome, use of naloxone, and use of PCA. Compared with an historical baseline cohort, the development and implementation of a VOC care pathway for patients with SCD led to reduction in average hospital LOS by 1.44 days (P < 0.05) and an increase in use of PCAs (P < 0.05). Patient readmission rates, number of transfusions, incidence of acute chest syndrome, and use of naloxone did not significantly change. Hospitalist-led management of patients with SCD VOCs using a care pathway that emphasizes early, aggressive PCA-based pain control is associated with reduced hospital LOS. The LOS reduction seen in our study is

  6. The effect of a diabetes collaborative care management program on clinical and economic outcomes in patients with type 2 diabetes.

    PubMed

    McAdam-Marx, Carrie; Dahal, Arati; Jennings, Brandon; Singhal, Mukul; Gunning, Karen

    2015-06-01

    Clinical pharmacy services (CPS) in the primary care setting have been shown to help patients attain treatment goals and improve outcomes. However, the availability of CPS in community-based primary care is not widespread. One reason is that current fee-for-service models offer limited reimbursement opportunities for CPS in the community setting. Furthermore, data demonstrating the value of CPS in this setting are limited, making it difficult for providers to determine the feasibility and sustainability of incorporating CPS into primary care practice. To (a) evaluate the association between a pharmacist-led, diabetes collaborative drug therapy management program and patient outcomes, including glycemic control and health care costs, and (b) assess short-term economic outcomes in a primary care setting. A retrospective cohort analysis was conducted using medical record data. This study was conducted using patients with uncontrolled type 2 diabetes (T2DM), defined as HbA1c ≥ 7.0%. Outcomes were compared between patients referred to a diabetes collaborative care management (DCCM) intervention from 2009-2012 and patients who did not participate in the DCCM program. To illustrate the difference in HbA1c between the 2 cohorts over the follow-up period, mean time adjusted HbA1c values were estimated using a panel-type random effects regression model, with results plotted at 90-day intervals from index date through the end of the study period. To help control for confounding by other factors, multivariate regression models were run. A difference-in-difference model was employed to estimate the effect of the program on resource utilization and all-cause charges. A total of 303 DCCM and 394 comparison patients were included. Mean (95% CI) age was 57.4 years (55.963, 58.902) versus 59.9 years (58.613, 61.276; P < 0.001) with 48% and 44% female for DCCM and comparison patients, respectively (P = 0.49). Mean baseline HbA1c was higher for DCCM (10.3%; 10.10, 10.53) than

  7. Identifying and Coordinating Care for Complex Patients

    PubMed Central

    Rudin, Robert S.; Gidengil, Courtney A.; Predmore, Zachary; Schneider, Eric C.; Sorace, James; Hornstein, Rachel

    2017-01-01

    Abstract In the United States, a relatively small proportion of complex patients---defined as having multiple comorbidities, high risk for poor outcomes, and high cost---incur most of the nation's health care costs. Improved care coordination and management of complex patients could reduce costs while increasing quality of care. However, care coordination efforts face multiple challenges, such as segmenting populations of complex patients to better match their needs with the design of specific interventions, understanding how to reduce spending, and integrating care coordination programs into providers' care delivery processes. Innovative uses of analytics and health information technology (HIT) may address these challenges. Rudin and colleagues at RAND completed a literature review and held discussions with subject matter experts, reaching the conclusion that analytics and HIT are being used in innovative ways to coordinate care for complex patients but that the capabilities are limited, evidence of their effectiveness is lacking, and challenges are substantial, and important foundational work is still needed. PMID:28845354

  8. Patients, care partners, and shared access to the patient portal: online practices at an integrated health system.

    PubMed

    Wolff, Jennifer L; Berger, Andrea; Clarke, Deserae; Green, Jamie A; Stametz, Rebecca; Yule, Christina; Darer, Jonathan D

    2016-11-01

    To describe the characteristics and online practices of patients and "care partners" who share explicit access to a patient portal account at a large integrated health system that implemented shared access functionality in 2003. Survey of 323 patients and 389 care partners at Geisinger Health System with linked information regarding access and use of patient portal functionality. Few (0.4%) registered adult patient portal users shared access to their account. Patients varied in age (range: 18-102); more than half had a high school education or less (53.6%). Patient motivations for sharing access included: to help manage care (41.9%), for emergency reasons (29.7%), lack of technology experience (18.4%), or care partner request (10.0%). Care partners were parents (39.8%), adult children (27.9%), spouses (26.2%), and other relatives (6.1%). Patients were more likely than care partners to have inadequate health literacy (54.8% versus 8.8%, P < .001) and less confident in their ability to manage their care (53.0% versus 88.1%; P < .001). Care partners were more likely than patients to perform health management activities electronically (95.5% versus 48.4%; P < .001), access the patient portal (89.2% versus 30.3%; P < .001), and use patient portal functionality such as secure messaging (39.6% versus 13.9%; P < .001). Care partners used their own credentials (89.1%) and patient credentials (23.3%) to access the patient portal. Shared access is an underused strategy that may bridge patients' health literacy deficits and lack of technology experience and that helps but does not fully resolve concerns regarding patient and care partner identity credentials. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  9. Effectiveness of the Smart Care Service for Diabetes Management

    PubMed Central

    Chung, Young-Soon; Lee, Chang Hee

    2014-01-01

    Objectives The aim of this study was to assess the effectiveness of the Smart Care service for the diabetes management. Methods Fifty-six patients with diabetes mellitus were recruited in Daegu, Korea. All participants completed a diabetes management education course (diet, exercise, and complications) for their self-care and received access to a care management website through a netbook and smartphone. The website accepts uploads of glucose level, body weight, HbA1c, low-density lipoprotein cholesterol level, and blood pressure. Participants communicated with the care manager through the internal management system of the website. The intervention was applied for 6 months. Results Participants receiving the Smart Care service had lower blood glucose and HbA1c during 6 months follow-up when 1-month values (p < 0.001) were compared. There was no significant difference in body weight and body mass index between 1 month and 6 months. The average number of remote consultation with the Smart Care service per person was 10.4 by nurses, 3.0 by nutritionists, and 1.6 by sports curers. Regression analysis indicated that the number of times counseling was offered by nurses influences body weight and that the number of minutes of telephone counseling influences both body weight and body mass index. Conclusions We have confirmed that the Smart Care service might be an effective system for reduction in blood glucose and HbA1c. We expect that the Smart Care service will contribute to delaying diabetes complications and improving the quality of life of patients with diabetes. PMID:25405065

  10. Effectiveness of the smart care service for diabetes management.

    PubMed

    Chung, Young-Soon; Kim, Yongsuk; Lee, Chang Hee

    2014-10-01

    The aim of this study was to assess the effectiveness of the Smart Care service for the diabetes management. Fifty-six patients with diabetes mellitus were recruited in Daegu, Korea. All participants completed a diabetes management education course (diet, exercise, and complications) for their self-care and received access to a care management website through a netbook and smartphone. The website accepts uploads of glucose level, body weight, HbA1c, low-density lipoprotein cholesterol level, and blood pressure. Participants communicated with the care manager through the internal management system of the website. The intervention was applied for 6 months. Participants receiving the Smart Care service had lower blood glucose and HbA1c during 6 months follow-up when 1-month values (p < 0.001) were compared. There was no significant difference in body weight and body mass index between 1 month and 6 months. The average number of remote consultation with the Smart Care service per person was 10.4 by nurses, 3.0 by nutritionists, and 1.6 by sports curers. Regression analysis indicated that the number of times counseling was offered by nurses influences body weight and that the number of minutes of telephone counseling influences both body weight and body mass index. We have confirmed that the Smart Care service might be an effective system for reduction in blood glucose and HbA1c. We expect that the Smart Care service will contribute to delaying diabetes complications and improving the quality of life of patients with diabetes.

  11. Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.

    PubMed

    Moreo, Kathleen; Lattimer, Cheri; Lett, James E; Heggen-Peay, Cherilyn L; Simone, Laura

    Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF). The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes. Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article. In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise

  12. Challenges for Managed Care from 340B Contract Pharmacies.

    PubMed

    Fein, Adam J

    2016-03-01

    The federal 340B Drug Pricing Program has expanded rapidly, with important yet still unmeasured impact on both managed care practice and policies. Notably, providers increasingly rely on external, contract pharmacies to extend 340B pricing to a broad set of patients. In 2014, 1 in 4 U.S. retail, mail, and specialty pharmacy locations acted as contract pharmacies for 340B-covered entities. This commentary discusses crucial ways in which 340B growth is affecting managed care pharmacy through formulary rebates, profits from managed care paid prescriptions, disruption of retail pharmacy networks, and reduced generic dispensing rates. Managed care should become more engaged in the discussion on how the 340B program should evolve and offer policy proposals to mitigate the challenges being encountered. There is also an urgent need for objective, transparent research on the 340B program's costs, benefits, and implications for managed care pharmacy and practice.

  13. Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors

    PubMed Central

    Russell, Grant M.; Dahrouge, Simone; Hogg, William; Geneau, Robert; Muldoon, Laura; Tuna, Meltem

    2009-01-01

    PURPOSE New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care. METHODS We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management. RESULTS Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians. CONCLUSIONS The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario’s CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality

  14. Overcoming the barriers to implementing patient-focused care.

    PubMed

    McQueen, J

    1993-01-01

    Potential barriers to implementing PFC sometimes seem enormous. Instead of orienting toward problems associated with implementing PFC, we can eliminate some of the barriers simply by focusing on and pursuing the ideal, "the seamless patient care experience." Fundamentally improving our health care delivery systems is not really a strategic option. It is our responsibility. We must do things better, faster, with more compassion, and at less cost. What evidence will demonstrate that your organization is becoming more patient-focused? Patients will not be inconvenienced because of "how the system works." They will consider your organization "best in class." They will know that the hospital's medical care and services will meet or exceed their expectations. Physicians and staff will feel more highly valued by the organization. Management empowers them by improving the systems they must use, providing ongoing training, and decentralizing the authority they need to deliver excellent medical care and satisfy patients' personal needs. Communication improves vertically and horizontally throughout the organization. The hospital becomes increasingly attractive to employers and HMOs. Reengineered processes result in increases in productivity. Better patient outcomes, at less cost, can be demonstrated. Occupancy rates stabilize or grow, utilization is carefully managed, and improvements in the bottom line strengthen the organization. How do we make these visions a reality? By committing to PFC and getting started right away. Just as "quality" is multidimensional, so must be our operating strategy. Patient-focused care is the model that will redefine the future of health care.

  15. Audit of co-management and critical care outreach for high risk postoperative patients (The POST audit).

    PubMed

    Story, D A; Shelton, A; Jones, D; Heland, M; Belomo, R

    2013-11-01

    Co-management and critical care outreach for high risk surgical patients have been proposed to decrease postoperative complications and mortality. We proposed that a clinical project with postoperative comanagement and critical care outreach, the Post Operative Surveillance Team: (POST), would be associated with decreased hospital length of stay. We conducted a retrospective before (control group) and after (POST group) audit of this hospital program. POST was staffed for four months in 2010 by two intensive care nurses and two senior registrars who conducted daily ward rounds for the first five postoperative days on high risk patients undergoing inpatient general or urological surgery. The primary endpoint was length of hospital stay and secondary endpoints were Medical Emergency Team (MET) calls, cardiac arrests and in-hospital mortality. There were 194 patients in the POST group and 1,185 in the control group. The length of stay in the POST group, median nine days (Inter-quartile range [IQR]: 5 to 17 days), was longer than the control group, median seven days (IQR: 4 to 13 days): difference two days longer (95.0% confidence interval [95.0% CI]: 1 to 3 days longer, P <0.001). There were no important differences in the proportion of patients having MET calls (16.0% POST versus. 13% control (P=0.25)) or mortality (2.1% POST versus 2.8% Control (P=0.82)). Our audit found that the POST service was not associated with reduced length of stay. Models of co-management, different to POST, or with different performance metrics, could be tested.

  16. Nontraditional or noncentralized models of diabetes care: models in which other HCPs take on a leading role in managing patients' diabetes.

    PubMed

    Arnold, K C

    2011-11-01

    Nurse practitioners (NPs) are advanced practice nurses who have increased responsibility,such as prescribing authority. In the NP-led model, the NP is the primary care provider for clinic patients and takes on an autonomous role in patient management. In some states, NP-led clinics are required to have a supervising or collaborating physician. There is evidence that NP-led and physician-led primary care is comparable for multiple health outcomes. The NP-led model emphasizes the strong interaction between health care provider and patient. Challenges of NP-led care include physician resistance, legal restrictions, inaccessibility and cost of malpractice insurance, and limited payouts from insurance companies

  17. Nurses' knowledge and barriers regarding pain management in intensive care units.

    PubMed

    Wang, Hsiang-Ling; Tsai, Yun-Fang

    2010-11-01

    To explore nurses' knowledge and barriers regarding pain management in intensive care units. Pain is a common and treatable condition among intensive care patients. Quality care of these patients depends on the pain knowledge and pain management skills of critical care nurses. However, no single study has explored these nurses' knowledge of and perceived barriers to pain management in Taiwan. A cross-sectional study. Intensive care unit nurses (n = 370) were recruited from 16 hospitals chosen by stratified sampling across Taipei County in Taiwan. Data were collected on nurses' knowledge of pain management using the Nurses' Knowledge and Attitudes Survey-Taiwanese version, on perceived barriers to pain management using a researcher-developed scale and on background information. The overall average correct response rate for the knowledge scale was 53.4%, indicating poor knowledge of pain management. The top barrier to managing pain identified by these nurses was 'giving proper pain prescription needs doctor's approval; can't depend on me'. Knowledge of pain management was significantly and negatively related to perceived barriers to pain management. In addition, scores for knowledge and perceived barriers differed significantly by specific intensive care unit. Knowledge also differed significantly by nurses' education level, clinical competence level (nursing ladder) and hospital accreditation category. Our results indicate an urgent need to strengthen pain education by including case analysis for intensive care nurses in Taiwan. Pain education should target knowledge deficits and barriers to changing pain management approaches for Taiwanese nurses in intensive care units. © 2010 Blackwell Publishing Ltd.

  18. Managing crisis: the role of primary care for people with serious mental illness.

    PubMed

    Lester, Helen; Tritter, Jonathan Q; Sorohan, Helen

    2004-01-01

    More than 30% of patients with serious mental illness in the United Kingdom now receive all their health care solely from primary care. This study explored the process of managing acute mental health crises from the dual perspective of patients and primary care health professionals. Eighteen focus groups involving 45 patients, 39 general practitioners, and eight practice nurses were held between May and November 2002 in six Primary Care Trusts across the British West Midlands. The topic guide explored perceptions of gold standard care, current issues and critical incidents in receiving/providing care, and ideas on improving services. Themes relevant to the management of acute crisis included issues of process, such as access, advocacy, communication, continuity, and coordination of care; the development of more structured care that might reduce the need for crisis responses; and issues raised by the development of a more structured approach to care. Access to services is a complicated yet crucial feature of managing care in a crisis, with patients identifying barriers at the level of primary care and health professionals at the interface with secondary care. The development of more structured systems as a solution may generate its own ethical and pragmatic challenges.

  19. Managing Your Loved One's Health: Development of a New Care Management Measure for Dementia Family Caregivers.

    PubMed

    Sadak, Tatiana; Wright, Jacob; Borson, Soo

    2018-05-01

    The National Alzheimer's Plan calls for improving health care for people living with dementia and supporting their caregivers as capable health care partners. Clinically useful measurement tools are needed to monitor caregivers' knowledge and skills for managing patients' often complex health care needs as well as their own self-care. We created and validated a comprehensive, caregiver-centered measure, Managing Your Loved One's Health (MYLOH), based on a core set of health care management domains endorsed by both providers and caregivers. In this article, we describe its development and preliminary cultural tailoring. MYLOH is a questionnaire containing 29 items, grouped into six domains, which requires <20 min to complete. MYLOH can be used to guide conversations between clinicians and caregivers around health care management of people with dementia, as the basis for targeted health care coaching, and as an outcome measure in comprehensive dementia care management interventions.

  20. Dyspnea Management in Palliative Home Care: A Case Series in Malaysia

    PubMed Central

    Thongkhamcharoen, Rojanasak; Breaden, Katrina; Agar, Meera; Hamzah, Ednin

    2012-01-01

    Managing dyspnea at home is a challenging task. Although a competent palliative home care team can assist a patient to live at home with better pain control, dyspnea is usually not as well managed. In the Asian context, there are few research studies in dyspnea management in palliative home care. This paper aims to illustrate the cultural context that has an impact on dyspnea management at home and the assessment and management of dyspnea in a community palliative care setting in Malaysia. This paper reports on a study of 5 dyspneic patients suffering from both cancer-related and non–cancer-related dyspnea. Its focus is on a unique Asian cultural belief system that affects communication about prognosis and the role of family in palliative home care. In addition, this paper also describes dyspnea assessment, the barriers to morphine use, benzodiazepine prescription, oxygen therapy, and nonpharmacologic intervention in this center. PMID:23093829

  1. [Toward a new model of pharmacy management comprehensive care of patients with chronic kidney disease].

    PubMed

    Muros-Ortega, M; Ramos, R; Molina, M

    2014-07-01

    The treatment of chronic kidney disease represents 2.5% of the National Healthcare System budget. Given the panorama of economic crisis, actions aimed at containing the costs in this kind of pathologies should be implemented. Centralization of the management of the medications used for the treatment of chronic kidney disease and its complications aims at reducing the pharmaceutical expenditure. The new contracts of public healthcare administrations with companies of dialysis centers establish a single price by which the contractor takes care of the integral management of the patients, including the dialysis therapy and pharmacological treatment. Drug management at dialysis centers will be handled by specialized pharmacists by means of the creation of pharmacy departments or drug warehouse. these measures aim at improving healthcare of the patient in hemodialysis program, with health benefits at a lower healthcare cost. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

  2. Twelve evidence-based principles for implementing self-management support in primary care.

    PubMed

    Battersby, Malcolm; Von Korff, Michael; Schaefer, Judith; Davis, Connie; Ludman, Evette; Greene, Sarah M; Parkerton, Melissa; Wagner, Edward H

    2010-12-01

    Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed. The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active followup, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options. There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.

  3. Where Personalized Medicine, Patient Engagement, and Primary Care Collide.

    PubMed

    Bell, Megan

    2017-01-01

    Personalized medicine and patient engagement have become common buzzwords in the context of health care reform. Independently both concepts have showed some promise in impacting health outcomes, but when synergistically applied, they have more power, as both are critical pieces of personalized health care (PHC). PHC is a health care model that embraces the need for patient engagement along with personalized medicine technologies to make the health care process more personalized, patient-driven, and proactive. Primary care presents an ideal setting for the application of PHC through the use of patient engagement techniques such as patient portals, patient-generated health data, and self-management programs, with the goal of supporting a preventative proactive health care approach. Copyright© South Dakota State Medical Association.

  4. [Quality management is associated with high quality services in health care].

    PubMed

    Nielsen, Tenna Hassert; Riis, Allan; Mainz, Jan; Jensen, Anne-Louise Degn

    2013-12-09

    In these years, quality management has been the focus in order to meet high quality services for the patients in Danish health care. This article provides information on quality management and quality improvement and it evaluates its effectiveness in achieving better organizational structures, processes and results in Danish health-care organizations. Our findings generally support that quality management is associated with high quality services in health care.

  5. Self-Management: Enabling and empowering patients living with cancer as a chronic illness

    PubMed Central

    McCorkle, Ruth; Ercolano, Elizabeth; Lazenby, Mark; Schulman-Green, Dena; Schilling, Lynne S.; Lorig, Kate; Wagner, Edward H.

    2010-01-01

    With recent improvements in early detection, diagnosis and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this paper, we review self-management interventions that enable patients and families to participate in managing their care along this continuum. We review randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer-care continuum. We also present the Chronic Care Model as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. We conclude that, the need for a common language by which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually-agreed upon care plans that enable and empower patients to care for themselves in the way they prefer. PMID:21205833

  6. Patients, persons or partners? Involving those with chronic disease in their care.

    PubMed

    McWilliam, Carol L

    2009-12-01

    Self-care management is essential for effective chronic disease management. Yet prevailing approaches of healthcare practitioners often undermine the efforts of those who require on-going medical attention for chronic conditions, emphasizing their status as patients, failing to consider their larger life experience as people, and most importantly, failing to consider them as people with the potential to be partners in their care. This article explores two approaches for professional-patient interaction in chronic disease management, namely, patient-centred care and empowering partnering, illuminating how professionals might better interact with chronically ill individuals who seek their care. The opportunities, challenges, theory and research evidence associated with each approach are explored. The advantages of moving beyond patient-centred care to the empowering partnering approach are elaborated. For people with chronic disease, having the opportunity to engage in the social construction of their own health as a resource for everyday living, the opportunity to experience interdependence rather than dependence/independence throughout on-going healthcare, and the opportunity to optimize their potential for self-care management of chronic disease are important justifications for being involved in an empowering partnering approach to their chronic disease management.

  7. The brave new world of managed care.

    PubMed

    Korcok, M

    1995-07-01

    Canadian hospitals that think they can charge higher-than-normal rates to foreign visitors are learning a lesson as US-style managed care moves north of the border. Dr. Robert MacMillan, president and medical director of Florida-based Insurance Claims Management Systems and past president of the Ontario Medical Association, says that south of the border US-style managed care has already hauled in the reins on wild expectations about high payments, and it is expected to do the same for Canadian hospitals that charge private insurers "as much as the traffic will bear." He says it is no longer uncommon for a large Toronto hospital to charge a foreign patient $3000 a day for care that can now be purchased in a US hospital for one-third that price.

  8. [Coordinating home assistance and nursing care for global patient management].

    PubMed

    Cerf, Dominique

    2016-01-01

    Enabling patients to remain in their home is only possible when the different services, both from within and outside the hospital are able to communicate and when the recommended actions are properly coordinated. Entrusting the coordination of the care to the Spasad (polyvalent service for home assistance and nursing care) enables the expectations of the patients and family carers to be analysed. This allows the team to put in place the appropriate actions both in terms of assistance and nursing care. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  9. Making it local: Beacon Communities use health information technology to optimize care management.

    PubMed

    Allen, Amy; Des Jardins, Terrisca R; Heider, Arvela; Kanger, Chatrian R; Lobach, David F; McWilliams, Lee; Polello, Jennifer M; Rein, Alison L; Schachter, Abigail A; Singh, Ranjit; Sorondo, Barbara; Tulikangas, Megan C; Turske, Scott A

    2014-06-01

    Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks--including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation--the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability.

  10. The association between managed care enrollments and potentially preventable hospitalization among adult Medicaid recipients in Florida

    PubMed Central

    2014-01-01

    Background The intent of adopting managed care plans is to improve access to health care services while containing costs. To date, there have been a number of studies that examine the relationship between managed care and access to health care. However, the results from previous studies have been inconsistent. Specifically, previous studies did not demonstrate a clear benefit of Medicaid managed care. In this study we have examine whether Medicaid managed care is associated with the probabilities of preventable hospitalizations. This study also analyzes the spillover effect of Medicaid managed care into Medicaid patients in traditional FFS plans and the interaction effects of other patient- and county-level variables on preventable hospitalizations. Methods The study included 254,321 Medicaid patients who were admitted to short-term general hospital in the 67 counties in Florida. Using 2008 hospital inpatient discharge data for working-age adult Medicaid enrollees (18-64 years) in Florida, we conduct multivariate logistic regression analyses to identify possible factors associated with preventable hospitalizations. The first model includes patient- and county-level variables. Then, we add interaction terms between Medicaid HMO and other variables such as race, rurality, market-level factors, and resource for primary care. Results The results show that Medicaid HMO patients are more likely to be hospitalized for ambulatory care sensitive conditions (ACSCs) (OR = 1.30; CI = 1.21, 1.40). We also find that market structure (i.e., competition) is significantly associated with preventable hospitalizations. However, our study does not support that there are spillover effects of Medicaid managed care on preventable hospitalizations for other Medicaid recipients. We find that interactions between Medicaid managed care and race, rurality and market structure are significant. Conclusions The results of our study show that the Medicaid managed care program in Florida

  11. Post resuscitation management of cardiac arrest patients in the critical care environment: A retrospective audit of compliance with evidence based guidelines.

    PubMed

    Milonas, Annabel; Hutchinson, Ana; Charlesworth, David; Doric, Andrea; Green, John; Considine, Julie

    2017-11-01

    There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. The Australian Resuscitation Council (ARC) recommends protocol driven care to enhance chance of survival following cardiac arrest. Healthcare providers have an obligation to ensure protocol driven post resuscitation care is timely and evidence based. The aim of this study was to examine adherence to best practice guidelines for post resuscitation care in the first 24h from Return of Spontaneous Circulation for patients admitted to the intensive care unit from the emergency department having suffered out of hospital or emergency department cardiac arrest and survived initial resuscitation. A retrospective audit of medical records of patients who met the criteria for survivors of cardiac arrest was conducted at two health services in Melbourne, Australia. Criteria audited were: primary cardiac arrest characteristics, oxygenation and ventilation management, cardiovascular care, neurological care and patient outcomes. The four major findings were: (i) use of fraction of inspired oxygen (FiO 2 ) of 1.0 and hyperoxia was common during the first 24h of post resuscitation management, (ii) there was variability in cardiac care, with timely 12 lead Electrocardiograph and majority of patients achieving systolic blood pressure (SBP) greater than 100mmHg, but delays in transfer to cardiac catheterisation laboratory, (iii) neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide therapeutic hypothermia in almost 50% of patients and (iv) there was an association between in-hospital mortality and specific elements of post resuscitation care during the first 24h of hospital admission. Evidence-based context-specific guidelines for post resuscitation care that span the whole patient journey are needed. Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so

  12. Managing Bias in Palliative Care: Professional Hazards in Goals of Care Discussions at the End of Life.

    PubMed

    Callaghan, Katharine A; Fanning, Joseph B

    2018-02-01

    In the setting of end-of-life care, biases can interfere with patient articulation of goals and hinder provision of patient-centered care. No studies have addressed clinician bias or bias management specific to goals of care discussions at the end of life. To identify and determine the prevalence of palliative care clinician biases and bias management strategies in end-of-life goals of care discussions. A semistructured interview guide with relevant domains was developed to facilitate data collection. Participants were asked directly to identify biases and bias management strategies applicable to this setting. Two researchers developed a codebook to identify themes using a 25% transcript sample through an iterative process based on grounded theory. Inter-rater reliability was evaluated using Cohen κ. It was 0.83, indicating near perfect agreement between coders. The data approach saturation. A purposive sampling of 20 palliative care clinicians in Middle Tennessee participated in interviews. The 20 clinicians interviewed identified 16 biases and 11 bias management strategies. The most frequently mentioned bias was a bias against aggressive treatment (n = 9), described as a clinician's assumption that most interventions at the end of life are not beneficial. The most frequently mentioned bias management strategy was self-recognition of bias (n = 17), described as acknowledging that bias is present. This is the first study identifying palliative care clinicians' biases and bias management strategies in end-of-life goals of care discussions.

  13. ProvenCare-Psoriasis: A disease management model to optimize care.

    PubMed

    Gionfriddo, Michael R; Pulk, Rebecca A; Sahni, Dev R; Vijayanagar, Sonal G; Chronowski, Joseph J; Jones, Laney K; Evans, Michael A; Feldman, Steven R; Pride, Howard

    2018-03-15

    There are a variety of evidence-based treatments available for psoriasis. The transition of this evidence into practice is challenging. In this article, we describe the design of our disease management approach for Psoriasis (ProvenCare®) and present preliminary evidence of the effect of its implementation. In designing our approach, we identified three barriers to optimal care: 1) lack of a standardized and discrete disease activity measure within the electronic health record, 2) lack of a system-wide, standardized approach to care, and 3) non-uniform financial access to appropriate non-pharmacologic treatments. We implemented several solutions, which collectively form our approach. We standardized the documentation of clinical data such as body surface area (BSA), created a disease management algorithm for psoriasis, and aligned incentives to facilitate the implementation of the algorithm. This approach provides more coordinated, cost effective care for psoriasis, while being acceptable to key stakeholders. Future work will examine the effect of the implementation of our approach on important clinical and patient outcomes.

  14. Chronic disease management for patients with respiratory disease.

    PubMed

    Bryant, Elizabeth

    National and international awareness of the heavy burden of chronic disease has led to the development of new strategies for managing care. Elisabeth Bryant explains how self-care, education and support for more patients with complex needs should be built into planned care delivery, and emphasises that the patient is the key member of the care team.

  15. Integration of Palliative Care in Chronic Critical Illness Management

    PubMed Central

    Nelson, Judith E; Hope, Aluko A

    2016-01-01

    Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient’s values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. We also discuss approaches to optimize communication among clinicians, patients, and families about care goals. Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review “consultative” and “integrative” models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families. PMID:22663973

  16. Contributions of relational coordination to care management in accountable care organizations: Views of managerial and clinical leaders.

    PubMed

    Rundall, Thomas G; Wu, Frances M; Lewis, Valerie A; Schoenherr, Karen E; Shortell, Stephen M

    2016-01-01

    The accountable care organization (ACO) is a new type of health care organization incentivized to improve quality of care, improve population health, and reduce the cost of care. An ACO's success in meeting these objectives depends greatly upon its ability to improve patient care management. Numerous studies have found relational coordination to be positively associated with key measures of organizational performance in health care organizations, including quality and efficiency. The purpose of this paper is twofold: (a) identify the extent to which ACO leaders are aware of the dimensions of relational coordination, and (b) identify the ways these leaders believe the dimensions influenced care management practices in their organization. We performed content analysis of interviews with managerial and clinical leaders from a diverse group of 11 ACOs to assess awareness of relational coordination and identify the ways that dimensions of relational coordination were perceived to influence development of care management practices. ACO leaders mentioned four relational coordination dimensions: shared goals, frequency of communication, timeliness of communication, and problem solving communication. Three dimensions - shared knowledge of team members' tasks, mutual respect, and accuracy of communication - were not mentioned. Our analysis identified numerous ways leaders believed the four mentioned dimensions contributed to the development of care management, including contributions to standardization of care, patient engagement, coordination of care, and care planning. We propose two hypotheses for future research on relational coordination and care management. If relational coordination is to have a beneficial influence on ACO performance, organizational leaders must become more aware of relational coordination and its various dimensions and become cognizant of relational coordination's influence on care management in their ACO. We suggest a number of means by which ACO

  17. Management of patients in a dedicated burns intensive care unit (BICU) in a developing country.

    PubMed

    Hashmi, Madiha; Kamal, Rehana

    2013-05-01

    In Pakistan the practice of managing extensive burns in dedicated intensive care units is not well established. This audit aims to define the characteristics of the victims of major burns and factors that increase mortality and outcome of the protocol-based management in a dedicated burns intensive care unit (BICU). This prospective audit included all patients admitted to the BICU of Suleiman Dawood Burns Unit in Karachi from 1st September 2002 to 31st August 2011. Demographic information, type and place of burn, total body surface area burn (TBSA), type of organ support provided, length of ICU stay, any associated medical diseases, and out outcome were documented. A total of 1597 patients were admitted to the BICU in 9 years. Median age of the patients was 22 (IQR =32-7). 32% victims were children <14 years and only 7% were >50 years old. Male to female ratio was 1.4:1. Fire was the leading cause of burns in adults (64%) and scald burns were most common in (64%) in children. 72.4% of the accidents happened at home, where kitchen was the commonest location (597 cases). Mean TBSA burnt was 32.5% (SD ± 22.95%, 95%CI: 31.36-33.61). 27% patients needed ventilatory support, 4% were dialyzed and split skin graftings were performed in 20% patients. Average length of ICU stay was 10.42 days. Epilepsy, psychiatric illness and drug addiction were not common associations with burns. Overall mortality was 41.30% but it decreased over the years from 75% to 27%. Groups of people most vulnerable to sustain burn are young females getting burnt in the kitchen, young males getting burnt at work, and small children falling in pots of hot water stored for drinking or bathing. TBSA >40%, age >50 years, fire burn and female gender were associated with a higher risk of death. Carefully planned, protocol based management of burn patients by burn teams of dedicated healthcare professionals, even with limited resources reduced mortality. Burn hazard awareness, prevention and educational

  18. Tools for Successful Weight Management in Primary Care

    PubMed Central

    Turer, Christy Boling

    2015-01-01

    Obesity is one of the most pervasive and costly public-health problems. Clinicians need effective tools to address weight management in primary care, including evaluation and communication methods, guideline-based weight-management interventions, and safe and effective weight-loss medications and surgery. The objective of this Grand-Rounds presentation is to provide practicing clinicians with the latest information regarding effective ways to care for and communicate with patients about weight loss; evidence-based guidelines for selecting weight-management therapies; and safety, efficacy, and adverse effects of weight-loss medications and surgery. PMID:26218666

  19. The role of peer support in diabetes care and self-management.

    PubMed

    Brownson, Carol A; Heisler, Michele

    2009-03-01

    In light of the growing prevalence and healthcare costs of diabetes mellitus, it is critically important for healthcare providers to improve the efficiency and effectiveness of their diabetes care. A key element of effective disease management for diabetes is support for patient self-management. Barriers to care exist for both patients and healthcare systems. As a result, many people with diabetes do not get the care and support needed to successfully manage their diabetes.Disease management approaches that incorporate peer support may be a promising way to help provide self-management support to patients with diabetes. Trained peers provide emotional support, instrumental (tangible or material) support, education, and skills training to those they serve, and outreach and care coordination for provider systems. They play a unique role that complements and supports clinical care.To describe how peers are currently supporting diabetes care, a number of databases were searched for studies describing the roles of peers using relevant key words. This paper reviews current literature that describes the roles and duties of peers in interventions to improve diabetes care, with a focus on their contributions to six essential elements of self-management support: (i) access to regular, high-quality clinical care; (ii) an individualized approach to assessment and treatment; (iii) patient-centered collaborative goal setting; (iv) education and skills training; (v) ongoing follow-up and support; and (vi) linkages to community resources.Peers worked under a variety of titles, which did not define their duties. The scope of their work ranged from assisting health professionals to playing a central role in care. Providing education and follow-up support were the two most common roles. In all but one study, these roles were carried out during face-to-face contact, most frequently in community sites.A growing body of literature supports the value of peer models for diabetes

  20. Experiences of Patient-Centredness With Specialized Community-Based Care

    PubMed Central

    Winsor, S; Smith, A; Vanstone, M; Giacomini, M; Brundisini, FK; DeJean, D

    2013-01-01

    Background Specialized community-based care (SCBC) endeavours to help patients manage chronic diseases by formalizing the link between primary care providers and other community providers with specialized training. Many types of health care providers and community-based programs are employed in SCBC. Patient-centred care focuses on patients’ psychosocial experience of health and illness to ensure that patients’ care plans are modelled on their individual values, preferences, spirituality, and expressed needs. Objectives To synthesize qualitative research on patient and provider experiences of SCBC interventions and health care delivery models, using the core principles of patient-centredness. Data Sources This report synthesizes 29 primary qualitative studies on the topic of SCBC interventions for patients with chronic conditions. Included studies were published between 2002 and 2012, and followed adult patients in North America, Europe, Australia, and New Zealand. Review Methods Qualitative meta-synthesis was used to integrate findings across primary research studies. Results Three core themes emerged from the analysis: patients’ health beliefs affect their participation in SCBC interventions; patients’ experiences with community-based care differ from their experiences with hospital-based care; patients and providers value the role of nurses differently in community-based chronic disease care. Limitations Qualitative research findings are not intended to generalize directly to populations, although meta-synthesis across several qualitative studies builds an increasingly robust understanding that is more likely to be transferable. The diversity of interventions that fall under SCBC and the cross-interventional focus of many of the studies mean that findings might not be generalizable to all forms of SCBC or its specific components. Conclusions Patients with chronic diseases who participated in SCBC interventions reported greater satisfaction when SCBC

  1. HIPAA and patient care: the role for professional judgment.

    PubMed

    Lo, Bernard; Dornbrand, Laurie; Dubler, Nancy N

    2005-04-13

    Federal health privacy regulations, commonly known as the Health Insurance Portability and Accountability Act (HIPAA) regulations, came into effect in April 2003. Many clinicians and institutions have relied on consultants and risk managers to tell them how to implement these regulations. Much of the controversy and confusion over the HIPAA regulations concern so-called incidental disclosures. Some interpretations of the privacy regulations would limit essential communication and compromise good patient care. This article analyzes misconceptions regarding what the regulations say about incidental disclosures and discusses the reasons for such misunderstandings. Many misconceptions arise from gaps in the regulations. These gaps are appropriately filled by professional judgment informed by ethical guidelines. The communication should be necessary and effective for good patient care, and the risks of a breach of confidentiality should be proportional to the likely benefit for the patient's care. The alternative for communication should be impractical. We offer specific recommendations to help physicians think through what incidental disclosures in patient care are ethically permissible and what safeguards ought to be taken. Physicians should work with risk managers and practice administrators to develop policies that promote good communication in patient care, while taking appropriate steps to protect patient privacy.

  2. Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

    PubMed

    Liu, Wei; Gerdtz, Marie; Manias, Elizabeth

    2016-10-01

    This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication

  3. [The hospital perspective: disease management and integrated health care].

    PubMed

    Schrappe, Matthias

    2003-06-01

    Disease Management is a transsectoral, population-based form of health care, which addresses groups of patients with particular clinical entities and risk factors. It refers both to an evidence-based knowledge base and corresponding guidelines, evaluates outcome as a continuous quality improvement process and usually includes active participation of patients. In Germany, the implementation of disease management is associated with financial transactions for risk adjustment between health care assurances [para. 137 f, Book V of Social Code (SGB V)] and represents the second kind of transsectoral care, besides a program designed as integrated health care according to para. 140 a ff f of Book V of Social Code. While in the USA and other countries disease management programs are made available by several institutions involved in health care, in Germany these programs are offered by health care insurers. Assessment of disease management from the hospital perspective will have to consider three questions: How large is the risk to compensate inadequate quality in outpatient care? Are there synergies in internal organisational development? Can the risk of inadequate funding of the global "integrated" budget be tolerated? Transsectoral quality assurance by valid performance indicators and implementation of a quality improvement process are essential. Internal organisational changes can be supported, particularly in the case of DRG introduction. The economic risk and financial output depends on the kind of disease being focussed by the disease management program. In assessing the underlying scientific evidence of their cost effectiveness, societal costs will have to be precisely differentiated from hospital-associated costs.

  4. Training tomorrow's clinicians today--managed care essentials: a process for curriculum development.

    PubMed

    Colenda, C C; Wadland, W; Hayes, O; Anderson, W; Priester, F; Pearson, R; Keefe, C; Fleck, L

    2000-05-01

    To develop a managed care curriculum for primary care residents. This article outlines a 4-stage curriculum development process focusing on concepts of managed care organization and finance. The stages consist of: (1) identifying the curriculum development work group and framing the scope of the curriculum, (2) identifying stakeholder buy-in and expectations, (3) choosing curricular topics and delivery mechanisms, and (4) outlining the evaluation process. Key elements of building a curriculum development team, content objectives of the curriculum, the rationale for using problem-based learning, and finally, lessons learned from the partnership among the stakeholders are reviewed. The curriculum was delivered to an entering group of postgraduate-year 1 primary care residents. Attitudes among residents toward managed care remained relatively negative and stable over the yearlong curriculum, especially over issues relating to finance, quality of care, control and autonomy of practitioners, time spent with patients, and managed care's impact on the doctor-patient relationship. Residents' baseline knowledge of core concepts about managed care organization and finance improved during the year that the curriculum was delivered. Satisfaction with a problem-based learning approach was high. Problem-based learning, using real-life clinical examples, is a successful approach to resident instruction about managed care.

  5. Audit of cholesterol management among primary care patients in rural southern Italy.

    PubMed

    Buono, Nicola; Petrazzuoli, Ferdinando; D'Addio, Filippo; Farinaro, Carmine; Soler, Jean Karl

    2013-01-01

    There has not yet been an audit of achievement rates of therapeutic targets for cholesterol management in the rural Italian primary care setting. The purpose of this study was to measure the percentage of patients with hypercholesterolaemia in a rural primary care setting in southern Italy, classify their risk category and measure the proportions of those patients who achieved optimal cholesterol levels according to the Adult Treatment Panel III guidelines. The audit was completed using records from 1 January 2005 to 31 December 2007. An electronic search key was entered into the electronic clinical records of 10 family doctors in a rural area of southern Italy for subjects with a diagnosis of or being treated for hypercholesterolaemia. A total of 194 hypercholesterolaemic patients were randomly selected from a cohort of patients registered with these family doctors. The low density lipoprotein cholesterol (LDL-C) target level was 100 mg/dL (2.6 mmol/L) in patients with existing cardiovascular disease, 130 mg/dL (3.3 mmol/L) for patients with ≥2 risk factors, and 160 mg/dL (4.1 mmol/L) for all other patients. The results regarding the efficacy of the therapy were categorised as follows: (1) on target, LDL-C lower or equal to levels of affiliated class; (2) poor control, 1-30 mg/dL (0.03-0.78 mmol/L) above the target level of LDL-C; (3) very poor control, ≥31 mg/dL (≥0.8 mmol/L) above the LDL-C target level. The average age of the hypercholesterolaemic patients included in the study was 62.0 ± 9.0 years; 55% were males, 30% were smokers, 71.3% suffered from hypertension, 46.3% had diabetes, 39.9% were obese and 31.9% had a family history of coronary disease. There were 114 subjects in Class I (personal history of coronary disease, cardiovascular risk ≥ 20, diabetes mellitus) LDL-C target level. Of these patients, 24.6% were at target, 30.7% had poor control and 44.7% had very poor control. A total of 42.3% of the subjects examined with the

  6. [The patient blood management concept : Joint recommendation of the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery].

    PubMed

    Meybohm, P; Schmitz-Rixen, T; Steinbicker, A; Schwenk, W; Zacharowski, K

    2017-10-01

    Patient blood management is a multimodal concept that aims to detect, prevent and treat anemia, optimize hemostasis, minimize iatrogenic blood loss, and support a patient-centered decision to provide optimal use of allogeneic blood products. Although the World Health Organization (WHO) has already recommended patient blood management as a new standard in 2010, many hospitals have not implemented it at all or only in part in clinical practice. The German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery therefore demand that i) all professionals involved in the treatment should implement important aspects of patient blood management considering local conditions, and ii) the structural, administrative and budgetary conditions should be created in the health care system to implement more intensively many of the measures in Germany.

  7. [Quality assurance of pain care in Austria : Classification of management facilities].

    PubMed

    Jaksch, Wolfgang; Likar, Rudolf; Folkes, Erika; Machold, Klaus; Herbst, Friedrich; Pils, Katharina; Stippl, Peter; Lettner, Sandra; Alfons, Mildred; Crevenna, Richard; Wiederer, Christian; Dieber, Janina; Glehr, Reinhold

    2017-11-01

    In Austria there is no nationwide coverage of pain management, which meets even approximately international criteria. At present there are about 30 interdisciplinary pain management offices and clinics providing care according to a concept of the Austrian Pain Society (ÖSG), about 10 other outpatient pain clinics are located in district and country hospitals. A few years ago, there still were about 50 pain clinics. Yet closure of outpatient clinics and cost-cutting measures in the health sector jeopardize adequate pain relief for patients with chronic pain conditions.Hence, the supply of care for approx. 1.8 mio. Austrians with chronic pain is not guaranteed due to lack of a comprehensive demand planning of pain care facilities. Furthermore, existing structures such as specialized clinics or emergency services in hospitals are primarily based on the personal commitment of individuals. At present, the various centres for pain management in Austria are run with very different operating times, so that for 74% of the chronic pain patients the desired requirements for outpatient pain management are not met and about 50 full-time pain clinics are missing.Under the patronage of the Austrian Pain Society, various national specialist societies have defined the structure and quality criteria for pain management centres in Austria, include, among others, proof of training, cooperation in interdisciplinary teams or minimum number of new patients per year, depending on the classification of the institution.This stepwise concept of care provision for pain patients is intended as first step to help improve the care of pain patients in Austria!

  8. Making It Local: Beacon Communities Use Health Information Technology to Optimize Care Management

    PubMed Central

    Allen, Amy; Des Jardins, Terrisca R.; Heider, Arvela; Kanger, Chatrian R.; Lobach, David F.; McWilliams, Lee; Polello, Jennifer M.; Schachter, Abigail A.; Singh, Ranjit; Sorondo, Barbara; Tulikangas, Megan C.; Turske, Scott A.

    2014-01-01

    Abstract Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks—including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation—the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability. (Population Health Management 2014;17:149–158) PMID

  9. High-quality chronic care delivery improves experiences of chronically ill patients receiving care

    PubMed Central

    Cramm, Jane Murray; Nieboer, Anna Petra

    2013-01-01

    Objective Investigate whether high-quality chronic care delivery improved the experiences of patients. Design This study had a longitudinal design. Setting and Participants We surveyed professionals and patients in 17 disease management programs targeting patients with cardiovascular diseases, chronic obstructive pulmonary disease, heart failure, stroke, comorbidity and eating disorders. Main Outcome Measures Patients completed questionnaires including the Patient Assessment of Chronic Illness Care (PACIC) [T1 (2010), 2637/4576 (58%); T2 (2011), 2314/4330 (53%)]. Professionals' Assessment of Chronic Illness Care (ACIC) scores [T1, 150/274 (55%); T2, 225/325 (68%)] were used as a context variable for care delivery. We used two-tailed, paired t-tests to investigate improvements in chronic illness care quality and patients' experiences with chronic care delivery. We employed multilevel analyses to investigate the predictive role of chronic care delivery quality in improving patients' experiences with care delivery. Results Overall, care quality and patients' experiences with chronic illness care delivery significantly improved. PACIC scores improved significantly from 2.89 at T1 to 2.96 at T2 and ACIC-S scores improved significantly from 6.83 at T1 to 7.18 at T2. After adjusting for patients' experiences with care delivery at T1, age, educational level, marital status, gender and mental and physical quality of life, analyses showed that the quality of chronic care delivery at T1 (P < 0.001) and changes in care delivery quality (P < 0.001) predicted patients' experiences with chronic care delivery at T2. Conclusion This research showed that care quality and changes therein predict more positive experiences of patients with various chronic conditions over time. PMID:24123243

  10. Improving population management through pharmacist-primary care integration: a pilot study.

    PubMed

    Kennedy, Amanda G; Chen, Harry; Corriveau, Michele; MacLean, Charles D

    2015-02-01

    Pharmacists have unique skills that may benefit primary care practices. The objective of this demonstration project was to determine the impact of integrating pharmacists into patient-centered medical homes, with a focus on population management. Pharmacists were partnered into 5 primary care practices in Vermont 1 day per week to provide direct patient care, population-based medication management, and prescriber education. The main measures included a description of drug therapy problems identified and cost avoidance models. The pharmacists identified 708 drug therapy problems through direct patient care (336/708; 47.5%), population-based strategies (276/708; 38.9%), and education (96/708; 13.6%). Common population-based strategies included adjusting doses and discontinuing unnecessary medications. Pharmacists' recommendations to correct drug therapy problems were accepted by prescribers 86% of the time, when data about acceptance were known. Of the 49 recommendations not accepted, 47/49 (96%) were population-based and 2/49 (4%) were related to direct patient care. The cost avoidance model suggests $2.11 in cost was avoided for every $1.00 spent on a pharmacist ($373,092/$176,690). There was clear value in integrating pharmacists into primary care teams. Their inclusion prevented adverse drug events, avoided costs, and improved patient outcomes. Primary care providers should consider pharmacists well suited to offer direct patient care, population-based management, and prescriber education to their practices. To be successful, pharmacists must have full permission to document findings in the primary care practices' electronic health records. Given that many pharmacist services do not involve billable activities, sustainability requires identifying alternative funding mechanisms that do not rely on a traditional fee-for-service approach.

  11. Adult HIV care resources, management practices and patient characteristics in the Phase 1 IeDEA Central Africa cohort

    PubMed Central

    Divaris, Kimon; Newman, Jamie; Hemingway-Foday, Jennifer; Akam, Wilfred; Balimba, Ashu; Dusengamungu, Cyrille; Kalenga, Lucien; Mbaya, Marcel; Molu, Brigitte Mfangam; Mugisha, Veronicah; Mukumbi, Henri; Mushingantahe, Jules; Nash, Denis; Niyongabo, Théodore; Atibu, Joseph; Azinyue, Innocent; Kiumbu, Modeste; Woelk, Godfrey

    2012-01-01

    Introduction Despite recent advances in the management of HIV infection and increased access to treatment, prevention, care and support, the HIV/AIDS epidemic continues to be a major global health problem, with sub-Saharan Africa suffering by far the greatest humanitarian, demographic and socio-economic burden of the epidemic. Information on HIV/AIDS clinical care and established cohorts’ characteristics in the Central Africa region are sparse. Methods A survey of clinical care resources, management practices and patient characteristics was undertaken among 12 adult HIV care sites in four countries of the International Epidemiologic Databases to Evaluate AIDS Central Africa (IeDEA-CA) Phase 1 regional network in October 2009. These facilities served predominantly urban populations and offered primary care in the Democratic Republic of Congo (DRC; six sites), secondary care in Rwanda (two sites) and tertiary care in Cameroon (three sites) and Burundi (one site). Results Despite some variation in facility characteristics, sites reported high levels of monitoring resources, including electronic databases, as well as linkages to prevention of mother-to-child HIV transmission programs. At the time of the survey, there were 21,599 HIV-positive adults (median age=37 years) enrolled in the clinical cohort. Though two-thirds were women, few adults (6.5%) entered HIV care through prevention of mother-to-child transmission services, whereas 55% of the cohort entered care through voluntary counselling and testing. Two-thirds of patients at sites in Cameroon and DRC were in WHO Stage III and IV at baseline, whereas nearly all patients in the Rwanda facilities with clinical stage information available were in Stage I and II. WHO criteria were used for antiretroviral therapy initiation. The most common treatment regimen was stavudine/lamivudine/nevirapine (64%), followed by zidovudine/lamivudine/nevirapine (19%). Conclusions Our findings demonstrate the feasibility of

  12. ME Cares: a statewide system engaging providers in disease management.

    PubMed

    Wexler, Richard; Bean, Claudette; Ito, Diane; Kopp, Zoe; LaCasse, John A; Rea, Vicki

    2004-01-01

    ME Cares (Maine Cares) is a coalition of 32 Maine hospitals that offer community-based, telephonic care support (disease management) programs for patients with heart failure and/or coronary heart disease. We describe the steps, challenges, and lessons learned in coalition development and maintenance. We also present a pre- and post-analysis of our clinical outcomes after enrolling 2145 patients.

  13. Minimal impact of a care pathway for geriatric hip fracture patients.

    PubMed

    Panella, Massimiliano; Seys, Deborah; Sermeus, Walter; Bruyneel, Luk; Lodewijckx, Cathy; Deneckere, Svin; Sermon, An; Nijs, Stefaan; Boto, Paulo; Vanhaecht, Kris

    2018-06-04

    Adherence to guidelines for patients with proximal femur fracture is suboptimal. To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes. The European Quality of Care Pathways study is a cluster randomized controlled trial. 26 hospitals in Belgium, Italy and Portugal. Older adults with a proximal femur fracture (n = 514 patients) were included. Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures. In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team. Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied. ClinicalTrials.gov: NCT00962910. Copyright © 2018 Elsevier Ltd. All rights reserved.

  14. Intensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy.

    PubMed

    Zieleskiewicz, Laurent; Chantry, Anne; Duclos, Gary; Bourgoin, Aurelie; Mignon, Alexandre; Deneux-Tharaux, Catherine; Leone, Marc

    2016-10-01

    In developed countries, the rate of obstetric ICU admissions (admission during pregnancy or the postpartum period) is between 0.5 and 4 per 1000 deliveries and the overall case-fatality rate is about 2%. The most two common causes of obstetric ICU admissions concerned direct obstetric pathologies: obstetric hemorrhage and hypertensive disorders of pregnancy. This review summarized the principles of management of critically ill pregnant patient. Its imply taking care of two patients in the same time. A coordinated multidisciplinary team including intensivists, anesthesiologists, obstetricians, pediatricians and pharmacists is therefore necessary. This team must work effectively together with regular staff aiming to evaluate daily the need to maintain the patient in intensive care unit or to prompt delivery. Keeping mother and baby together and fetal well-being must be balanced with the need of specialized advanced life support for the mother. The maternal physiological changes imply various consequences on management. The uterus aorto-caval compression implies tilting left the parturient. In case of cardiac arrest, uterus displacement and urgent cesarean delivery are needed. The high risk of aspiration and difficult tracheal intubation must be anticipated. Even during acute respiratory distress syndrome, hypoxemia and permissive hypercapnia must be avoided due to their negative impact on the fetus. Careful analysis of the benefit-risk ratio is needed before all drug administration. Streptococcal toxic shock syndrome and perineal fasciitis must be feared and a high level of suspicion of sepsis must be maintained. Finally the potential benefits of an ultrasound-based management are detailed. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

  15. Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

    PubMed

    Hunter, David J; Hinman, Rana S; Bowden, Jocelyn L; Egerton, Thorlene; Briggs, Andrew M; Bunker, Stephen J; Kasza, Jessica; Forbes, Andrew B; French, Simon D; Pirotta, Marie; Schofield, Deborah J; Zwar, Nicholas A; Bennell, Kim L

    2018-04-30

    To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged ≥45 years and have experienced knee pain ≥4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving

  16. The Chronic Care Model as vehicle for the development of disease management in Europe

    PubMed Central

    Spreeuwenberg, Cor

    2008-01-01

    The Chronic Care Model (Wagner, WHO) aims to improve the functioning and clinical situation of chronic patients by focussing on the patient, the practice team and the conditions that determine the functioning of the team. The patient is the most important actor who must be stimulated proactively by a competent, integrated practice team. Six interdependent conditional components are essential: health care organisation, delivery system design, community resources and policies, self-management support systems, decision support and clinical information systems. While the Chronic Care Model focuses on quality and effectiveness of care, disease management programmes underline more the efficiency of care. These programmes apply industrial management principles in health care. Information about process, structure and outcome is gathered and used systematically and human and material sources are used efficiently. There is evidence that the approaches of the Chronic Care Model and disease management can be integrated. Both approaches underline the need of information and focus on the patient as the main actor to improve and that a balance can be found between effectiveness and efficiency. Ideas will be given how the Chronic Care Model can be used as a framework for the development of a European way of disease management for people with a chronic condition.

  17. Care management: agreement between nursing prescriptions and patients' care needs.

    PubMed

    Faeda, Marília Silveira; Perroca, Márcia Galan

    2016-08-08

    analyze agreement between nursing prescriptions recorded in medical files and patients' care needs; investigate the correlation between the nurses' professional background and agreement of prescriptions. descriptive study with quantitative and documentary approach conducted in the medical clinic, surgical, and specialized units of a university hospital in the interior of São Paulo, Brazil. The new validated version of a Patient Classification Instrument was used and 380 nursing prescriptions written at the times of hospital admission and discharge were assessed. 75% of the nursing prescriptions items were compatible with the patients' care needs. Only low correlation between nursing prescription agreement and professional background was found. the nursing prescriptions did not fully meet the care needs of patients. The care context and work process should be analyzed to enable more effective prescriptions, while strategies to assess the care needs of patients are recommended. analisar a concordância entre prescrições de enfermagem, registradas nos prontuários, e as necessidades de cuidados dos pacientes; investigar a correlação entre o perfil profissional dos enfermeiros e a concordância das prescrições. estudo descritivo com abordagem quantitativa e documental, realizado em unidades de clínica médica, cirúrgica e especializada de um hospital de ensino, no interior do Estado de São Paulo. Foi aplicada a nova versão validada do Instrumento de Classificação de Pacientes e, posteriormente, investigadas 380 prescrições de enfermagem no momento da admissão e alta hospitalar. foi identificado que 75% dos itens das prescrições de enfermagem estavam compatíveis com as necessidades cuidativas dos pacientes. Encontrou-se baixa correlação entre a concordância da prescrição de enfermagem e o perfil profissional. as prescrições de enfermagem não estão sendo realizadas, em sua totalidade, em consonância com as necessidades dos pacientes. Para

  18. Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial.

    PubMed

    Yoon, Jean; Chang, Evelyn; Rubenstein, Lisa V; Park, Angel; Zulman, Donna M; Stockdale, Susan; Ong, Michael K; Atkins, David; Schectman, Gordon; Asch, Steven M

    2018-06-05

    Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization. To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients. Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526). 5 U.S. Department of Veterans Affairs (VA) medical centers. Primary care patients at high risk for hospitalization who had a recent acute care episode. Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. Utilization and costs (including intensive management program expenses) 12 months before and after randomization. 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization. Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed. High-risk patients with access to an intensive management program

  19. Implementation of a care management model for depression at two primary care clinics.

    PubMed

    Williams, Mark; Angstman, Kurt; Johnson, Isaac; Katzelnick, David

    2011-01-01

    The Mayo clinic participated in the Depression Improvement Across Minnesota, Offering a New Direction model at two Mayo Family Clinics, that is, the Rochester Northwest and Northeast sites. Although the Northwest and Northeast clinics demonstrated the best 6-month remission rates in the state during the first year of implementation, they were retrospectively found to differ on several process issues and on measures related to the populations served. Six-month remission rates were significantly better at Northwest clinic; yet, Northeast clinic had more patient contacts. Differences in rates of activation into care management, care management accessibility, and differences in maintaining contact with patients at 6 months may explain some of these results.

  20. Position of the American Dietetic Association: nutrition services in managed care.

    PubMed

    Chima, Cinda S; Pollack, Harold A

    2002-10-01

    It is the position of the American Dietetic Association that medical nutrition therapy is an essential component of disease management and healthcare provided by managed care organizations, and that such care must be provided by qualified nutrition professionals. Compared with traditional fee-for-service reimbursement systems, managed care presents new opportunities for dietetics professionals. Until recently, the lack of billing infrastructure has handicapped nutrition providers who wish to bill for their services and has made it difficult to track the outcomes of nutrition care. With the publication of current procedure terminology codes for medical nutrition therapy (MNT) and the implementation of MNT benefits in Medicare part B for diabetes and nondialysis kidney disease, commercial payers, including managed care organizations (MCOs) are likely to implement or expand their coverage of MNT. A large body of evidence supports the efficacy and cost-effectiveness of MNT coverage within managed care plans. This evidence includes cost analyses of conditions treated by MNT, and clinical trial data confirming the efficacy of MNT in improving patient outcomes. MNT is also an important part of national standards of care for many chronic disease conditions. Based on evidence supporting the role of MNT in improving patient outcomes, the Institute of Medicine (IOM) recommended that MNT services be reimbursed by Medicare when patients are referred by a physician. Provision of appropriate MNT can also help MCOs meet accreditation and quality standards established by entities such as the National Committee for Quality Assurance and the Joint Commission for the Accreditation of Health Care Organizations. Much of the work required to secure a place for MNT in MCOs will be done at the practitioner level, by nutrition professionals themselves. Registered dietitians must market MNT to their customers in managed care by addressing the needs of each player. By emphasizing the

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